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Arnaíz de Las Revillas F, Sousa D, Ardunay C, García-Vidal C, Montejo M, Rodríguez-Álvarez R, Pasquau J, Bouza E, Oteo JA, Balseiro C, Méndez C, Lwoff N, Llinares P, Fariñas MC. Healthcare-associated pneumonia: a prospective study in Spain. REVISTA ESPANOLA DE QUIMIOTERAPIA 2020; 33:358-368. [PMID: 32693555 PMCID: PMC7528418 DOI: 10.37201/req/067.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The aim of the study was to describe the epidemiological characteristics and factors related to outcome in Streptococcus pneumoniae and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated pneumonia (HCAP). Patients and method A 3-year prospective observational epidemiological case study of HCAP was conducted in seven Spanish hospitals. Microbiological and patient characteristics and outcomes were collected and classified by causative pathogen into 4 categories: “S. pneumoniae”, “MRSA”, “Others” and “Unknown”. Patients were followed up 30 days after discharge. Results A total of 258 (84.6%) patients were enrolled (170 were men [65.9%]). Mean age was 72.4 years ± 15 years (95% CI [70.54-74.25]). The etiology of pneumonia was identified in 73 cases (28.3%):S. pneumoniae in 35 patients (13.6%), MRSA in 8 (3.1%), and other microorganisms in 30 patients (11.6%). Significant differences in rates of chronic obstructive pulmonary disease (p < 0.05), previous antibiotic treatment (p < 0.05), other chronic respiratory diseases, inhaled corticosteroids (p < 0.01), and lymphoma (p < 0.05) were observed among the four groups. Patients with MRSA pneumonia had received more previous antibiotic treatment (87.5%). Thirty-three (12.8%) patients died during hospitalisation; death in 27 (81.2%) was related to pneumonia. Conclusions The etiology of HCAP was identified in only one quarter of patients, with S. pneumoniae being the most prevalent microorganism. Patients with chronic respiratory diseases more frequently presented HCAP due to MRSA than to S. pneumoniae. Death at hospital discharge was related in most cases to pneumonia.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - M C Fariñas
- María Carmen Fariñas. Infectious Diseases Unit, Hospital Universitario Marqués de Valdecilla, Av. Valdecilla, 25, 39008 Santander, Cantabria, Spain.
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Critically ill patients with community-onset intraabdominal infections: Influence of healthcare exposure on resistance rates and mortality. PLoS One 2019; 14:e0223092. [PMID: 31557256 PMCID: PMC6762167 DOI: 10.1371/journal.pone.0223092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 09/15/2019] [Indexed: 01/29/2023] Open
Abstract
The concept of healthcare-associated infections (as opposed to hospital-acquired infections) in intraabdominal infections (IAIs) is scarcely supported by data in the literature. The aim of the present study was to analyse community-onset IAIs (non-postoperative/non-nosocomial) in patients admitted to intensive care units (ICUs), to investigate differences in resistance patterns linked to healthcare exposure and mortality-associated factors. A one-year prospective observational study (17 Spanish ICUs) was performed distributing cases as healthcare-associated infections (HCAI), community-acquired infections (CAI) and immunocompromised patients (ICP). Bacteria producing extended-spectrum β-lactamases (ESBL) and/or carbapenemase (CPE), high-level aminoglycoside- and/or methicillin- and/or vancomycin- resistance were considered antimicrobial resistant (AMR). Mortality-associated factors were identified by regression multivariate analysis. Of 345 patients included (18.8% HCAI, 6.1% ICP, 75.1% CAI), 51.6% presented generalized peritonitis; 32.5% were >75 years (55.4% among HCAI). Overall, 11.0% cases presented AMR (7.0% ESBL- and/or CPE), being significantly higher in HCAI (35.4%) vs. CAI (5.8%) (p<0.001) vs. ICP (0%) (p = 0.003). Overall 30-day mortality was 14.5%: 23.1% for HCAI and 11.6% for CAI (p = 0.016). Mortality (R2 = 0.262, p = 0.021) was positively associated with age >75 years (OR = 6.67, 95%CI = 2.56-17.36,p<0.001), Candida isolation (OR = 3.05, 95%CI = 1.18-7.87,p = 0.022), and SAPS II (per-point, OR = 1.08, 95%CI = 1.05-1.11, p<0.001) and negatively with biliary infections (OR = 0.06, 95%CI = 0.01-0.48,p = 0.008). In this study, the antimicrobial susceptibility pattern of bacteria isolated from patients with healthcare contact was shifted to resistance, suggesting the need for consideration of the healthcare category (not including hospital-acquired infections) for severe IAIs. 30-day mortality was positively related with age >75 years, severity and Candida isolation but not with AMR.
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Jones TM, Drew RH, Wilson DT, Sarubbi C, Anderson DJ. Impact of automatic infectious diseases consultation on the management of fungemia at a large academic medical center. Am J Health Syst Pharm 2019; 74:1997-2003. [PMID: 29167141 DOI: 10.2146/ajhp170113] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE The impact of automatic infectious diseases (ID) consultation for inpatients with fungemia at a large academic medical center was studied. METHODS In this single-center, retrospective study, the time to appropriate antifungal therapy before and after implementing a policy requiring automatic ID consultation for the management of fungemia for all patients with an inpatient positive blood culture for fungus was examined. The rates of ID consultation; the likelihood of receiving appropriate antifungal therapy; central venous catheter (CVC) removal rates; performance of ophthalmologic examinations; infection-related length of stay (LOS); rates of all-cause inhospital mortality, death, or transfer to an intensive care unit within 7 days of first culture; and inpatient cost of antifungals were also evaluated. RESULTS A total of 173 unique episodes (94 and 79 in the control and intervention groups, respectively) were included. Candida species were the most frequently cultured organisms, isolated from over 90% of patients in both groups. No differences were observed between the control and intervention groups in time to appropriate therapy, infection-related LOS, or time to CVC removal. However, patients in the intervention group were more likely than those in the control group to receive appropriate antifungal therapy (p = 0.0392), undergo ophthalmologic examination (p = 0.003), have their CVC removed (p = 0.0038), and receive ID consultation (p = 0.0123). Inpatient antifungal costs were significantly higher in the intervention group (p = 0.0177). CONCLUSION While automatic ID consultation for inpatients with fungemia did not affect the time to administration of appropriate therapy, improvement was observed for several process indicators, including rates of appropriate antifungal therapy selection, time to removal of CVCs, and performance of ophthalmologic examinations.
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Affiliation(s)
- Travis M Jones
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC .,Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC
| | - Richard H Drew
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC.,Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC
| | - Dustin T Wilson
- Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC.,Department of Pharmacy, Duke University Medical Center, Durham, NC
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Peeters P, Ryan K, Karve S, Potter D, Baelen E, Rojas-Farreras S, Rodríguez-Baño J. The impact of initial antibiotic treatment failure: real-world insights in patients with complicated, health care-associated intra-abdominal infection. Infect Drug Resist 2019; 12:329-343. [PMID: 30774399 PMCID: PMC6362915 DOI: 10.2147/idr.s184116] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose The RECOMMEND study (NCT02364284; D4280R00005) assessed the clinical management patterns and treatment outcomes associated with initial antibiotic therapy (IAT; antibiotics administered ≤48 hours post-initiation of antibiotic therapy) for health care-associated infections across five countries. Patients and methods Data were collected from a retrospective chart review of patients aged ≥18 years with health care-associated complicated intra-abdominal infection (cIAI). Potential risk factors for IAT failure were identified using logistic regression analyses. Results Of 385 patients with complete IAT data, bacterial pathogens were identified in 270 (70.1%), including Gram-negative isolates in 221 (81.9%) and Gram-positive isolates in 92 (34.1%). Multidrug-resistant (MDR) pathogens were identified in 112 patients (41.5% of patients with a pathogen identified). IAT failure rate was 68.3% and in-hospital mortality rate was 40.8%. Multivariate regression analysis demonstrated three factors to be significantly associated with IAT failure: patients admitted/transferred to the intensive care unit during index hospitalization, isolation of an MDR pathogen and previous treatment with β-lactam antibiotics. Conclusion We reveal the real-world insights into the high rates of IAT failure and mortality observed among patients with cIAI. These data highlight the challenges associated with choosing IAT, the impact of MDR pathogens on IAT outcomes and the importance of tailoring IAT selection to account for local epidemiology and patient history.
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Affiliation(s)
| | - Kellie Ryan
- Health Economics and Outcomes Research, AstraZeneca, Gaithersburg, MD, USA
| | - Sudeep Karve
- Health Economics and Outcomes Research, AstraZeneca, Gaithersburg, MD, USA
| | - Danielle Potter
- Medical Evidence and Observational Research Center, AstraZeneca, Gaithersburg, MD, USA
| | - Elisa Baelen
- Real-World Insights, IQVIA, St Prex, Switzerland
| | | | - Jesús Rodríguez-Baño
- Department of Medicine, Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena - Instituto de Biomedicina de Sevilla (IBiS), Universidad de Sevilla, Seville, Spain,
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Greenberg JA, Balk RA, Shah RC. Score for Predicting Ventilator Weaning Duration in Patients With Tracheostomies. Am J Crit Care 2018; 27:477-485. [PMID: 30385539 DOI: 10.4037/ajcc2018532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Factors affecting the timing of ventilator liberation among patients requiring prolonged mechanical ventilation (≥21 consecutive days) are poorly understood. After tracheostomy placement, ventilator liberation typically involves daily reductions in ventilator support as patients regain the capacity to breathe independently. OBJECTIVES To determine the association between ventilator requirements on the day after tracheostomy placement and subsequent weaning duration. METHODS Retrospective review of medical records of adults with tracheostomies treated at an academic medical center from 2011 to 2015. A new ventilator independence score based on ventilator settings on the day after tracheostomy was developed. Scores range from 0% to 100%; higher scores reflect greater levels of unassisted breathing for a greater proportion of the day. A multi-variable competing-risk survival regression model was used to determine the association between the ventilator independence score and time from tracheostomy placement to ventilator liberation. RESULTS Of 372 patients, 72% were liberated from mechanical ventilation. The ventilator independence score measured on the day after tracheostomy placement had an area under the receiver operating characteristic curve value of 0.71 (95% CI, 0.65-0.76) for differentiating patients who were liberated within the next 14 days from those who were not. Median time from tracheostomy placement to ventilator liberation was 41 days for patients with a score of 0%, 20 days for scores between 0% and 50%, 15 days for scores between 50% and 75%, and 10 days for scores between 75% and 100%. CONCLUSIONS A score derived from ventilator settings may help clinicians predict the timing of ventilator liberation in patients requiring prolonged mechanical ventilation.
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Affiliation(s)
- Jared A. Greenberg
- Jared A. Greenberg is an assistant professor and Robert A. Balk is a professor, Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois. Raj C. Shah is an associate professor, Center for Community Health Equity, Department of Family Medicine, and the Rush Alzheimer’s Disease Center, Rush University Medical Center
| | - Robert A. Balk
- Jared A. Greenberg is an assistant professor and Robert A. Balk is a professor, Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois. Raj C. Shah is an associate professor, Center for Community Health Equity, Department of Family Medicine, and the Rush Alzheimer’s Disease Center, Rush University Medical Center
| | - Raj C. Shah
- Jared A. Greenberg is an assistant professor and Robert A. Balk is a professor, Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois. Raj C. Shah is an associate professor, Center for Community Health Equity, Department of Family Medicine, and the Rush Alzheimer’s Disease Center, Rush University Medical Center
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[Hospital-acquired pneumonia]. Med Klin Intensivmed Notfmed 2018; 113:685-695. [PMID: 30302527 DOI: 10.1007/s00063-018-0494-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/10/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
Hospital-acquired pneumonia (HAP) is a frequent complication of hospitalisation. Due to rising multidrug resistant bacteria an appropriate, empiric and targeted therapy is essential and requires an accurate assessment of risk for multidrug resistant bacteria. A targeted, temporal therapy is indispensable and should begin after a focussed diagnosis. Re-evaluation of therapy is important, as clinical course, microbiological and laboratory results might lead to de-escalation of therapy. In this review article the current German guidelines on the diagnosis and therapy of hospital-acquired pneumonia are summarized. Special focus is put on targeted, risk-adapted therapy.
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Kim ES, Park KU, Lee SH, Lee YJ, Park JS, Cho YJ, Yoon HI, Lee CT, Lee JH. Comparison of viral infection in healthcare-associated pneumonia (HCAP) and community-acquired pneumonia (CAP). PLoS One 2018; 13:e0192893. [PMID: 29447204 PMCID: PMC5813982 DOI: 10.1371/journal.pone.0192893] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 01/11/2018] [Indexed: 12/21/2022] Open
Abstract
Background Although viruses are known to be the second most common etiological factor in community-acquired pneumonia (CAP), the respiratory viral profile of the patients with healthcare-associated pneumonia (HCAP) has not yet been elucidated. We investigated the prevalence and the clinical impact of respiratory virus infection in adult patients with HCAP. Methods Patients admitted with HCAP or CAP, between January and December 2016, to a tertiary referral hospital in Korea, were prospectively enrolled, and virus identification was performed using reverse-transcription polymerase chain reaction (RT-PCR). Results Among 452 enrolled patients (224 with HCAP, 228 with CAP), samples for respiratory viruses were collected from sputum or endotracheal aspirate in 430 (95.1%) patients and from nasopharyngeal specimens in 22 (4.9%) patients. Eighty-seven (19.2%) patients had a viral infection, and the proportion of those with viral infection was significantly lower in the HCAP than in the CAP group (13.8% vs 24.6%, p = 0.004). In both the HCAP and CAP groups, influenza A was the most common respiratory virus, followed by entero-rhinovirus. The seasonal distributions of respiratory viruses were also similar in both groups. In the HCAP group, the viral infection resulted in a similar length of hospital stay and in-hospital mortality as viral–bacterial coinfection and bacterial infection, and the CAP group showed similar results. Conclusions The prevalence of viral infection in patients with HCAP was lower than that in patients with CAP, and resulted in a similar prognosis as viral–bacterial coinfection or bacterial infection.
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Affiliation(s)
- Eun Sun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Kyoung Un Park
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Sang Hoon Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Yeon Joo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jong Sun Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Young-Jae Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ho Il Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Choon-Taek Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Jae Ho Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
- * E-mail:
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Rodríguez-Acelas AL, de Abreu Almeida M, Engelman B, Cañon-Montañez W. Risk factors for health care-associated infection in hospitalized adults: Systematic review and meta-analysis. Am J Infect Control 2017; 45:e149-e156. [PMID: 29031433 DOI: 10.1016/j.ajic.2017.08.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 07/25/2017] [Accepted: 08/14/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Health care-associated infections (HAIs) are a public health problem that increase health care costs. This article aimed to systematically review the literature and meta-analyze studies investigating risk factors (RFs) independently associated with HAIs in hospitalized adults. METHODS Electronic databases (MEDLINE, Embase, and LILACS) were searched to identify studies from 2009-2016. Pooled risk ratios (RRs) or odds ratios (ORs) or mean differences (MDs) and 95% confidence intervals (CIs) were calculated and compared across the groups. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS Of 867 studies, 65 met the criteria for review, and the data of 18 were summarized in the meta-analysis. The major RFs independently associated with HAIs were diabetes mellitus (RR, 1.76; 95% CI, 1.27-2.44), immunosuppression (RR, 1.24; 95% CI, 1.04-1.47), body temperature (MD, 0.62; 95% CI, 0.41-0.83), surgery time in minutes (MD, 34.53; 95% CI, 22.17-46.89), reoperation (RR, 7.94; 95% CI, 5.49-11.48), cephalosporin exposure (RR, 1.77; 95% CI, 1.30-2.42), days of exposure to central venous catheter (MD, 5.20; 95% CI, 4.91-5.48), intensive care unit (ICU) admission (RR, 3.76; 95% CI, 1.79-7.92), ICU stay in days (MD, 21.30; 95% CI, 19.81-22.79), and mechanical ventilation (OR, 12.95; 95% CI, 6.28-26.73). CONCLUSIONS Identifying RFs that contribute to develop HAIs may support the implementation of strategies for their prevention, therefore maximizing patient safety.
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Richaud C, De Lastours V, Panhard X, Petrover D, Bruno F, Lefort A. Candida vertebral osteomyelitis (CVO) 28 cases from a 10-year retrospective study in France. Medicine (Baltimore) 2017; 96:e7525. [PMID: 28767571 PMCID: PMC5626125 DOI: 10.1097/md.0000000000007525] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Although increasingly frequent, little is known about the clinical presentation, radiological signs, and outcome of Candida vertebral osteomyelitis (CVO).We performed a nationwide retrospective study of laboratory-confirmed cases of CVO over a 10 year-period in France with a prolonged follow-up. We describe demographic, clinical, biological, and radiological characteristics of patients with CVO, patients' management, and long-term outcome and determine factors associated with a poor outcome.In total, 28 patients with laboratory-confirmed CVO were included. A prior systemic Candida infection was evidenced in 13/28 (46%), occurring a median of 6 weeks before CVO was diagnosed. Twenty-six of 28 (93%) had at least 1 underlying condition at risk of invasive fungal disease, and in 19/28 (68%) CVO was health-care related. C albicans was most frequently identified (21/28; 75%) Lumbo-sacral involvement was the most prevalent (20/28-71%). Nearly half patients had no fever at presentation, but all had pain. Initial antifungal therapy consisted in fluconazole in 15/28 (53%); surgery was needed in 5 (18%) cases.One-year mortality was 21% (6/28), directly related to fungal infection in 2 patients. Risk-factors associated with 1-year mortality were age (P=.02), a high Charlson comorbidity index (P = .001), and a shorter treatment duration (median, 3 months vs 6 months; P = .02). Among 22 patients who survived, the median follow up duration was 15.5 months (8-93.5); 10 had sequelae, consisting in pain in all and neurological deficit in one. A longer treatment duration was significantly associated with healing without sequelae (P = .04).CVO concerns patients with serious underlying conditions and risk-factors for invasive candidiasis. Prolonged antifungal treatment appears to improve survival without sequelae.
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Affiliation(s)
- Clémence Richaud
- Internal Medicine Department, Beaujon Hospital, Assistance-Publique Hôpitaux de Paris, Clichy
| | - Victoire De Lastours
- Internal Medicine Department, Beaujon Hospital, Assistance-Publique Hôpitaux de Paris, Clichy
- INSERM, IAME, UMR1137, Université Paris-Diderot, Sorbonne Paris Cité
| | | | - David Petrover
- Radiology Department Lariboisère Hospital, Assistance-Publique Hôpitaux de Paris, Paris
| | - Fantin Bruno
- Internal Medicine Department, Beaujon Hospital, Assistance-Publique Hôpitaux de Paris, Clichy
- INSERM, IAME, UMR1137, Université Paris-Diderot, Sorbonne Paris Cité
| | - Agnès Lefort
- Internal Medicine Department, Beaujon Hospital, Assistance-Publique Hôpitaux de Paris, Clichy
- INSERM, IAME, UMR1137, Université Paris-Diderot, Sorbonne Paris Cité
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Taeb AM, Hooper MH, Marik PE. Sepsis: Current Definition, Pathophysiology, Diagnosis, and Management. Nutr Clin Pract 2017; 32:296-308. [PMID: 28537517 DOI: 10.1177/0884533617695243] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a clinical syndrome that results from the dysregulated inflammatory response to infection that leads to organ dysfunction. The resulting losses to society in terms of financial burden, morbidity, and mortality are enormous. We provide a review of sepsis, its underlying pathophysiology, and guidance for diagnosis and management of this common disease. Current established treatments include appropriate antimicrobial agents to target the underlying infection, optimization of intravascular volume to improve stroke volume, vasopressors to counteract vasoplegic shock, and high-quality supportive care. Appropriate implementation of established treatments combined with novel therapeutic approaches promises to continue to decrease the impact of this disease.
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Affiliation(s)
- Abdalsamih M Taeb
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Michael H Hooper
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Paul E Marik
- 1 Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Epidemiología, factores de riesgo y sensibilidad in vitro en candidemias por especies diferentes de Candida albicans. Rev Iberoam Micol 2016; 33:248-252. [DOI: 10.1016/j.riam.2016.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 03/30/2016] [Accepted: 04/06/2016] [Indexed: 11/22/2022] Open
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Christabel A, Sharma R, Manikandhan R, Anantanarayanan P, Elavazhagan N, Subash P. Fever after maxillofacial surgery: a critical review. J Maxillofac Oral Surg 2015; 14:154-61. [PMID: 26028829 PMCID: PMC4444673 DOI: 10.1007/s12663-013-0611-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 12/28/2013] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The aim of this paper is to review the pathophysiology of thermoregulation mechanism, various causes of fever after maxillofacial surgery and the different treatment protocols advised in the literature. DISCUSSION Fever is one of the most common complaints after major surgery and is also considered to be an important clinical sign which indicates developing pathology that may go unnoticed by the clinician during post operative period. Several factors are responsible for fever after the maxillofacial surgery, inflammation and infection being the commonest. However, other rare causes such as drug allergy, dehydration, malignancy and endocrinological disorders, etc. should be ruled out prior to any definite diagnosis and initiate the treatment. Proper history and clinical examination is an essential tool to predict the causative factors for fever. Common cooling methods like tepid sponging are usually effective alone or in conjunction with analgesics to reduce the temperature. CONCLUSION Fever is a common postoperative complaint and should not be underestimated as it may indicate a more serious underlying pathology. A specific guideline towards the management of such patients is necessary in every hospital setting to ensure optimal care towards the patients during post operative period.
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Affiliation(s)
- Amelia Christabel
- />Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, 600 095 Tamil Nadu India
| | - Ravi Sharma
- />Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, 600 095 Tamil Nadu India
- />Nandan Apartment, C-72, Sarojini Marg, C-Scheme, Jaipur, 302001 Rajasthan India
| | - R. Manikandhan
- />Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, 600 095 Tamil Nadu India
| | - P. Anantanarayanan
- />Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, 600 095 Tamil Nadu India
| | - N. Elavazhagan
- />Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, 600 095 Tamil Nadu India
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Abstract
Pneumonia is a common disease that carries a high mortality. Traditionally, pneumonia has been classified and treated according to the setting where the pneumonia develops, namely community-acquired pneumonia, health-care-associated pneumonia, and hospital-acquired pneumonia. This classification was based on the risk of a patient being infected with a hospital-acquired drug-resistant pathogen. A new treatment paradigm has been proposed based on the risk of the patient being infected with a community-acquired drug-resistant pathogen. The risk factors for infection with a community-acquired drug-resistant pathogen include (1) hospitalization for > 2 days during the previous 90 days, (2) antibiotic use during the previous 90 days, (3) nonambulatory status, (4) tube feeds, (5) immunocompromised status, (6) use of acid-suppressive therapy, (7) chronic hemodialysis during the preceding 30 days, (8) positive methicillin-resistant Staphylococcus aureus history within the previous 90 days, and (9) present hospitalization > 2 days. This article reviews this new treatment paradigm and other issues relevant to the diagnosis and management of pneumonia based on information from MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School , Norfolk, VA , USA
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Abstract
Sepsis is among the most common reasons for admission to ICUs throughout the world, and it is believed to be the third most common cause of death in the United States. The pathogenetic mechanism and physiologic changes associated with sepsis are exceedingly complex, but our understanding is evolving rapidly. The major pathophysiologic changes in patients with septic shock include vasoplegic shock (distributive shock), myocardial depression, altered microvascular flow, and a diffuse endothelial injury. These pathophysiologic changes play a central role in the management of sepsis. The early management of patients with severe sepsis and septic shock centers on the administration of antibiotics, IV fluids, and vasoactive agents, followed by source control. However, the specific approach to the resuscitation of patients with septic shock remains highly controversial. This review provides a practical and physiologic-based approach to the early management of sepsis and explores the controversies surrounding the management of this complex condition.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
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Greenberg JA, David MZ, Hall JB, Kress JP. Immune dysfunction prior to Staphylococcus aureus bacteremia is a determinant of long-term mortality. PLoS One 2014; 9:e88197. [PMID: 24505428 PMCID: PMC3914899 DOI: 10.1371/journal.pone.0088197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 01/05/2014] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The clinical implications for patients who survive serious infections are not well understood. It has been hypothesized that the excess mortality for survivors of sepsis observed in epidemiological studies is due to increased vulnerability to subsequent infections. We undertook this study to identify characteristics of patients who are at high risk for death after surviving a common type of blood-stream infection. MATERIALS AND METHODS At a single academic medical center, 237 patients with Staphylococcus aureus bacteremia admitted during a three-year period were retrospectively identified. The primary outcomes were 30-day and 31 to 90-day mortality after the first positive blood culture. The primary predictor variable of interest was clinical immune dysfunction prior to bacteremia. RESULTS The 30-day mortality was not significantly different for patients with and without prior immune dysfunction. However, during days 31 to 90, 11 patients (20%) with prior immune dysfunction compared to 10 patients (8.6%) without prior immune dysfunction died (OR 2.59, 95% CI 1.03-6.53, p = 0.04). In a Cox-proportional hazard model controlling for age, there was a significant association between prior immune dysfunction and greater 31 to 90 day mortality (HR 2.44, 95% CI 1.01-5.90, p = 0.05) and a non-significant trend towards occurrence of subsequent infections and greater 31 to 90 day mortality (HR 2.12, 95% CI 0.89-5.07, p = 0.09). CONCLUSIONS Patients with prior immune dysfunction are at high risk for death 31 to 90 days, but not <30 days, after S. aureus bacteremia. Further investigation is needed to determine if this finding is due to poor prognosis of chronic disease or increased vulnerability to subsequent infections.
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Affiliation(s)
- Jared A. Greenberg
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Michael Z. David
- Section of Infectious Disease and Global Health, Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Jesse B. Hall
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - John P. Kress
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
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Risk factors for severe bacterial infections in patients with systemic autoimmune diseases receiving rituximab. Clin Rheumatol 2014; 33:799-805. [PMID: 24487486 PMCID: PMC4058071 DOI: 10.1007/s10067-014-2509-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/12/2014] [Accepted: 01/19/2014] [Indexed: 11/14/2022]
Abstract
The risk of serious bacterial infectious events (SIEs) after an RTX course used in severe and refractory cases of systemic autoimmune diseases (SAID) is well known. Risk factors for SIEs merit investigation. For this case–control study, data were collected in a single centre of internal medicine and included all patients who received rituximab (RTX) for SAID between 2005 and 2011 (rheumatoid arthritis was excluded). Sixty-nine patients with SAID received a total of 87 RTX courses. Thirteen SIEs were reported in 12 patients leading to death in 5 patients. Patients with a history of SIE were significantly older (63.6 ± 18.8 vs 48.8 ± 16.7; p = 0.0091), suffered most frequently of diabetes mellitus (33.3 % vs 5.3 %, p = 0.015), had a lower CD19 count (1.0 ± 1.2/mm3 vs 3.9 ± 7.2/mm3) and had most frequently a prednisone dose >15 mg/day (91.7 % vs 47.7 %) at the start of the first RTX course. The SIE rate was 18.7 per 100 patient-years. At the initiation of the RTX course, risk factors for SIEs were lower IgG levels (OR = 0.87, 95%CI = 0.77–0.99, p = 0.03), lower CD19 count (OR = 0.85, 95%CI = 0.73–1.00) and creatinine clearance ≤ 45 ml/min (OR = 7.78, 95%CI = 1.36–44.38, p = 0.002). Conversely history of pneumococcal vaccination significantly decreased the risk of SIEs (OR = 0.11, 95%CI = 0.03–0.41, p = 0.0009). Concomitant treatment with prednisone at a dose >15 mg/day significantly increased the SIE risk (OR = 8.07, 95%CI = 1.94–33.59, p = 0.0004). SIEs are frequent in SAID treated with RTX, particularly in patients receiving high-dose corticosteroids, in patients with renal insufficiency and in patients with low IgG levels or a low CD19 count.
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Micek ST, McEvoy C, McKenzie M, Hampton N, Doherty JA, Kollef MH. Fluid balance and cardiac function in septic shock as predictors of hospital mortality. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R246. [PMID: 24138869 PMCID: PMC4056694 DOI: 10.1186/cc13072] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 09/23/2013] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Septic shock is a major cause of morbidity and mortality throughout the world. Unfortunately, the optimal fluid management of septic shock is unknown and currently is empirical. METHODS A retrospective analysis was performed at Barnes-Jewish Hospital (St. Louis, Missouri). Consecutive patients (n = 325) hospitalized with septic shock who had echocardiographic examinations performed within 24 hours of shock onset were enrolled. RESULTS A total of 163 (50.2%) patients with septic shock died during hospitalization. Non-survivors had a significantly larger positive net fluid balance within the 24 hour window of septic shock onset (median (IQR): 4,374 ml (1,637 ml, 7,260 ml) vs. 2,959 ml (1,639.5 ml, 4,769.5 ml), P = 0.004). The greatest quartile of positive net fluid balance at 24 hours and eight days post-shock onset respectively were found to predict hospital mortality, and the greatest quartile of positive net fluid balance at eight days post-shock onset was an independent predictor of hospital mortality (adjusted odds ratio (AOR), 1.66; 95% CI, 1.39 to 1.98; P = 0.004). Survivors were significantly more likely to have mild left ventricular dysfunction as evaluated by bedside echocardiography and non-survivors had slightly elevated left ventricular ejection fraction, which was also found to be an independent predictor of outcome. CONCLUSIONS Our data confirms the importance of fluid balance and cardiac function as outcome predictors in patients with septic shock. A clinical trial to determine the optimal administration of intravenous fluids to patients with septic shock is needed.
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Epidemiology and outcomes of candidemia in 3648 patients: data from the Prospective Antifungal Therapy (PATH Alliance®) registry, 2004–2008. Diagn Microbiol Infect Dis 2012; 74:323-31. [DOI: 10.1016/j.diagmicrobio.2012.10.003] [Citation(s) in RCA: 287] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 10/05/2012] [Indexed: 12/29/2022]
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Azie N, Neofytos D, Pfaller M, Meier-Kriesche HU, Quan SP, Horn D. The PATH (Prospective Antifungal Therapy) Alliance® registry and invasive fungal infections: update 2012. Diagn Microbiol Infect Dis 2012; 73:293-300. [PMID: 22789847 DOI: 10.1016/j.diagmicrobio.2012.06.012] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 06/13/2012] [Indexed: 01/08/2023]
Abstract
The Prospective Antifungal Therapy Alliance (PATH Alliance®) performed prospective surveillance of invasive fungal infections (IFIs) among patients hospitalized at 25 medical centers in North America between 2004 and 2008, collecting information on the epidemiology, diagnosis, treatment, and mortality rates of IFIs. In total, 7526 IFIs were identified in 6845 patients. Candida spp. (73.4%) were the most common pathogens, followed by Aspergillus spp. (13.3%), and other yeasts (6.2%). Culture was the most frequently used diagnostic test in the majority of IFI categories. Most patients with invasive candidiasis were treated with fluconazole (48.3%) and the echinocandins (34.0%), while voriconazole (45.5%) was the main antifungal agent for invasive aspergillosis. The 12-week survival rate ranged from 37.5% for hematopoietic stem cell transplant recipients to ~75.0% for those with HIV/AIDS. In summary, the findings of the PATH Alliance® registry provide a better understanding of the epidemiology of a vast variety and large numbers of IFIs.
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Affiliation(s)
- Nkechi Azie
- Astellas Pharma Global Development, Deerfield, IL 60015, USA.
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Pharmacokinetic–pharmacodynamic evaluation of daptomycin, tigecycline, and linezolid versus vancomycin for the treatment of MRSA infections in four western European countries. Eur J Clin Microbiol Infect Dis 2012; 31:2227-35. [DOI: 10.1007/s10096-012-1560-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 01/14/2012] [Indexed: 12/14/2022]
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Abstract
Anesthesiologists are increasingly confronting the difficult problem of caring for patients with sepsis in the operating room and in the intensive care unit. Sepsis occurs in more than 750,000 patients in the United States annually and is responsible for more than 210,000 deaths. Approximately 40% of all intensive care unit patients have sepsis on admission to the intensive care unit or experience sepsis during their stay in the intensive care unit. There have been significant advances in the understanding of the pathophysiology of the disorder and its treatment. Although deaths attributable to sepsis remain stubbornly high, new treatment algorithms have led to a reduction in overall mortality. Thus, it is important for anesthesiologists and critical care practitioners to be aware of these new therapeutic regimens. The goal of this review is to include practical points on important advances in the treatment of sepsis and provide a vision of future immunotherapeutic approaches.
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Kollef MH, Golan Y, Micek ST, Shorr AF, Restrepo MI. Appraising contemporary strategies to combat multidrug resistant gram-negative bacterial infections--proceedings and data from the Gram-Negative Resistance Summit. Clin Infect Dis 2011; 53 Suppl 2:S33-55; quiz S56-8. [PMID: 21868447 DOI: 10.1093/cid/cir475] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The emerging problem of antibiotic resistance, especially among Gram-negative bacteria (GNB), has become a serious threat to global public health. Very few new antibacterial classes with activity against antibiotic-resistant GNB have been brought to market. Renewed and growing attention to the development of novel compounds targeting antibiotic-resistant GNB, as well as a better understanding of strategies aimed at preventing the spread of resistant bacterial strains and preserving the efficacy of existing antibiotic agents, has occurred. The Gram-Negative Resistance Summit convened national opinion leaders for the purpose of analyzing current literature, epidemiologic trends, clinical trial data, therapeutic options, and treatment guidelines related to the management of antibiotic-resistant GNB infections. After an in-depth analysis, the Summit investigators were surveyed with regard to 4 clinical practice statements. The results then were compared with the same survey completed by 138 infectious disease and critical care physicians and are the basis of this article.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8052, St Louis, MO 63110, USA.
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Kollef MH, Micek ST. Patients hospitalized with pneumonia: determining the need for broad-spectrum antibiotic therapy. Clin Infect Dis 2011; 54:479-82. [PMID: 22109952 DOI: 10.1093/cid/cir848] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Institutional Perspective on the Impact of Positive Blood Cultures on the Economic and Clinical Outcomes of Patients With Complicated Skin and Skin Structure Infections: Focus on Gram-Positive Infections. Clin Ther 2011; 33:1759-1768.e1. [DOI: 10.1016/j.clinthera.2011.09.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2011] [Indexed: 01/22/2023]
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Gould IM, Cauda R, Esposito S, Gudiol F, Mazzei T, Garau J. Management of serious meticillin-resistant Staphylococcus aureus infections: what are the limits? Int J Antimicrob Agents 2011; 37:202-9. [PMID: 21300528 DOI: 10.1016/j.ijantimicag.2010.10.030] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 10/29/2010] [Indexed: 01/16/2023]
Abstract
Severe (life-threatening) meticillin-resistant Staphylococcus aureus (MRSA) infection continues to be treated with vancomycin despite accumulating evidence of poor outcome, increasing resistance and unachievable pharmacokinetic/pharmacodynamic (PK/PD) targets. The minimum inhibitory concentration (MIC) susceptibility breakpoint for vancomycin was recently reduced to 2 mg/L. Whilst the great majority of clinical isolates are thus still classified as susceptible, the available clinical evidence argues for a method-dependent breakpoint of 0.5 mg/L (broth dilution) or 1.0 mg/L (Etest), which would classify many strains as resistant, or at best intermediate. However, automated susceptibility testing systems are not currently capable of performing accurately at this low level, and such low breakpoints are unsatisfactory because the poor reproducibility of tests (plus or minus one doubling dilution) results in a critical non-reproducibility around the modal MIC of 1 mg/L described in most published data. Therefore, vancomycin should be used with caution in severe (life-threatening) staphylococcal disease and the MIC should always be reported by method. Daptomycin is generally preferred for bacteraemia/endocarditis and linezolid for pneumonia. Better outcome data for vancomycin, based on achievable PK/PD targets and using robust MIC tests, are urgently required.
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Affiliation(s)
- Ian M Gould
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB252ZN, UK.
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Pfaller MA, Messer SA, Moet GJ, Jones RN, Castanheira M. Candida bloodstream infections: comparison of species distribution and resistance to echinocandin and azole antifungal agents in Intensive Care Unit (ICU) and non-ICU settings in the SENTRY Antimicrobial Surveillance Program (2008–2009). Int J Antimicrob Agents 2011; 38:65-9. [DOI: 10.1016/j.ijantimicag.2011.02.016] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 02/18/2011] [Accepted: 02/22/2011] [Indexed: 11/15/2022]
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Falcone M, Venditti M, Shindo Y, Kollef MH. Healthcare-associated pneumonia: diagnostic criteria and distinction from community-acquired pneumonia. Int J Infect Dis 2011; 15:e545-50. [PMID: 21616695 DOI: 10.1016/j.ijid.2011.04.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 12/27/2010] [Accepted: 04/19/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Traditionally, pneumonia developing in patients who receive healthcare services in the outpatient environment has been classified as community-acquired pneumonia (CAP). However, recent investigations suggest that this type of infection, known as healthcare-associated pneumonia (HCAP), is distinct from CAP in terms of its epidemiology, etiology, and risk for infection with multidrug-resistant (MDR) pathogens. METHODS A Medline literature review of available clinical studies using the term HCAP was conducted to determine outcomes compared to CAP and effective empiric treatment strategies. RESULTS Analysis of multi-institutional clinical data showed that mortality in hospitalized patients with HCAP is greater than that in CAP, and patients with HCAP received inappropriate initial empiric antibiotic treatment more frequently than CAP patients. The bacterial pathogens associated with HCAP also differed from CAP with potentially MDR Gram-positive and Gram-negative bacteria being more common in HCAP. CONCLUSIONS All patients hospitalized with suspected HCAP should be evaluated for their underlying risk of infection with MDR pathogens. Because HCAP is similar to hospital-acquired pneumonia (HAP), both clinically and etiologically, it should be treated as HAP until culture data become available.
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Affiliation(s)
- Marco Falcone
- Department of Infectious Diseases, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
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Boyer A, Amadeo B, Vargas F, Yu M, Maurice-Tison S, Dubois V, Bébéar C, Rogues AM, Gruson D. Severe community-acquired Enterobacter pneumonia: a plea for greater awareness of the concept of health-care-associated pneumonia. BMC Infect Dis 2011; 11:120. [PMID: 21569334 PMCID: PMC3118139 DOI: 10.1186/1471-2334-11-120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 05/11/2011] [Indexed: 11/25/2022] Open
Abstract
Background Patients with Enterobacter community-acquired pneumonia (EnCAP) were admitted to our intensive care unit (ICU). Our primary aim was to describe them as few data are available on EnCAP. A comparison with CAP due to common and typical bacteria was performed. Methods Baseline clinical, biological and radiographic characteristics, criteria for health-care-associated pneumonia (HCAP) were compared between each case of EnCAP and thirty age-matched typical CAP cases. A univariate and multivariate logistic regression analysis was performed to determine factors independently associated with ENCAP. Their outcome was also compared. Results In comparison with CAP due to common bacteria, a lower leukocytosis and constant HCAP criteria were associated with EnCAP. Empiric antibiotic therapy was less effective in EnCAP (20%) than in typical CAP (97%) (p < 0.01). A delay in the initiation of appropriate antibiotic therapy (3.3 ± 1.6 vs. 1.2 ± 0.6 days; p < 0.01) and an increase in duration of mechanical ventilation (8.4 ± 5.2 vs. 4.0 ± 4.3 days; p = 0.01) and ICU stay were observed in EnCAP patients. Conclusions EnCAP is a severe infection which is more consistent with HCAP than with typical CAP. This retrospectively suggests that the application of HCAP guidelines should have improved EnCAP management.
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Affiliation(s)
- Alexandre Boyer
- Medical Intensive Care Unit, Hôpital Pellegrin-Tripode, Place Amélie Raba Léon, France.
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Pritchard L, Baker C, Leggett J, Sehdev P, Brown A, Bayley KB. Increasing vancomycin serum trough concentrations and incidence of nephrotoxicity. Am J Med 2010; 123:1143-9. [PMID: 21183005 DOI: 10.1016/j.amjmed.2010.07.025] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 07/06/2010] [Accepted: 07/07/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND conflicting evidence regarding the association of vancomycin serum concentrations with efficacy and toxicity has resulted in controversy regarding optimal target concentrations. Recent publications recommend attaining higher vancomycin trough concentrations of 15 to 20 mg/L for target infections, yet limited research is available assessing the correlation of vancomycin serum concentrations with toxicity. The aim of this study was to evaluate the association between vancomycin serum trough concentrations and nephrotoxicity. METHODS a 2-phase retrospective analysis was completed. Phase 1 evaluated 2493 courses of vancomycin completed between January 2003 and December 2007. The analysis describes a 5-year trend in vancomycin prescribing practices and assesses the association of nephrotoxicity with baseline serum creatinine, vancomycin serum trough concentrations, and duration of vancomycin therapy. Phase 2 examined patients receiving vancomycin therapy during 2007 to evaluate specific risk factors for development of nephrotoxicity. RESULTS the proportion of vancomycin serum trough concentrations ≥ 15 mg/L and ≥ 20 mg/L increased significantly over time. Statistical analysis identified vancomycin serum trough concentrations ≥ 14 mg/L, duration of vancomycin therapy ≥ 7 days, and baseline serum creatinine levels ≥ 1.7 mg/dL as independent predictors of nephrotoxicity. Phase 2 analysis again implicated mean vancomycin serum trough concentration as a significant predictor of nephrotoxicity. Nephrotoxicity resolved in 81% (17/21) of cases evaluated. CONCLUSIONS a higher vancomycin serum trough concentration and prolonged vancomycin therapy are associated with an increased risk of nephrotoxicity. The decision to target increased vancomycin trough concentrations should be based on an assessment of the severity of the infection and must consider the nephrotoxicity risk associated with increased vancomycin levels.
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Candida bloodstream infections: comparison of species distributions and antifungal resistance patterns in community-onset and nosocomial isolates in the SENTRY Antimicrobial Surveillance Program, 2008-2009. Antimicrob Agents Chemother 2010; 55:561-6. [PMID: 21115790 DOI: 10.1128/aac.01079-10] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Community-onset (CO) candidemia, defined as a positive blood culture taken at or within 2 days of hospital admission, represents a distinct clinical entity associated with substantial morbidity and mortality. Reference MIC results from the SENTRY Antimicrobial Surveillance Program (2008-2009) were analyzed to compare the antifungal resistance patterns and species distributions from patients with CO and nosocomial bloodstream infections (BSI) in 79 medical centers. Among 1,354 episodes of BSI, 494 (36.5%) were classified as CO and 860 (63.5%) as nosocomial in origin. More than 95% of the isolates from both BSI types were contributed by Candida albicans (48.4%), C. glabrata (18.2%), C. parapsilosis (17.1%), C. tropicalis (10.6%), and C. krusei (2.0%). C. albicans was more common in CO BSI (51.0%) than nosocomial BSI (46.9%), whereas C. parapsilosis and C. krusei were more common in nosocomial BSIs (18.1 and 2.7%, respectively) than in CO BSIs (15.4 and 0.8%, respectively). C. glabrata and C. tropicalis were comparable in both CO (18.4 and 10.5%, respectively) and nosocomial (18.1 and 10.6%, respectively) episodes. Resistance to azoles (fluconazole, posaconazole, and voriconazole) and echinocandins (anidulafungin, caspofungin, and micafungin) was uncommon (<5%) in CO BSI using recently established Clinical and Laboratory Standards Institute breakpoint criteria. Resistance to echinocandins (anidulafungin [3.8%], caspofungin [5.1%], and micafungin [3.2%]) and azoles (fluconazole [7.7%], posaconazole [5.1%], and voriconazole [6.4%]) was most prevalent among nosocomial BSI isolates of C. glabrata. CO candidemia is not uncommon and appears to be increasing worldwide due to changing health care practices. Although resistance to the azoles and echinocandins remains uncommon among CO isolates, we demonstrate the emergence of nosocomial occurrences of C. glabrata expressing resistance to both monitored classes of antifungal agents.
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Pfaller MA, Mendes RE, Sader HS, Jones RN. Telavancin activity against Gram-positive bacteria isolated from respiratory tract specimens of patients with nosocomial pneumonia. J Antimicrob Chemother 2010; 65:2396-404. [DOI: 10.1093/jac/dkq335] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Napolitano LM. Perspectives in surgical infections: what does the future hold? Surg Infect (Larchmt) 2010; 11:111-23. [PMID: 20374004 DOI: 10.1089/sur.2010.9932] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109-0033, USA.
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Dryden M, Andrasevic AT, Bassetti M, Bouza E, Chastre J, Cornaglia G, Esposito S, French G, Giamarellou H, Gyssens IC, Nathwani D, Unal S, Voss A. A European survey of antibiotic management of methicillin-resistant Staphylococcus aureus infection: current clinical opinion and practice. Clin Microbiol Infect 2010; 16 Suppl 1:3-30. [PMID: 20222890 DOI: 10.1111/j.1469-0691.2010.03135.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Although the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) varies across Europe, healthcare-associated MRSA infections are common in many countries. Despite several national guidelines, the approach to treatment of MRSA infections varies across the continent, and there are multiple areas of management uncertainty for which there is little clinical evidence to guide practice. A faculty, convened to explore some of these areas, devised a survey that was used to compare the perspectives of infection specialists from across Europe on the management of MRSA infections with those of the faculty specialists. The survey instrument, a web-based questionnaire, was sent to 3840 registered delegates of the 19th European Congress of Clinical Microbiology and Infectious Diseases, held in April 2009. Of the 501 (13%) respondents to the survey, 84% were infection/microbiology specialists and 80% were from Europe. This article reports the survey results from European respondents, and shows a broad range of opinion and practice on a variety of issues pertaining to the management of minor and serious MRSA infections, such as pneumonia, bacteraemia, and skin and soft tissue infections. The issues include changing epidemiology, when and when not to treat, choice of treatment, and duration and route of treatment. The survey identified areas where practice can be improved and where further research is needed, and also identified areas of pan-European consensus of opinion that could be applied to European guidelines for the management of MRSA infection.
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Affiliation(s)
- M Dryden
- Department of Microbiology and Communicable Diseases, Royal Hampshire County Hospital, Winchester, UK.
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Micek ST, Hoban AP, Pham V, Doherty JA, Zilberberg MD, Shorr AF, Kollef MH. Bacteremia Increases the Risk of Death among Patients with Soft-Tissue Infections. Surg Infect (Larchmt) 2010; 11:169-76. [DOI: 10.1089/sur.2009.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Scott T. Micek
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Alex P. Hoban
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Victor Pham
- BJC Health Care, Center for Health Care Quality and Effectiveness, St. Louis, Missouri
| | - Joshua A. Doherty
- BJC Health Care, Center for Health Care Quality and Effectiveness, St. Louis, Missouri
| | - Marya D. Zilberberg
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts
| | | | - Marin H. Kollef
- Pulmonary and Critical Care Division, Washington University School of Medicine, St. Louis, Missouri
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Abstract
The incidence of invasive mycoses is increasing, especially among patients who are immunocompromised or hospitalized with serious underlying diseases. Such infections may be broken into two broad categories: opportunistic and endemic. The most important agents of the opportunistic mycoses are Candida spp., Cryptococcus neoformans, Pneumocystis jirovecii, and Aspergillus spp. (although the list of potential pathogens is ever expanding); while the most commonly encountered endemic mycoses are due to Histoplasma capsulatum, Coccidioides immitis/posadasii, and Blastomyces dermatitidis. This review discusses the epidemiologic profiles of these invasive mycoses in North America, as well as risk factors for infection, and the pathogens' antifungal susceptibility.
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Hunter PA, Dawson S, French GL, Goossens H, Hawkey PM, Kuijper EJ, Nathwani D, Taylor DJ, Teale CJ, Warren RE, Wilcox MH, Woodford N, Wulf MW, Piddock LJV. Antimicrobial-resistant pathogens in animals and man: prescribing, practices and policies. J Antimicrob Chemother 2010; 65 Suppl 1:i3-17. [DOI: 10.1093/jac/dkp433] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Phenotypic and Genotypic Analyses of Methicillin-Resistant Staphylococcus aureus Isolates from a Community Hospital. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2009. [DOI: 10.1097/ipc.0b013e3181ab2c75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shorr AF, Tabak YP, Johannes RS, Sun X, Spalding J, Kollef MH. Candidemia on presentation to the hospital: development and validation of a risk score. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R156. [PMID: 19788756 PMCID: PMC2784380 DOI: 10.1186/cc8110] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 08/26/2009] [Accepted: 09/29/2009] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Candidemia results in substantial morbidity and mortality, especially if initial antifungal therapy is delayed or is inappropriate; however, candidemia is difficult to diagnose because of its nonspecific presentation. METHODS To develop a risk score for identifying hospitalized patients with candidemia, we performed a retrospective analysis of a large database of 176 acute-care hospitals in the United States. We studied 64,019 patients with bloodstream infection (BSI) on presentation from 2000 through 2005 (derivation cohort) and 24,685 from 2006 to 2007 (validation cohort). We used recursive partitioning (RPART) to identify the best discriminators for Candida as the cause of BSI. We compared three sets of models (equal-weight, unequal-weight, vs full model with additional variables from logistic regression model) for sensitivity analysis. RESULTS The RPART identified 6 variables as the best discriminators: age < 65 years, temperature <or= 98 degrees F or severe altered mental status, cachexia, previous hospitalization within 30 days, admitted from other healthcare facility, and need for mechanical ventilation. The prevalence for patients presented with 0 through 6 risk factors in the derivation cohort was 28.7%, 38.8%, 21.8%, 8.3%, 2.1%, 0.3%, and < 0.1% respectively. The corresponding candidemia rates were 0.4% (69/18,355), 0.8% (196/24,811), 1.6% (229/13,984), 3.2% (168/5,330), 4.2% (58/1,371), 9.6% (15/157), and 27.3% (3/11) respectively (P < 0.0001). Findings were similar in the validation cohort (P < 0.0001). The equal-weight risk score model, which signed 1 point to each risk factor, yielded good discrimination in both cohorts with areas under the receiver operating curve (AUROCs) of 0.70 versus 0.71 (derivation versus validation). AUROC values were similar for the unequal-weight model, which signed different weight to each risk factor based on multivariable logistic regression coefficient, (AUROCs, 0.70-0.72). Both equal-weight and unequal-weight models were well calibrated (all Hosmer-Lemshow P > 0.10, indicating predicted and observed candidemia rates did not differ significant across the 7 risk stratus). The full model with 16 risk factors had slightly higher AUROCs (0.74 versus 0.73 for derivation versus validation); however, 7 variables were no longer significant in the recalibrated model for the validation cohort, indicating that the additional items did not materially enhance the model. CONCLUSIONS A simple equal-weight risk score differentiated patients' risk for candidemia in a graded fashion upon hospital presentation.
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Affiliation(s)
- Andrew F Shorr
- Pulmonary and Critical Care Medicine Service, Washington Hospital Center, Washington, DC 20010, USA.
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Nathwani D. New antibiotics for the management of complicated skin and soft tissue infections: are they any better? Int J Antimicrob Agents 2009; 34 Suppl 1:S24-9. [DOI: 10.1016/s0924-8579(09)70546-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, Micek ST, Kollef MH. The importance of fluid management in acute lung injury secondary to septic shock. Chest 2009; 136:102-109. [PMID: 19318675 DOI: 10.1378/chest.08-2706] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Recent studies have suggested that early goal-directed resuscitation of patients with septic shock and conservative fluid management of patients with acute lung injury (ALI) can improve outcomes. Because these may be seen as potentially conflicting practices, we set out to determine the influence of fluid management on the outcomes of patients with septic shock complicated by ALI. METHODS A retrospective analysis was performed at Barnes-Jewish Hospital (St. Louis, MO) and in the medical ICU of Mayo Medical Center (Rochester, MN). Patients hospitalized with septic shock were enrolled into the study if they met the American-European Consensus definition of ALI within 72 h of septic shock onset. Adequate initial fluid resuscitation (AIFR) was defined as the administration of an initial fluid bolus of >or= 20 mL/kg prior to and achievement of a central venous pressure of >or= 8 mm Hg within 6 h after the onset of therapy with vasopressors. Conservative late fluid management (CLFM) was defined as even-to-negative fluid balance measured on at least 2 consecutive days during the first 7 days after septic shock onset. RESULTS The study cohort was made up of 212 patients with ALI complicating septic shock. Hospital mortality was statistically lowest for those achieving both AIFR and CLFM and higher for those achieving only CLFM, those achieving only AIFR, and those achieving neither (17 of 93 patients [18.3%] vs 13 of 31 patients [41.9%] vs 30 of 53 patients [56.6%] vs 27 of 35 [77.1%], respectively; p < 0.001). CONCLUSIONS Both early and late fluid management of septic shock complicated by ALI can influence patient outcomes.
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Affiliation(s)
| | - Garrett E Schramm
- Barnes-Jewish Hospital, St. Louis, MO; Hospital Pharmacy Services, Mayo Clinic, Rochester, MN
| | - Joshua A Doherty
- Medical Informatics, BJC Healthcare, St. Louis, MO, Washington University School of Medicine, St. Louis, MO
| | - Richard M Reichley
- Medical Informatics, BJC Healthcare, St. Louis, MO, Washington University School of Medicine, St. Louis, MO
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Bekele Afessa
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.
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