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Carpenter L, Miller S, Flynn E, Choo JM, Collins J, Shoubridge AP, Gordon D, Lynn DJ, Whitehead C, Leong LEX, Ivey KL, Wesselingh SL, Inacio MC, Crotty M, Papanicolas LE, Taylor SL, Rogers GB. Exposure to doxycycline increases risk of carrying a broad range of enteric antimicrobial resistance determinants in an elderly cohort. J Infect 2024; 89:106243. [PMID: 39142392 DOI: 10.1016/j.jinf.2024.106243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 08/04/2024] [Accepted: 08/05/2024] [Indexed: 08/16/2024]
Abstract
OBJECTIVES High rates of antibiotic prescription in residential aged care are likely to promote enteric carriage of antibiotic-resistant pathogens and increase the risk of antibiotic treatment failure. Despite their importance, relationships between antibiotic exposures and patterns of enteric resistance carriage in this population remain poorly understood. METHODS We conducted a cross-sectional metagenomic cohort analysis of stool samples from residents of five long-term aged-care facilities in South Australia. Taxonomic composition was determined, and enteric carriage of antibiotic resistance genes (ARGs) was identified and quantified against the Comprehensive Antibiotic Resistance Database. Both the detection and abundance of stool taxa and ARGs were related to antibiotic exposures up to 12 months prior. Factors associated with the abundance of ARGs of high clinical concern were identified. RESULTS Stool samples were provided by 164 participants (median age: 88 years, IQR 81-93; 72% female). Sixty-one percent (n = 100) of participants were prescribed antibiotics at least once in the prior 12 months (median prescriptions: 4, range: 1-52), most commonly a penicillin (n = 55, 33.5%), cephalosporin (n = 53, 32.3%), diaminopyrimidine (trimethoprim) (n = 36, 22%), or tetracycline (doxycycline) (n = 21, 12.8%). More than 1100 unique ARGs, conferring resistance to 38 antibiotic classes, were identified, including 20 ARGs of high clinical concern. Multivariate logistic regression showed doxycycline exposure to be the greatest risk factor for high ARG abundance (adjusted odds ratio [aOR]=14.8, q<0.001) and a significant contributor to inter-class selection, particularly for ARGs relating to penicillins (aOR=3.1, q=0.0004) and cephalosporins (aOR=3.4, q=0.003). High enteric ARG abundance was associated with the number of separate antibiotic exposures (aOR: 6.4, q<0.001), exposures within the prior 30 days (aOR: 4.6, q=0.008) and prior 30-100 days (aOR: 2.6, q=0.008), high duration of antibiotic exposure (aOR: 7.9, q<0.001), and exposure to 3 or more antibiotic classes (aOR: 7.4, q<0.001). Carriage of one or more ARGs of high clinical concern was identified in 99% of participants (n = 162, median: 3, IQR: 2-4), involving 11 ARGs conferring resistance to aminoglycosides, four to beta-lactams, one to glycopeptides, three to fluoroquinolones, and one to oxazolidinones. Carriage of ARGs of high clinical concern was positively associated with exposure to doxycycline (aminoglycoside, fluoroquinolone, and oxazolidinone ARGs) and trimethoprim (fluoroquinolone and beta-lactam ARGs). Analysis of doxycycline impact on microbiota composition suggested that observed resistome changes arose principally through direct ARG selection, rather than through the antibiotic depletion of sensitive bacterial populations. CONCLUSIONS The gut microbiome of aged care residents is a major reservoir of antibiotic resistance. As a critical antibiotic in medical practice, a comprehensive understanding of the impact of doxycycline exposure on the gut resistome is paramount for informed antibiotic use, particularly in an evolving landscape of prophylactic applications. Near-universal asymptomatic carriage of clinically critical resistance determinants is highly concerning and reinforces the urgent need for improved management of antibiotic use in long-term aged care.
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Affiliation(s)
- Lucy Carpenter
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Sophie Miller
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Erin Flynn
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; SA Pathology, SA Health, Adelaide, SA, Australia
| | - Jocelyn M Choo
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Josephine Collins
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Andrew P Shoubridge
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - David Gordon
- SA Pathology, SA Health, Adelaide, SA, Australia; Department of Microbiology and Infectious Diseases, Flinders Medical Centre, Bedford Park, SA, Australia
| | - David J Lynn
- Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia; Computational & Systems Biology Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Craig Whitehead
- Department of Rehabilitation, Aged and Palliative Care, Flinders Medical Centre, Flinders University, Bedford Park, SA, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | | | - Kerry L Ivey
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Steve L Wesselingh
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Maria C Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Allied Health and Human Performance, University of South Australia, Adelaide, SA, Australia
| | - Maria Crotty
- Department of Rehabilitation, Aged and Palliative Care, Flinders Medical Centre, Flinders University, Bedford Park, SA, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Lito E Papanicolas
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia; SA Pathology, SA Health, Adelaide, SA, Australia
| | - Steven L Taylor
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Geraint B Rogers
- Microbiome and Host Health Program, South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Infection and Immunity, Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia.
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2
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Nierenberg NE, Levine JM. Infectious Aspects of Chronic Wounds. Clin Geriatr Med 2024; 40:471-480. [PMID: 38960538 DOI: 10.1016/j.cger.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
The treatment, maintenance, and suppression of infection in chronic wounds remain a challenge to all practitioners. From an infectious disease standpoint, knowing when a chronic wound has progressed from colonized to infected, when to use systemic antimicrobial therapy and when and how to culture such wounds can be daunting. With few standardized clinical guidelines for infections in chronic wounds, caring for them is an art form. However, there have been notable advances in the diagnosis, treatment, and management of infected wounds. This article will discuss the pathophysiology of infection in older adults, including specific infections such as cutaneous candidiasis, necrotizing soft tissue infection, osteomyelitis, and infections involving hardware.
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Affiliation(s)
- Natalie E Nierenberg
- Wound Care, Department of Infectious Diseases, Tufts Medical Center, Boston, MA 02111, USA
| | - Jeffrey M Levine
- Icahn School of Medicine at Mount Sinai, New York, NY 10010, USA.
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3
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Hossain MJ, Azad AK, Shahid MSB, Shahjahan M, Ferdous J. Prevalence, antibiotic resistance pattern for bacteriuria from patients with urinary tract infections. Health Sci Rep 2024; 7:e2039. [PMID: 38617042 PMCID: PMC11009458 DOI: 10.1002/hsr2.2039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/09/2024] [Accepted: 03/26/2024] [Indexed: 04/16/2024] Open
Abstract
Background and Aims Antibiotic resistance presents a significant global public health challenge, particularly for urinary tract infections (UTIs), and is notably severe in developing countries. Surveillance of the antimicrobial susceptibility patterns of UTI-causing bacteria is crucial for effective treatment selection. This study aimed to analyze these patterns in bacteria isolated from the urine samples of patients at Mughda Medical College Hospital, Dhaka, Bangladesh. Methods A retrospective study (January 2019 to December 2020) at Mugdha Medical College and Hospital, Dhaka, examined clinical and laboratory data from patients with positive urine cultures (≥105 CFU/mL). The study classified patients into four age groups: children (1-<18 years), young adults (18-<33 years), middle-aged adults (33-50 years), and old adults (>50 years). The standard Kirby-Bauer method was used to assess antibiotic sensitivity to 28 common antibiotics. Results Among 243 positive urine cultures in both community- and hospital-acquired UTIs, Escherichia coli was the most common uropathogen (65.84%), followed by Klebsiella spp. (12.34%), Enterococcus spp. (8.23%), and other types of bacteria. Conclusion Old adults are particularly vulnerable to UTIs, with E. coli being the predominant causative agent in the study region. The observed antimicrobial resistance patterns underscore the necessity of judicious antibiotic selection to effectively treat UTIs across different age groups.
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Affiliation(s)
- Md. Jubayer Hossain
- Population Health Studies Division, Center for Health Innovation, ResearchAction, and Learning – Bangladesh (CHIRAL Bangladesh)DhakaBangladesh
| | - Abul Kalam Azad
- Department of MicrobiologyJagannath UniversityDhakaBangladesh
| | - Md. Shahadat Bin Shahid
- Population Health Studies Division, Center for Health Innovation, ResearchAction, and Learning – Bangladesh (CHIRAL Bangladesh)DhakaBangladesh
- Department of MicrobiologyJagannath UniversityDhakaBangladesh
| | - Muhibullah Shahjahan
- Population Health Studies Division, Center for Health Innovation, ResearchAction, and Learning – Bangladesh (CHIRAL Bangladesh)DhakaBangladesh
- Department of MicrobiologyJagannath UniversityDhakaBangladesh
| | - Jannatul Ferdous
- Department of Transfusion MedicineMugdha Medical College and HospitalDhakaBangladesh
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Ibarz M, Haas LEM, Ceccato A, Artigas A. The critically ill older patient with sepsis: a narrative review. Ann Intensive Care 2024; 14:6. [PMID: 38200360 PMCID: PMC10781658 DOI: 10.1186/s13613-023-01233-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Sepsis is a significant public health concern, particularly affecting individuals above 70 years in developed countries. This is a crucial fact due to the increasing aging population, their heightened vulnerability to sepsis, and the associated high mortality rates. However, the morbidity and long-term outcomes are even more notable. While many patients respond well to timely and appropriate interventions, it is imperative to enhance efforts in identifying, documenting, preventing, and treating sepsis. Managing sepsis in older patients poses greater challenges and necessitates a comprehensive understanding of predisposing factors and a heightened suspicion for diagnosing infections and assessing the risk of sudden deterioration into sepsis. Despite age often being considered an independent risk factor for mortality and morbidity, recent research emphasizes the pivotal roles of frailty, disease severity, and comorbid conditions in influencing health outcomes. In addition, it is important to inquire about the patient's preferences and establish a personalized treatment plan that considers their potential for recovery with quality of life and functional outcomes. This review provides a summary of the most crucial aspects to consider when dealing with an old critically ill patient with sepsis.
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Affiliation(s)
- Mercedes Ibarz
- Department of Intensive Care Medicine, Hospital Universitari Sagrat Cor, Quirón Salud, Viladomat 288, 08029, Barcelona, Spain.
| | - Lenneke E M Haas
- Department of Intensive Care Medicine, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Adrián Ceccato
- Department of Intensive Care Medicine, Hospital Universitari Sagrat Cor, Quirón Salud, Viladomat 288, 08029, Barcelona, Spain
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporación Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporación Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
- Institut d'investigació i innovació Parc Tauli (I3PT-CERCA), Sabadell, Spain
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5
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Quang HV, Nhung LTK, Thuy PTT, Quyen PC, Huy LB, Dung HS. Blood-Stream Infections: Causative Agents, Antibiotic Resistance and Associated Factors in Older Patients. Mater Sociomed 2024; 36:82-89. [PMID: 38590604 PMCID: PMC10999148 DOI: 10.5455/msm.2024.36.82-89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/25/2024] [Indexed: 04/10/2024] Open
Abstract
Background The rate of multi-drug antibiotic resistance in nosocomial bloodstream infections in elderly patients is increasing. This study examined the data for bloodstream infections to gain a better understanding of bacterial antibiotic resistance. Methods This was a retrospective study of 817 patients with the first positive blood culture between January 1, 2016 and December 31, 2019. Results Moyen's age was 77.4 ± 9.8 years, male (52.4%) and SOFA 5.0 ± 4. ESBL(+) rate was 78/817 (9.5%). ESBL(+) rate for Escherichia coli and Klebsiella pneumoniae was 69/141 (48.9%) and 9/52 (17.3%), respectively. The most common isolates were Escherichia coli (17.3%), Stenotrophomonas maltophilia (13.7%), and Staphylococcus species (23.1%). The rate of septic shock and mortality accounted for 22.3% and 28.9%, respectively. Escherichia coli is highly sensitive to carbapenem, and resistant (>50%) with quinolone and aminoside. Klebsiella pneumoniae and Pseudomonas aeruginosa were highly sensitive to carbapenem. Acinetobacter baumannii was resistant to meropenem (75%). Stenotrophomonas maltophilia was sensitive to quinolone (13.8 %), and highly resistant to remaining antibiotics. Methicillin-resistant Staphylococcus aureus had a low resistance rate for vancomycin, teicoplanin, and linezolid. Multivariate analysis showed that the significant factors associated with mortality were age >75; SOFA >7; respiratory infection; intensive care unit treatment and presentation with septic shock. Conclusion The mortality rate was still high, especially for antibiotic-resistant agents.
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Affiliation(s)
- Hoang-Van Quang
- Department of Internal Medicine, Medical Faculty, Nguyen Tat Thanh University, Ho Chi Minh City, Viet Nam
- ICU Department, Thong Nhat Hospital, Ho Chi Minh City, Viet Nam
| | - Le-Thi Kim Nhung
- Department of Internal Medicine, Medical Faculty, Nguyen Tat Thanh University, Ho Chi Minh City, Viet Nam
| | | | - Phan Chau Quyen
- ICU Department, Thong Nhat Hospital, Ho Chi Minh City, Viet Nam
| | - Le Bao Huy
- Department of Emergency Medicine, Thong Nhat Hospital, Ho Chi Minh City, Viet Nam
| | - Ho Si Dung
- ICU Department, Thong Nhat Hospital, Ho Chi Minh City, Viet Nam
- Department of Internal Medicine, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam
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Sharma A, Elligsen M, Daneman N, Lam PW. Patient predictors of pathogenic versus commensal Gram-positive bacilli organisms isolated from blood cultures. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e245. [PMID: 38156236 PMCID: PMC10753492 DOI: 10.1017/ash.2023.506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 12/30/2023]
Abstract
Objective Gram-positive bacilli represent a diverse species of bacteria that range from commensal flora to pathogens implicated in severe and life-threatening infection. Following the isolation of Gram-positive bacilli from blood cultures, the time to species identification may take upward of 24 hours, leaving clinicians to conjecture whether they may represent a contaminant (inadvertent inoculation of commensal flora) or pathogenic organism. In this study, we sought to identify patient variables that could help predict the isolation of contaminant versus pathogenic Gram-positive bacilli from blood cultures. Design Retrospective cohort study. Settings One quaternary academic medical center affiliated with the University of Toronto. Patients Adult inpatients were admitted to hospital over a 5-year period (May 2014 to December 2019). Methods A total of 260 unique Gram-positive bacilli blood culture results from adult inpatients were reviewed and analyzed in both a univariable and multivariable model. Results Malignancy (aOR 2.78, 95% CI 1.33-5.91, p = 0.007), point increments in the Quick Sepsis Related Organ Failure Assessment score for sepsis (aOR 2.25, 95% CI 1.50-3.47, p < 0.001), peptic ulcer disease (aOR 5.63, 95% CI 1.43-21.0, p = 0.01), and the receipt of immunosuppression prior to a blood culture draw (aOR 3.80, 95% CI 1.86-8.01, p < 0.001) were associated with an increased likelihood of speciating pathogenic Gram-positive bacilli from blood cultures such as Clostridium species and Listeria monocytogenes. Conclusion Such predictors can help supplement a clinician's assessment on determining when empirical therapy is indicated when faced with Gram-positive bacilli from blood cultures and may direct future stewardship interventions for responsible antimicrobial prescribing.
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Affiliation(s)
- Arjun Sharma
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nick Daneman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Philip W. Lam
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Aubert L. [Rules of good practice for the elderly]. SOINS. GERONTOLOGIE 2023; 28:13-18. [PMID: 37716775 DOI: 10.1016/j.sger.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
The treatment of infectious diseases in geriatric medicine is a complex subject. Diagnosis is often difficult, as is the correct indication for antibiotic therapy. To combat antibiotic resistance, we need to limit unnecessary antibiotic prescriptions and prevent the onset of bacterial infections, notably through vaccination.
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Affiliation(s)
- Lucie Aubert
- Université Paris-Saclay, Site Ambroise-Paré, Boulogne-Billancourt, France.
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Sanyaolu LN, Cooper E, Read B, Ahmed H, Lecky DM. Impact of Menopausal Status and Recurrent UTIs on Symptoms, Severity, and Daily Life: Findings from an Online Survey of Women Reporting a Recent UTI. Antibiotics (Basel) 2023; 12:1150. [PMID: 37508246 PMCID: PMC10376736 DOI: 10.3390/antibiotics12071150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/30/2023] Open
Abstract
Introduction: Current UKHSA UTI diagnostic guidance advises empirical antibiotics if two of the following symptoms are present: cloudy urine, dysuria, and new onset nocturia. Hormonal changes during menopause may impact UTI symptoms, and qualitative studies suggest women with recurrent UTIs may present with different UTI symptoms. This study aims to assess whether menopausal status and the presence of recurrent UTIs impact UTI symptoms in women. Methods: An e-survey was conducted between 13 March 2021 and 13 April 2021. Women aged 16 years or older with a history of a UTI in the last year were eligible for inclusion. We defined menopause as those aged 45-64 years; pre-menopause as those less than 45 years; and post-menopause as those 65 years and older. Recurrent UTIs were defined as three or more UTIs in the last year. The data were weighted to be representative of the UK population. Crude unadjusted and adjusted odds ratios were estimated using logistic regression. Results: In total, 1096 women reported a UTI in the last year. There were significant differences in UTI symptoms based on menopausal status and the presence of recurrent UTIs. Post-menopausal women self-reported more incontinence (OR 2.76, 95% CI 1.50,5.09), whereas menopausal women reported more nocturia. Women with recurrent UTIs reported less dysuria, more severe symptoms (OR 1.93 95% CI 1.37,2.73) and a greater impact on daily life (OR 1.68, 95% CI 1.19,2.37). Conclusions: This survey provides evidence that acute UTIs present differently based on menopausal status and in women with recurrent UTIs. It is important that healthcare professionals are aware of these differences when assessing women presenting with an acute UTI and, therefore, further research in this area is needed.
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Affiliation(s)
- Leigh N. Sanyaolu
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff CF14 4YS, UK;
| | - Emily Cooper
- Primary Care and Interventions Unit, UK Health Security Agency, Twyver House, Gloucester GL1 1DQ, UK; (E.C.); (B.R.); (D.M.L.)
| | - Brieze Read
- Primary Care and Interventions Unit, UK Health Security Agency, Twyver House, Gloucester GL1 1DQ, UK; (E.C.); (B.R.); (D.M.L.)
| | - Haroon Ahmed
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff CF14 4YS, UK;
| | - Donna M. Lecky
- Primary Care and Interventions Unit, UK Health Security Agency, Twyver House, Gloucester GL1 1DQ, UK; (E.C.); (B.R.); (D.M.L.)
- School of Medicine, Cardiff University, Cardiff CF14 4XN, UK
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Azzini AM, Be G, Naso L, Lambertenghi L, Salerno ND, Coledan I, Bazaj A, Mirandola M, Miotti J, Mazzaferri F, Accordini S, Lo Cascio G, Tacconelli E. Risk factors for colonization with multidrug-resistant Gram-negative bacteria and Clostridioides difficile in Long Term Care Facilities (LTCFs) residents: the evidence from 27 facilities in a high endemic setting. Front Cell Infect Microbiol 2023; 13:1155320. [PMID: 37377644 PMCID: PMC10292821 DOI: 10.3389/fcimb.2023.1155320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Residency in LTCFs increases the likelihood of colonization with multidrug resistant Gram-negative bacteria (MDR-GNB). We assessed the prevalence and risk factors for enteric colonization by III-generation cephalosporins-resistant and carbapenem-resistant (CR) GNB in a large group of LTCFs in a high endemic setting. We also assessed the prevalence and risk factors for C. difficile colonization. Methods A point prevalence survey with rectal screening (RS) was conducted in 27 LTCFs in north Italy. Epidemiological and clinical variables on the survey day, history of hospitalization and surgery within one year, and antibiotics within three months, were collected. The presence of III-generation cephalosporin resistant and CR GNB was assessed using a selective culture on chromogenic medium and PCR for carbapenemase detection. The presence of C. difficile was assessed using ELISA for GDH and RT-PCR to identify toxigenic strains. Multi-variable analyses were performed using two-level logistic regression models. Results In the study period 1947 RSs were performed. The prevalence of colonization by at least one GNB resistant to III-generation cephalosporin was 51% (E. coli 65%, K. pneumoniae 14% of isolates). The prevalence of colonization by CR GNB was 6%. 6% of all isolates (1150 strains) resulted in a carbapenem-resistant K. pneumoniae, and 3% in a carbapenem-resistant E. coli. KPC was the most frequent carbapenemase (73%) identified by PCR, followed by VIM (23%). The prevalence of colonization by C. difficile was 11.7%. The presence of a medical device (OR 2.67) and previous antibiotic use (OR 1.48) were significantly associated with III-generation cephalosporin resistant GNB colonization. The presence of a medical device (OR 2.67) and previous hospitalization (OR 1.80) were significantly associated with CR GNB. The presence of a medical device (OR 2.30) was significantly associated with C. difficile colonization. Main previously used antibiotic classes were fluoroquinolones (32% of previously treated subjects), III-generation cephalosporins (21%), and penicillins (19%). Conclusion Antimicrobial stewardship in LTCFs is a critical issue, being previous antibiotic treatment a risk factor for colonization by MDR-GNB. The prevalence of colonization by III-generation cephalosporin and CR GNB among LTCF residents also underlines the importance to adhere to hand hygiene indications, infection prevention and control measures, and environmental hygiene protocols, more achievable than rigorous contact precautions in this type of social setting.
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Affiliation(s)
- Anna Maria Azzini
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giorgia Be
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Disease Unit, Mater Salutis Hospital - ULSS 9 Scaligera, Legnago, Italy
| | - Laura Naso
- Microbiology and Virology Unit, AOUI Verona, Verona, Italy
| | - Lorenza Lambertenghi
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nicola Duccio Salerno
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Ilaria Coledan
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- SerT Suzzara, SC Ser.D. Mantova, ASST Mantova, Suzzara, Italy
| | - Alda Bazaj
- Microbiology Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Massimo Mirandola
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jessica Miotti
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Simone Accordini
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giuliana Lo Cascio
- Microbiology and Virology Unit, AOUI Verona, Verona, Italy
- Microbiology Unit, AUSL Piacenza, Piacenza, Italy
| | - Evelina Tacconelli
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Abstract
PURPOSE OF REVIEW To highlight the peculiarity of skin and soft tissue infections (SSTIs) in elderly patients and to provide useful elements for their optimal management. RECENT FINDINGS In the COVID-19 era, early discharge from the hospital and implementation of outpatient management is of key importance. SUMMARY Elderly patients are at high risk of SSTIs due to several factors, including presence of multiple comorbidities and skin factors predisposing to infections. Clinical presentation may be atypical and some signs of severity, such as fever and increase in C-reactive protein, may be absent or aspecific in this patients population. An appropriate diagnosis of SSTIs in the elderly is crucial to avoid antibiotic overtreatment. Further studies should explore factors associated with bacterial superinfections in patients with pressure ulcers or lower limb erythema. Since several risk factors for methicillin-resistant Staphylococcus aureus (MRSA) may coexist in elderly patients, these subjects should be carefully screened for MRSA risk factors and those with high risk of resistant etiology should receive early antibiotic therapy active against MRSA. Physicians should aim to several objectives, including clinical cure, patient safety, early discharge and return to community. SSTIs in the elderly may be managed using long-acting antibiotics, but clinical follow-up is needed.
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Affiliation(s)
- Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
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Al Bastaki NA, Sheek-Hussein M, Shukla A, Al-Bluwi N, Saddik B. An Evaluation of Non-Communicable Diseases and Risk Factors Associated with COVID-19 Disease Severity in Dubai, United Arab Emirates: An Observational Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14381. [PMID: 36361255 PMCID: PMC9659060 DOI: 10.3390/ijerph192114381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/27/2022] [Accepted: 10/29/2022] [Indexed: 06/16/2023]
Abstract
The aim of this study was to determine the prevalence of non-communicable diseases and their correlation with COVID-19 disease severity among patients infected in Dubai. Clinical and demographic data were extracted from hospital records of 34,687 COVID-19 patients who visited or were admitted into Dubai hospitals between 28 January 2020 and 30 September 2020. Prevalence of co-morbidities in COVID-19 patients were assessed. The main risk factors associated with COVID-19 disease severity were also identified using three regression models. All co-morbidities were significantly associated with COVID-19 severity in the bivariate analysis (p-value ≤ 0.05) except for vitamin-D deficiency and chronic lower respiratory diseases. Patients with ischemic heart diseases (AOR: 2.08; 95% CI: 1.37, 3.15), pulmonary and other heart diseases (AOR: 2.13; 95% CI: 1.36, 3.32) and chronic kidney diseases (AOR: 1.81; 95% CI: 1.01, 3.25) had higher odds of severe COVID-19 symptoms. Suffering from multiple co-morbidities increased the odds of developing severe COVID-19 symptoms substantially in comparison to having only one co-morbidity i.e., (AOR: 1.52; 95% CI 1.76-2.60) to (AOR: 2.33; 95% CI: 1.37, 3.97). Identifying these risk factors could assist in the early recognition of high-risk populations and ensure the most appropriate preventive measures and required medical management during the pandemic.
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Affiliation(s)
| | - Mohamud Sheek-Hussein
- Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain P.O. Box 15551, United Arab Emirates
- School of Public Health, Loma Linda University, Loma Linda, CA 92354, USA
| | - Ankita Shukla
- Sharjah Institute for Medical and Health Sciences Research, University of Sharjah, Sharjah P.O. Box 27272, United Arab Emirates
| | - Najlaa Al-Bluwi
- Sharjah Institute for Medical and Health Sciences Research, University of Sharjah, Sharjah P.O. Box 27272, United Arab Emirates
| | - Basema Saddik
- Sharjah Institute for Medical and Health Sciences Research, University of Sharjah, Sharjah P.O. Box 27272, United Arab Emirates
- Department of Family and Community Medicine and Behavioural Sciences, College of Medicine, University of Sharjah, Sharjah P.O. Box 27272, United Arab Emirates
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Kiemde F, Compaore A, Koueta F, Some AM, Kabore B, Valia D, Rouamba T, Bocoum FY, Sawadogo S, Nana M, Some DY, Kone NA, Pagbeleguem V, Sangare I, Bere AW, Bonko MDA, Tougri G, Youl SY, Schallig H, Tinto H. Development and evaluation of an electronic algorithm using a combination of a two-step malaria RDT and other rapid diagnostic tools for the management of febrile illness in children under 5 attending outpatient facilities in Burkina Faso. Trials 2022; 23:779. [PMID: 36109766 PMCID: PMC9476427 DOI: 10.1186/s13063-022-06717-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background In Sub-Saharan Africa (SSA), febrile illnesses remain a major public health problem in children. However, the persistence of hrp2 antigen and the low sensitivity of pLDH RDT negatively affect antimalarials and antibiotics prescription practices. These limitations lead to poor management of febrile diseases and antimicrobial resistance (AMR). To improve the diagnosis of these febrile diseases and subsequent prescription of antimicrobials, it is hypothesized that the implementation of an algorithm including a two-step malaria RDT PfHRP2/pLDH supported by point-of-care (PoC) tests for bacterial infections could significantly improve the management of febrile diseases and thereby tackling AMR. Methods To assess the value of the proposed algorithm, an open-label randomized controlled trial with three arms, enrolling febrile children from 6 to 59 months is proposed. In the control arm, febrile children will be managed according to the Integrated Management of Childhood Illnesses (IMCI), which is part of the standard of care in Burkina Faso. Treatment will be done according to national guidelines. In the RDT decisional algorithm (RDT-DA) arm (intervention), the clinical examination based on IMIC will be supported by a two-step malaria RDT and bacterial infections RDTs. Prescription will be left to the discretion of the healthcare workers based on clinical examination and PoC test results. In the e-algorithm arm (intervention), artificial intelligence integrating multiple layers of clinical information such as clinical examination, signs/symptoms and medical history, and biological information such as biomarkers (CRP and WBC) and pathogen-specific PoC tests, and oximetry will be developed. The e-algorithm will serve to guide the diagnostic and management of febrile infections in children. In the 3 arms, the case report forms will be digitalized. A final follow-up visit (day 7) will be scheduled for all participants. Patients will be asked to come back to the health facilities before the scheduled visit if the symptoms persist or in case of health condition worsening. Discussion If successful, this study could contribute to improve the management of febrile diseases and reduce inappropriate use of antimicrobials. Trial registration The trial is registered at ClinicalTrial.gov, NCT05285657. Enrolment started on 4 March 2022 with long-term outcome being assessed completely by 2023.
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Latour K, De Lepeleire J, Catry B, Buntinx F. Nursing home residents with suspected urinary tract infections: a diagnostic accuracy study. BMC Geriatr 2022; 22:187. [PMID: 35255822 PMCID: PMC8903673 DOI: 10.1186/s12877-022-02866-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 02/10/2022] [Indexed: 12/02/2022] Open
Abstract
Background Urinary tract infections (UTIs) are one of the most common infections in nursing homes (NHs). A high error rate of a UTI diagnosis based solely on clinical criteria is to be expected in older persons as they often present infections in an atypical way. A study was set up to assess the diagnostic value of signs/symptoms and urine dipstick testing in identifying UTIs in NH residents and to explore whether C-reactive protein (CRP) measured by point-of-care testing (POCT) can help in the diagnosis. Methods During a three month prospective multicentre study, urine sampling for culture, POCT CRP and urinary dipstick testing were performed in each NH resident with a suspected UTI. UTIs were defined according to Stone et al., i.e. criteria based upon the presence of a set of signs/symptoms and a positive urine culture. Results Eleven NHs and 1 263 residents participated. Sixteen out of 137 recorded UTI suspicions were confirmed. Acute dysuria (positive likelihood ratio (LR +): 7.56, 95% confidence interval (CI): 3.94–14.5) and acute suprapubic pain (LR + : 11.4, 95% CI: 3.58–35.9) were found to be significant predictors. The combined nitrite and leucocyte esterase urine dipstick test (one or both positive) had a 96.0% negative predictive value (95% CI: 80.5–99.3%). The sensitivity of a positive CRP test (≥ 5 mg/L) was 60.0% (95% CI: 32.3–83.7%). Antimicrobials were prescribed in 60.2% of suspected but unconfirmed UTIs and in 92.3% of confirmed UTIs. Conclusions Using a stringent definition, only 11.7% of our suspicions were confirmed. Besides acute dysuria and suprapubic pain, we were not able to prove that any other clinical sign/symptom or POCT CPR adds useful information to the UTI diagnosis. We confirmed the findings of earlier research that urine dipstick tests are useful in ruling out UTIs and identified a potential overuse of antimicrobials in our NH population. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-02866-2.
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Affiliation(s)
- Katrien Latour
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium. .,Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Boudewijn Catry
- Department of Epidemiology and Public Health, Sciensano, Brussels, Belgium.,Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Frank Buntinx
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Department of General Practice, Maastricht University, Maastricht, The Netherlands
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Partouche B, Pepin M, de Farcy PM, Kahn JE, Sawczynski B, Lechowski L, Teillet L, Barbot F, Herr M, Davido B. Persistent eosinopenia is associated with in-hospital mortality among older patients: unexpected prognostic value of a revisited biomarker. BMC Geriatr 2021; 21:557. [PMID: 34649512 PMCID: PMC8516088 DOI: 10.1186/s12877-021-02515-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/29/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Infection is one of the major causes of mortality and morbidity in older adults. Available biomarkers are not associated with prognosis in older patients. This study aimed to analyze the value of eosinopenia (eosinophil count< 100/mm3) as a prognosis marker among older patients with suspected or confirmed bacterial infection. Methods A retrospective study was performed from 1 January to 31 December 2018 among patients in a geriatrics ward suffering from a bacterial infection treated with antibiotics. Biomarker data including the eosinophil count, neutrophil count and C-reactive protein (CRP) were collected within 4 days after patient diagnosis. Persistent eosinopenia was defined as a consistent eosinophil count< 100/mm3 between Day 2 and Day 4. The association of biomarkers with 30-day hospital mortality in a multivariate analysis was assessed and their predictive ability using the area under the ROC curve (AUC) was compared. Results Our study included 197 patients with a mean age of 90 ± 6 years. A total of 36 patients (18%) died during their stay in hospital. The patients who died were more likely to have persistent eosinopenia in comparison to survivors (78% versus 34%, p < 0.001). In the multivariate analysis, persistent eosinopenia was associated with in-hospital mortality with an adjusted HR of 8.90 (95%CI 3.46–22.9). The AUC for eosinophil count, CRP and neutrophil count between Day 2 and Day 4 were 0.7650, 0.7130, and 0.698, respectively. Conclusion Persistent eosinopenia within 4 days of diagnosis of bacterial infection appeared to be a predictor of in-hospital mortality in older patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02515-0.
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Affiliation(s)
- Bethsabee Partouche
- Geriatrics Department, Paris-Saclay University, Versailles Saint Quentin en Yvelines University (UVSQ), AP-HP Ambroise Paré Hospital, 92100, Boulogne-Billancourt, France
| | - Marion Pepin
- Geriatrics Department, Paris-Saclay University, Versailles Saint Quentin en Yvelines University (UVSQ), AP-HP Ambroise Paré Hospital, 92100, Boulogne-Billancourt, France.,Paris-Saclay University, UVSQ, Inserm, CESP, Clinical Epidemiology, 92100, Boulogne Billancourt, France
| | - Pauline Mary de Farcy
- Geriatrics Department, Paris-Saclay University, UVSQ, AP-HP, Ste Périne Hospital, 75016, Paris, France
| | - Jean-Emmanuel Kahn
- Internal Medicine Department, Paris-Saclay University, UVSQ, AP-HP, Ambroise Paré Hospital, 92100, Boulogne-Billancourt, France
| | - Bruno Sawczynski
- Medical Information Department (DIM), Paris-Saclay University, AP-HP, Ambroise Paré Hospital, 92100, Boulogne-Billancourt, France
| | - Laurent Lechowski
- Geriatrics Department, Paris-Saclay University, UVSQ, AP-HP, Ste Périne Hospital, 75016, Paris, France
| | - Laurent Teillet
- Geriatrics Department, Paris-Saclay University, Versailles Saint Quentin en Yvelines University (UVSQ), AP-HP Ambroise Paré Hospital, 92100, Boulogne-Billancourt, France
| | - Frederic Barbot
- Paris-Saclay University, AP-HP, Raymond Poincaré Hospital, Clinical Investigation Center, Inserm (CIC 1429), 92380, Garches, France
| | - Marie Herr
- Epidemiology and Public Health Department, Paris-Saclay University, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology; AP-HP, Raymond-Poincaré Hospital, 92380, Garches, France
| | - Benjamin Davido
- Infectious and Tropical Disease Department, Paris-Saclay University, UVSQ, AP-HP, Raymond Poincaré Hospital, 92380, Garches, France.
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15
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Janke AT, Jain S, Hwang U, Rosenberg M, Biese K, Schneider S, Goyal P, Venkatesh AK. Emergency department visits for emergent conditions among older adults during the COVID-19 pandemic. J Am Geriatr Soc 2021; 69:1713-1721. [PMID: 33955546 PMCID: PMC8242842 DOI: 10.1111/jgs.17227] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/12/2021] [Accepted: 04/16/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND/OBJECTIVE Emergency department (ED) visits have declined while excess mortality, not attributable to COVID-19, has grown. It is not known whether older adults are accessing emergency care differently from their younger counterparts. Our objective was to determine patterns of ED visit counts for emergent conditions during the COVID-19 pandemic for older adults. DESIGN Retrospective, observational study. SETTING Observational analysis of ED sites enrolled in a national clinical quality registry. PARTICIPANTS One hundred and sixty-four ED sites in 33 states from January 1, 2019 to November 15, 2020. MAIN OUTCOME AND MEASURES We measured daily ED visit counts for acute myocardial infarction (AMI), stroke, sepsis, fall, and hip fracture, as well as deaths in the ED, by age categories. We estimated Poisson regression models comparing early and post-early pandemic periods (defined by the Centers for Disease Control and Prevention) to the pre-pandemic period. We report incident rate ratios to summarize changes in visit incidence. RESULTS For AMI, stroke, and sepsis, the older (75-84) and oldest old (85+ years) had the greatest decline in visit counts initially and the smallest recovery in the post-early pandemic periods. For falls, visits declined early and partially recovered uniformly across age categories. In contrast, hip fractures exhibited less change in visit rates across time periods. Deaths in the ED increased during the early pandemic period, but then fell and were persistently lower than baseline, especially for the older (75-84) and oldest old (85+ years). CONCLUSIONS The decline in ED visits for emergent conditions among older adults has been more pronounced and persistent than for younger patients, with fewer deaths in the ED. This is concerning given the greater prevalence and risk of poor outcomes for emergent conditions in this age group that are amenable to time-sensitive ED diagnosis and treatment, and may in part explain excess mortality during the COVID-19 era among older adults.
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Affiliation(s)
- Alexander T. Janke
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Snigdha Jain
- Section of Geriatrics and Section of Pulmonary, Critical Care and Sleep MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Ula Hwang
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
- Geriatrics Research, Education and Clinical CenterJames J. Peters VAMCBronxNew YorkUSA
| | - Mark Rosenberg
- St. Joseph's HealthPatersonNew JerseyUSA
- American College of Emergency PhysiciansIrvingTexasUSA
| | - Kevin Biese
- Department of Emergency MedicineUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | | | - Pawan Goyal
- American College of Emergency PhysiciansIrvingTexasUSA
| | - Arjun K. Venkatesh
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale University School of MedicineNew HavenConnecticutUSA
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16
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The association between four scoring systems and 30-day mortality among intensive care patients with sepsis: a cohort study. Sci Rep 2021; 11:11214. [PMID: 34045645 PMCID: PMC8159970 DOI: 10.1038/s41598-021-90806-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/18/2021] [Indexed: 12/28/2022] Open
Abstract
Several commonly used scoring systems (SOFA, SAPS II, LODS, and SIRS) are currently lacking large sample data to confirm the predictive value of 30-day mortality from sepsis, and their clinical net benefits of predicting mortality are still inconclusive. The baseline data, LODS score, SAPS II score, SIRS score, SOFA score, and 30-day prognosis of patients who met the diagnostic criteria of sepsis were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) intensive care unit (ICU) database. Receiver operating characteristic (ROC) curves and comparisons between the areas under the ROC curves (AUC) were conducted. Decision curve analysis (DCA) was performed to determine the net benefits between the four scoring systems and 30-day mortality of sepsis. For all cases in the cohort study, the AUC of LODS, SAPS II, SIRS, SOFA were 0.733, 0.787, 0.597, and 0.688, respectively. The differences between the scoring systems were statistically significant (all P-values < 0.0001), and stratified analyses (the elderly and non-elderly) also showed the superiority of SAPS II among the four systems. According to the DCA, the net benefit ranges in descending order were SAPS II, LODS, SOFA, and SIRS. For stratified analyses of the elderly or non-elderly groups, the results also showed that SAPS II had the most net benefit. Among the four commonly used scoring systems, the SAPS II score has the highest predictive value for 30-day mortality from sepsis, which is better than LODS, SIRS, and SOFA. The results of the DCA curves show that using the SAPS II score to predict the 30-day mortality of intensive care patients with sepsis to guide clinical applications may obtain the highest net benefit.
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17
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Mahmoud E, Abanamy R, Binawad E, Alhatmi H, Alzammam A, Habib A, Alturaifi D, Alharbi A, Alqahtani H, Aldohayan M. Infections and patterns of antibiotic utilization in support and comfort care patients: A tertiary care center experience. J Infect Public Health 2021; 14:839-844. [PMID: 34118733 DOI: 10.1016/j.jiph.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/07/2021] [Accepted: 05/18/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Little is known regarding the burden of infections and clinical practice towards hospitalized patients with limits on life-sustaining measures. We aim to describe the infectious syndromes, clinical care, the emergence of multi-drug resistant organisms and outcomes in this population. PATIENTS AND METHODS Retrospective cohort of patients labeled as support or comfort care in a tertiary care center between 2016-2019. RESULTS A total of 347 patients were included with a mean age of 68.5 years, who were predominantly males (59.94%), bedbound (69.74%), on tube feeding (66.86%), and required indwelling urinary catheters (61.96%). The total number of admissions during the first year was 498, with the mean length of stay being 30 days. The number of infectious syndromes identified during that period was 821episodes, with a mean of 2 infectious syndromes per admission. The most common infection identified was pneumonia (41.66%) followed by urinary tract infections (27.16%). A total of 3891 microbiological cultures were taken with a mean of 5 cultures per infectious syndrome. The most commonly identified pathogens were Gram-negative bacteria (61.03%), with a high rate of multidrug-resistant organisms (MDROs) (48.53%). The one-year mortality was 86.4%. Using carbapenem antibiotic and pneumonia were the independent predictors used for the MDROs. CONCLUSION Our study reflects the high burden of infections, antimicrobial resistance, and hospital admissions among a population with limited life expectancy. A consensus regarding investigating and managing of infectious syndromes, and antimicrobial prescription is needed to reduce the harms associated with overuse of antimicrobials.
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Affiliation(s)
- Ebrahim Mahmoud
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.
| | - Reem Abanamy
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Eman Binawad
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hind Alhatmi
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ali Alzammam
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Abdulrahman Habib
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Dana Alturaifi
- Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Alharbi
- Division of Infectious Diseases, Department of Medicine, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hajar Alqahtani
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Aldohayan
- Department of Health Informatics, CPHHI, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Data and Business Intelligence Management Department, ISID, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Prospective Surveillance of Healthcare-Associated Infections in Residents in Four Long-Term Care Facilities in Graz, Austria. Antibiotics (Basel) 2021; 10:antibiotics10050544. [PMID: 34067175 PMCID: PMC8151996 DOI: 10.3390/antibiotics10050544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/04/2021] [Accepted: 05/04/2021] [Indexed: 12/05/2022] Open
Abstract
Healthcare-associated infections (HCAI) are a common cause for residents’ mortality and morbidity associated with a significant socio-economic burden. Data on HCAIs in Austrian long-term care facilities are scare. Therefore, we evaluated the incidence rate of HCAIs per 1000 resident days in four LTC facilities in Graz, Austria, characterized the spectrum of HCAIs and the use of antimicrobial substances. We conducted a prospective surveillance study from 1 January to 31 December 2018 in four LTCFs of the Geriatric Health Centre of the City of Graz (total of 388 beds). Nursing staff collected data on HCAIs once a week using an electronic reporting system. During the 12-month surveillance period, 252 infections of 165 residents were recorded. The overall incidence rate of HCAIs was 2.1 per 1000 resident days. Urinary tract infections were the most commonly recorded HCAIs (49%, 124/252, 1.03 per 1000 resident days), followed by skin and soft tissue infections and respiratory tract infections. Beta-lactams (ATC class J01C) were prescribed most frequently (63/212), followed by fluoroquinolones (J01M; 54/212). In conclusion, the overall incidence rate for HCAIs was relatively low at 2.1 per 1000 resident days. Our real-life data can serve as a basis for future antimicrobial stewardship and infection prevention interventions.
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19
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Atypical Presentation of Bacteremic Urinary Tract Infection in Older Patients: Frequency and Prognostic Impact. Diagnostics (Basel) 2021; 11:diagnostics11030523. [PMID: 33804271 PMCID: PMC8001488 DOI: 10.3390/diagnostics11030523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
In older patients, urinary tract infection (UTI) often has an atypical clinical presentation, making its diagnosis difficult. We aimed to describe the clinical presentation in older inpatients with UTI-related bacteremia and to determine the prognostic impact of atypical presentation. This cohort study included all consecutive patients older than 75 years hospitalized in a university hospital in 2019 with a UTI-related gram-negative bacillus (GNB) bacteremia, defined by blood and urine cultures positive for the same GNB, and followed up for 90 days. Patients with typical symptoms of UTI were compared to patients with atypical forms. Among 3865 inpatients over 75 with GNB-positive urine culture over the inclusion period, 105 patients (2.7%) with bacteremic UTI were included (mean age 85.3 ± 5.9, 61.9% female). Among them, UTI symptoms were reported in only 38 patients (36.2%) and 44 patients (41.9%) had no fever on initial management. Initial diagnosis of UTI was made in only 58% of patient. Mortality at 90 days was 23.6%. After adjustment for confounders, hyperthermia (HR = 0.37; IC95 (0.14–0.97)) and early UTI diagnosis (HR = 0.35; IC95 (0.13–0.94)) were associated with lower mortality, while UTI symptoms were not associated with prognosis. In conclusion, only one third of older patients with UTI developing bacteremia had UTI symptoms. However, early UTI diagnosis was associated with better survival.
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20
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de Laroche M, Fellous L, Salomon E, Saadeh D, Duran C, Bouchand F, Lequintrec JL, Teillet L, Gaillard JL, Seridi Z, Michelon H, Dinh A. Bloodstream infections in older population: epidemiology, outcome, and impact of multidrug resistance. Eur J Clin Microbiol Infect Dis 2021; 40:1665-1672. [PMID: 33694038 DOI: 10.1007/s10096-021-04212-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
Bloodstream infections (BSIs) among older patients are frequent with high rate of mortality. Infections with multidrug-resistant organisms (MDRO) are associated with higher mortality than with susceptible microorganisms. We aimed to evaluate the prevalence of MDRO infection during BSI in older population and the factors associated with unfavorable outcome. This study is a retrospective cohort of all BSI episodes occurring among older patients (> 65yo), from April 1, 2010, to December 31, 2016, in a French university hospital for geriatric medicine. A total of 255 BSI episodes were analyzed. Mean age was 86.3±6.5 years, and sex ratio (M/F) was 0.96. Main comorbidities were orthopedic device (26.7%), active neoplasia (24.3%), and diabetes mellitus (18.4%). Main primary sites of infection were urinary tract infections (56.9%), respiratory tract infections (10.6%), intra-abdominal infections (7.1%), and skin and soft tissue infections (4.7%). Main bacteria identified were Escherichia coli (45.1%), Staphylococcus aureus (14.1%), enterococci (10.7%), coagulase-negative staphylococci (CoNS) (5.5%), and streptococci (5.1%). MDROs were involved in 17.2% of BSI (gram-negative bacilli: 9.0%; CoNS: 4.3%; and methicillin-resistant S. aureus (MRSA): 3.9%). The main factor associated with MDRO BSI was colonization with MDRO (OR=6.29; 95%CI=2.9-14.32). Total mortality was 18.4% and significantly higher in case of initial severity (OR=3.83; 95%CI=1.75-8.38), healthcare-associated infection (OR=5.29; 95%CI=1.11-25.30), and MRSA BSI (OR=9.16; 95%CI=1.67-50.16). BSI due to MDRO is frequent in older population and is strongly associated with carriage of MDRO. Healthcare-associated BSI, severe episodes, and BSI due to MRSA are associated with unfavorable outcome. In these cases, a broad-spectrum antibiotic should be promptly initiated.
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Affiliation(s)
- Marine de Laroche
- Internal Medicine Department, Ambroise-Paré University Hospital, AP-HP Paris Saclay University, Boulogne-Billancourt, France
| | - Lesly Fellous
- Pharmacy Department, Sainte-Périne Hospital, AP-HP Paris Saclay University, Paris, France
| | - Elsa Salomon
- Microbiology Laboratory, Ambroise-Paré University Hospital, AP-HP Paris Saclay University, Boulogne-Billancourt, France
| | - Danielle Saadeh
- Faculty of Public Health, Lebanese University, Beirut, Lebanon
| | - Clara Duran
- Internal Medicine Department, Ambroise-Paré University Hospital, AP-HP Paris Saclay University, Boulogne-Billancourt, France
| | - Frédérique Bouchand
- Pharmacy Department, Raymond-Poincaré University Hospital, AP-HP Paris Saclay University, Garches, France
| | - Jean-Laurent Lequintrec
- Geriatric Medicine Department, Sainte-Périne Hospital, AP-HP Paris Saclay University, Paris, France
| | - Laurent Teillet
- Geriatric Medicine Department, Sainte-Périne Hospital, AP-HP Paris Saclay University, Paris, France.,Geriatric Medicine Department, Ambroise-Paré University Hospital, AP-HP Paris Saclay University, Boulogne-Billancourt, France
| | - Jean-Louis Gaillard
- Microbiology Laboratory, Ambroise-Paré University Hospital, AP-HP Paris Saclay University, Boulogne-Billancourt, France
| | - Zineb Seridi
- Geriatric Medicine Department, Sainte-Périne Hospital, AP-HP Paris Saclay University, Paris, France
| | - Hugues Michelon
- Pharmacy Department, Sainte-Périne Hospital, AP-HP Paris Saclay University, Paris, France.,Pharmacy Department, Raymond-Poincaré University Hospital, AP-HP Paris Saclay University, Garches, France
| | - Aurélien Dinh
- Internal Medicine Department, Ambroise-Paré University Hospital, AP-HP Paris Saclay University, Boulogne-Billancourt, France. .,Infectious Diseases Unit, Raymond-Poincaré University Hospital, AP-HP Paris Saclay University, 104 Bd R. Poincaré, 92380, Garches, France.
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21
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Schoevaerdts D, Sibille FX, Gavazzi G. Infections in the older population: what do we know? Aging Clin Exp Res 2021; 33:689-701. [PMID: 31656032 DOI: 10.1007/s40520-019-01375-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/04/2019] [Indexed: 12/20/2022]
Abstract
The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.
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Affiliation(s)
- Didier Schoevaerdts
- Geriatric Department, CHU UCL Namur, Site Godinne, Avenue Dr. Gaston Thérasse, 1, B-5530, Yvoir, Belgium.
| | - François-Xavier Sibille
- Geriatric Department, CHU UCL Namur, Site Godinne, Avenue Dr. Gaston Thérasse, 1, B-5530, Yvoir, Belgium
| | - Gaetan Gavazzi
- Geriatric Department, CHU UCL Namur, Site Godinne, Avenue Dr. Gaston Thérasse, 1, B-5530, Yvoir, Belgium
- Service Gériatrie Clinique, Centre Hospitalo-Universitaire Grenoble-Alpes, Avenue Central 621, 38400, Saint-Martin-d'Hères, France
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22
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Reliability of nonlocalizing signs and symptoms as indicators of the presence of infection in nursing-home residents. Infect Control Hosp Epidemiol 2020; 43:417-426. [PMID: 33292915 DOI: 10.1017/ice.2020.1282] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Antibiotics are among the most common medications prescribed in nursing homes. The annual prevalence of antibiotic use in residents of nursing homes ranges from 47% to 79%, and more than half of antibiotic courses initiated in nursing-home settings are unnecessary or prescribed inappropriately (wrong drug, dose, or duration). Inappropriate antibiotic use is associated with a variety of negative consequences including Clostridioides difficile infection (CDI), adverse drug effects, drug-drug interactions, and antimicrobial resistance. In response to this problem, public health authorities have called for efforts to improve the quality of antibiotic prescribing in nursing homes.
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23
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Wang S, Ruan WQ, Yu Z, Zhao X, Chen ZX, Li Q. Validity of presepsin for the diagnosis and prognosis of sepsis in elderly patients admitted to the Intensive Care Unit. Minerva Anestesiol 2020; 86:1170-1179. [DOI: 10.23736/s0375-9393.20.13661-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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24
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Avelino-Silva TJ, Steinman MA. Diagnostic discrepancies between emergency department admissions and hospital discharges among older adults: secondary analysis on a population-based survey. SAO PAULO MED J 2020; 138:359-367. [PMID: 32935740 PMCID: PMC9673862 DOI: 10.1590/1516-3180.0471.r1.05032020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/05/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Older adults frequently experience nonspecific clinical features. However, there is limited evidence on how often admission diagnoses for hospitalized older patients are incorrect, potentially leading to treatment delays. OBJECTIVES To determine the consistency between hospital admission and discharge diagnoses, and identify factors associated with diagnostic discrepancies in older adults. DESIGN AND SETTING Population-based cohort study in the United States. We included adults aged ≥ 18 years who were admitted from emergency departments (EDs) to hospitals, identified using the 2005-2010 National Hospital Ambulatory Medical Survey, a nationally representative survey. METHODS Three admission diagnoses and the principal discharge diagnosis were captured and classified as discrepant if they involved considerably different conditions within the same organ system, or different organ systems altogether. RESULTS Each year, 12 million adults were hospitalized following ED visits in the United States; 45% were aged ≥ 65 years. These patients' mean age was 79 years and 58% were women. Diagnostic discrepancies between admission and discharge were more common among adults ≥ 65 years (12.5 versus 8.3%; P < 0.001). Certain admission diagnoses had particularly high rates of diagnostic discrepancies: 26-27% of patients presenting with mental disorders or with endocrine and metabolic diseases had substantial diagnostic discrepancies between admission and discharge. Substantial diagnostic discrepancy was independently associated with longer hospitalization and higher in-hospital mortality. CONCLUSION One out of eight older adults hospitalized from EDs was discharged with a principal diagnosis differing considerably from the admission diagnosis. Given that missed or delayed diagnoses are a critical safety problem, clinicians should be vigilant and frequently cogitate alternative diagnostic possibilities.
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Affiliation(s)
- Thiago Junqueira Avelino-Silva
- MD, PhD. Physician and Adjunct Professor, Division of Geriatrics, Department of Internal Medicine, Hospital das Clinicas (HC), Faculdade de Medicina FMUSP, Universidade de São Paulo; Vice-Director, Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Division of Geriatrics, Hospital das Clinicas, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo (SP), Brazil.
| | - Michael Alan Steinman
- MD. Physician and Professor of Medicine, Division of Geriatrics, Department of Medicine, University of California San Francisco (UCSF), San Francisco (CA), United States; Professor of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco (CA), United States.
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25
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Kurtaran B, Kuscu F, Korkmaz P, Ozdemir B, Inan D, Oztoprak N, Ozatag DM, Daglı O, Birengel S, Ozdemir K. A snapshot of geriatric infections in Turkey: ratio of geriatric inpatients in hospitals and evaluation of their infectious diseases: A multicenter point prevalence study. Int J Infect Dis 2020; 100:337-342. [PMID: 32835788 DOI: 10.1016/j.ijid.2020.08.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The human population is aging at an astonishing rate. The aim of this study is to capture a situation snapshot revealing the proportion of individuals aged 65 years and over among inpatients in healthcare institutions in Turkey and the prevalence and type of infections in this patient group in order to draw a road map. MATERIALS AND METHODS Hospitalized patients over 65 years at any of the 62 hospitals in 29 cities across Turkey on February 9, 2017 were included in the study. Web-based SurveyMonkey was used for data recording and evaluation system. RESULTS Of 17,351 patients 5871 (33.8%) were ≥65 years old. The mean age was 75.1±7.2 years; 3075 (52.4%) patients were male. Infection was reason for admission for 1556 (26.5%) patients. Pneumonia was the most common infection. The median length of hospital stay was 5 days (IQR: 2-11 days). The Antibiotic therapy was initiated for 2917 (49.7%) patients at the time of admission, and 23% of the antibiotics prescribed were inappropriate. Healthcare-associated infections developed in 1059 (18%) patients. Urinary catheters were placed in 2388 (40.7%) patients with 7.5% invalid indication. CONCLUSION This study used real data to reveal the proportion of elderly patients in hospital admissions. The interventions done, infections developed during hospitalization, length of hospital stay, and excessive drug load emphasize the significant impact on health costs and illustrate the importance of preventive medicine in this group of patients.
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Affiliation(s)
- Behice Kurtaran
- Cukurova University, Faculty of Medicine, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Ferit Kuscu
- Cukurova University, Faculty of Medicine, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Pinar Korkmaz
- Dumlupınar University, Kutahya Evliya Celebi Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Burcu Ozdemir
- Ankara Numune Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Dilara Inan
- AkdenizUniversity, Faculty of Medicine, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Nefise Oztoprak
- Antalya Training and Research Hospital,Infectious Diseases and Clinical Microbiology, Turkey.
| | - Duru Mistanoglu Ozatag
- Dumlupınar University, Kutahya Evliya Celebi Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Ozgur Daglı
- Bursa Yüksek İhtisas Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Serhat Birengel
- AnkaraUniversity, Faculty of Medicine, İbn-i Sina Hospital, Infectious Diseases and Clinical Microbiology, Turkey.
| | - Kevser Ozdemir
- Pamukkale University, Faculty of Medicine, Infectious Diseases and Clinical Microbiology, Turkey.
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26
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Rawson TM, Hernandez B, Moore LSP, Blandy O, Herrero P, Gilchrist M, Gordon A, Toumazou C, Sriskandan S, Georgiou P, Holmes AH. Supervised machine learning for the prediction of infection on admission to hospital: a prospective observational cohort study. J Antimicrob Chemother 2020; 74:1108-1115. [PMID: 30590545 DOI: 10.1093/jac/dky514] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 10/11/2018] [Accepted: 11/14/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Infection diagnosis can be challenging, relying on clinical judgement and non-specific markers of infection. We evaluated a supervised machine learning (SML) algorithm for diagnosing bacterial infection using routinely available blood parameters on presentation to hospital. METHODS An SML algorithm was developed to classify cases into infection versus no infection using microbiology records and six available blood parameters (C-reactive protein, white cell count, bilirubin, creatinine, ALT and alkaline phosphatase) from 160203 individuals. A cohort of patients admitted to hospital over a 6 month period had their admission blood parameters prospectively inputted into the SML algorithm. They were prospectively followed up from admission to classify those who fulfilled clinical case criteria for a community-acquired bacterial infection within 72 h of admission using a pre-determined definition. Predictive ability was assessed using receiver operating characteristics (ROC) with cut-off values for optimal sensitivity and specificity explored. RESULTS One hundred and four individuals were included prospectively. The median (range) cohort age was 65 (21-98) years. The majority were female (56/104; 54%). Thirty-six (35%) were diagnosed with infection in the first 72 h of admission. Overall, 44/104 (42%) individuals had microbiological investigations performed. Treatment was prescribed for 33/36 (92%) of infected individuals and 4/68 (6%) of those with no identifiable bacterial infection. Mean (SD) likelihood estimates for those with and without infection were significantly different. The infection group had a likelihood of 0.80 (0.09) and the non-infection group 0.50 (0.29) (P < 0.01; 95% CI: 0.20-0.40). ROC AUC was 0.84 (95% CI: 0.76-0.91). CONCLUSIONS An SML algorithm was able to diagnose infection in individuals presenting to hospital using routinely available blood parameters.
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Affiliation(s)
- T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - B Hernandez
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - L S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - O Blandy
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK
| | - P Herrero
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - M Gilchrist
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - A Gordon
- Section of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, South Kensington Campus, London, UK
| | - C Toumazou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - S Sriskandan
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
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Walker SAN, Bannerman H, Ma N, Peragine C, Elligsen M, Palmay L, Williams E, Liu B. Development and validation of a screening tool for early identification of bloodstream infection in older patients - a retrospective case-control study. BMC Geriatr 2020; 20:6. [PMID: 31900110 PMCID: PMC6942330 DOI: 10.1186/s12877-019-1402-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 12/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed diagnosis of bloodstream infection (BSI) occurs in > 20% of older patients, with misdiagnosis in 35%. Our objective was to develop and validate a clinically useful screening tool to identify older patients with a high probability of having a BSI. METHODS Hospitalized patients > 80 years old with BSI (n = 105/group) were evaluated for the tool development in this retrospective matched case-controlled study (learn cohort). The tool was validated in different retrospectively matched case and control patients > 80 years old (n = 120/group) and 65 to 79 years old (n = 250/group) (test cohort). Binary logistic regression was used to develop a screening tool using laboratory and clinical parameters that were significantly associated with BSI (P < 0.05; adjusted odds ratio (OR) > 1); and Classification and Regression Tree (CART) analysis was used to identify parameter breakpoints. Performance metrics were used to evaluate and validate the tool. RESULTS The significant parameters associated with BSI were maximum temperature (Tmax)(> 37.55C)(OR = 42.575), neutrophils (> 7.95)(OR = 1.923), a change in level of consciousness (LOC) (Yes = 1, No = 0)(OR = 1.571), blood urea nitrogen (BUN)(> 10.05)(OR = 1.359), glucose (> 7.35)(OR = 1.167), albumin (< 33.5)(OR = 1.038) and alanine aminotransferase (ALT) (> 19.5)(OR = 1.005). The optimal screening tool [Ln (odds of BSI) = - 150.299 + 3.751(Tmax) + 0.654(neutrophils) + 0.452(change in LOC) + 0.307(BUN) + 0.154(glucose) + 0.038(albumin) + 0.005(ALT)] had favorable performance metrics in the learn and test cohorts (sensitivity, specificity and accuracy of 95% in the learn cohort and 77, 89, and 81% in the total test cohort); and performed better than using only temperature and neutrophil count. CONCLUSIONS The validated tool had high predictive value which may improve early identification and management of BSI in older patients.
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Affiliation(s)
- Sandra A. N. Walker
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada ,0000 0001 2157 2938grid.17063.33Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Heather Bannerman
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Nathan Ma
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada ,0000 0001 2157 2938grid.17063.33Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Christine Peragine
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada ,0000 0001 2157 2938grid.17063.33Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Marion Elligsen
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Lesley Palmay
- 0000 0000 9743 1587grid.413104.3Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada
| | - Evelyn Williams
- 0000 0000 9743 1587grid.413104.3Division Long-Term Care, Sunnybrook Health Sciences Centre, Toronto, Canada ,0000 0001 2157 2938grid.17063.33Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Barbara Liu
- 0000 0000 9743 1587grid.413104.3Division Long-Term Care, Sunnybrook Health Sciences Centre, Toronto, Canada ,0000 0001 2157 2938grid.17063.33Faculty of Medicine, University of Toronto, Toronto, Canada
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Chou HC, Huang CT, Sheng WH. Differential roles of comorbidity burden and functional status in elderly and non-elderly patients with infections in general wards. J Formos Med Assoc 2019; 119:821-828. [PMID: 31521468 DOI: 10.1016/j.jfma.2019.08.032] [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: 06/28/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Differential roles of comorbidity burden, functional status and severity of illness in elderly and non-elderly patients admitted to general wards with infections in terms of short-term and long-term mortality remain poorly understood and worth further investigation. METHODS From 2011 to 2013, patients admitted to general wards with a main diagnosis of infections were included and their Barthel index, Charlson comorbidity index and Pitt bacteremia score were collected to evaluate their association with in-hospital and 1-year outcomes of the study cohort. Age stratification was applied for all outcome analysis. RESULTS A total of 2481 patients were identified, with main diagnoses of pneumonia (57%), urinary tract infection (28%) and intra-abdominal infection (18%). In-hospital mortality occurred in 291 (12%) of the population and was independently predicted by Barthel index ≤50 (odds ratio [OR] 5.67 and 2.73, respectively) and Charlson comorbidity index >2 (OR 1.49 and 2.87, respectively) in both elderly and non-elderly patients. Among 2190 hospital survivors, Barthel index ≤50 (hazard ratio [HR] 1.38) and Charlson comorbidity index >2 (HR 1.96) were associated with a higher hazard of 1-year mortality in elderly patients. However, only Charlson comorbidity index >2 (HR 2.87) was a significant characteristic of non-elderly patients to be correlated with higher 1-year mortality. CONCLUSION This study found that functional status on admission was predictive of in-hospital mortality of general patients with infections irrespective of age groups; however, it played a differential role in 1-year mortality in between elderly and non-elderly patients, emphasizing the importance of functional assessment among the elderly.
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Affiliation(s)
- Hsiao-Chen Chou
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Ta Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan.
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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29
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De Freitas G, Gudur A, Vela-Ortiz M, Jodelka J, Livert D, Krishnamurthy M. Where there is sodium there may be sepsis. J Community Hosp Intern Med Perspect 2019; 9:296-299. [PMID: 31528275 PMCID: PMC6735289 DOI: 10.1080/20009666.2019.1634407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/17/2019] [Indexed: 11/14/2022] Open
Abstract
Hypernatremia affects up to 9% of critically ill patients upon hospital admission, especially in elderly patients with thirst impairment. However, hypernatremia is not entirely explained by fluid imbalance. Recent studies suggest that sodium is an important enhancer of the immune system, raising the question of whether inflammatory states such as sepsis may contribute to hypernatremia. Although sepsis patients with hypernatremia face a greater mortality rate, there is a lack of studies examining a potential association between hypernatremia and sepsis. Motivated by the frequent concurrence of hypernatremia and sepsis observed at an eastern Pennsylvanian community hospital, the current study was conducted to evaluate whether hypernatremia on admission may serve as a potential surrogate marker for sepsis. The medical records of 153 patients with hypernatremia on admission (serum sodium > 145mEq/L) were retrospectively analyzed. The mean age of patients was 81.1. Sepsis was observed in 77.1% of patients, of which 86.2% had dementia. This study demonstrated a positive correlation between hypernatremia on admission and the presence of sepsis. We suggest that the existence of hypernatremia should prompt clinicians to further investigate for sources of infection, especially in the elderly and patients with dementia.
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Affiliation(s)
| | - Anuragh Gudur
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Jacek Jodelka
- St. Luke's University Hospital, Fountain Hill, PA, USA
| | - David Livert
- Internal Medicine, Easton Hospital, Easton, PA, USA.,Drexel University College of Medicine, Philadelphia, PA, USA
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30
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Seth-Smith HMB, Egli A. Whole Genome Sequencing for Surveillance of Diphtheria in Low Incidence Settings. Front Public Health 2019; 7:235. [PMID: 31497588 PMCID: PMC6713046 DOI: 10.3389/fpubh.2019.00235] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/06/2019] [Indexed: 12/29/2022] Open
Abstract
Corynebacterium diphtheriae (C. diphtheriae) is a relatively rare pathogen in most Western countries. While toxin producing strains can cause pharyngeal diphtheria with potentially fatal outcomes, the more common presentation is wound infections. The diphtheria toxin is encoded on a prophage and can also be carried by Corynebacterium ulcerans and Corynebacterium pseudotuberculosis. Currently, across Europe, infections are mainly diagnosed in travelers and refugees from regions where diphtheria is more endemic, patients from urban areas with poor hygiene, and intravenous drug users. About half of the cases are non-toxin producing isolates. Rapid identification of the bacterial pathogen and toxin production is a critical element of patient and outbreak management. Beside the immediate clinical management of the patient, public health agencies should be informed of toxigenic C. diphtheriae diagnoses as soon as possible. The collection of case-related epidemiological data from the patient is often challenging due to language barriers and social circumstances. However, information on patient contacts, vaccine status and travel/refugee route, where appropriate, is critical, and should be documented. In addition, isolates should be characterized using high resolution typing, in order to identify transmissions and outbreaks. In recent years, whole genome sequencing (WGS) has become the gold standard of high-resolution typing methods, allowing detailed investigations of pathogen transmissions. De-centralized sequencing strategies with redundancy in sequencing capacities, followed by data exchange may be a valuable future option, especially since WGS becomes more available and portable. In this context, the sharing of sequence data, using public available platforms, is essential. A close interaction between microbiology laboratories, treating physicians, refugee centers, social workers, and public health officials is a key element in successful management of suspected outbreaks. Analyzing bacterial isolates at reference centers may further help to provide more specialized microbiological techniques and to standardize information, but this is also more time consuming during an outbreak. Centralized communication strategies between public health agencies and laboratories helps considerably in establishing and coordinating effective surveillance and infection control. We review the current literature on high-resolution typing of C. diphtheriae and share our own experience with the coordination of a Swiss-German outbreak.
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Affiliation(s)
- Helena M. B. Seth-Smith
- Division of Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
- Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
- SIB Swiss Institute of Bioinformatics, Basel, Switzerland
| | - Adrian Egli
- Division of Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
- Applied Microbiology Research, Department of Biomedicine, University of Basel, Basel, Switzerland
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Saeed K, González Del Castillo J, Backous C, Drevet S, Ferrer R, Gavazzi G, Gluck E, Jensen JU, Kanizsai P, Ruiz-Rodríguez JC, Molnar G, Fazakas J, Umpleby H, Townsend J, Schuetz P. Hot topics on procalcitonin use in clinical practice, can it help antibiotic stewardship? Int J Antimicrob Agents 2019; 54:686-696. [PMID: 31369813 DOI: 10.1016/j.ijantimicag.2019.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/12/2019] [Accepted: 07/21/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Kordo Saeed
- Hampshire Hospitals NHS Foundation Trust and University of Southampton, UK.
| | - Juan González Del Castillo
- Emergency Department, Instituto de Investigación Sanitaria (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Craig Backous
- Swedish Covenant Hospital, Finch University Health Sciences/ The Chicago Medical School, USA
| | - Sabine Drevet
- GREPI EA 7408 University of Grenoble-Alpes, and Geriatric department, University Hospital of Grenoble-Alpes, France
| | - Ricard Ferrer
- Intensive Care Department. Vall d'Hebron University Hospital. Barcelona, Spain & Shock, Organ Dysfunction and Resuscitation Research Group. Vall d'Hebron Institute of Research, Spain
| | - Gaëtan Gavazzi
- GREPI EA 7408 University of Grenoble-Alpes, and Geriatric department, University Hospital of Grenoble-Alpes, France
| | - Eric Gluck
- Swedish Covenant Hospital, Finch University Health Sciences/ The Chicago Medical School, USA
| | - Jens-Ulrik Jensen
- CHIP & PERSIMUNE, Department of Infectious Diseases, Rigshospitalet and University of Copenhagen, Denmark; Section for Respiratory Medicine, Department of Internal Medicine, Herlev-Gentofte Hospital, Hellerup, Denmark
| | | | - Juan Carlos Ruiz-Rodríguez
- Intensive Care Department. Vall d'Hebron University Hospital. Barcelona, Spain & Shock, Organ Dysfunction and Resuscitation Research Group. Vall d'Hebron Institute of Research, Spain
| | - Gyula Molnar
- Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Janos Fazakas
- Semmelweis University, Department of Transplant Surgery, Budapest, Hungary
| | | | - Jennifer Townsend
- Johns Hopkins University, Division of Infectious Diseases, Johns Hopkins Bayview Medical Center, USA
| | - Philipp Schuetz
- Kantonsspital Aarau, Internal Medicine, Aarau, Switzerland; University of Basel, Switzerland
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Impact of urinary tract infection on nursing and healthcare-associated pneumonia. J Infect Chemother 2019; 25:950-954. [PMID: 31196770 DOI: 10.1016/j.jiac.2019.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 11/24/2022]
Abstract
Nursing and healthcare-associated pneumonia (NHCAP), a concept of pneumonia proposed by the Japanese Respiratory Society, mostly occurs among elderly people in long-term care facilities. Similarly, the risk of urinary tract infection (UTI) also increases with age, with UTIs common among those in long-term care. Therefore, NHCAP is sometimes complicated by the presence of a UTI. However, pneumonia complicated by a UTI has not been clinically well characterized. We retrospectively analyzed 376 patients with NHCAP admitted to our hospital over a three-year period. Sixty-seven patients (17.8%) showed complications by a UTI. Patients with a UTI had lower renal function (higher blood urea nitrogen [P = 0.001], higher creatinine [P = 0.001]), lower systolic blood pressure (P = 0.04), higher A-DROP scores (P = 0.005) and higher positive blood culture rates (P = 0.03) than those without a UTI. Furthermore, based on urine, sputum and blood culture results, nearly half of the microorganisms (4/7) in blood cultures were identical with those of urine, suggesting that a concurrent UTI increases positive blood culture rates. Multivariate analysis showed that UTI was not an independent factor associated with 30-day mortality (P = 0.17), although patients with a UTI showed higher 30-day mortality (P = 0.04) than those without a UTI in univariate analysis. In summary, patients with NHCAP and a UTI were more prone to complications than those without a UTI, although UTI itself did not affect the prognosis of patients with NHCAP. A concurrent UTI had a negative impact on the severity of NHCAP.
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Perceptions of Antibiotic Therapy Among Nursing Home Residents: Perspectives of Caregivers and Residents in a Mixed Exploratory Study. Antibiotics (Basel) 2019; 8:antibiotics8020066. [PMID: 31137842 PMCID: PMC6627220 DOI: 10.3390/antibiotics8020066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 12/17/2022] Open
Abstract
Antimicrobial resistance is a major public health threat worldwide. Some authors have suggested that end-users of nursing homes have an influence on antibiotic prescribing. The objective of this study is to describe the views of end-users and professionals on residents' behavior towards antibiotic therapy in terms of knowledge, beliefs, and attitudes towards this drug class and its prescribing process. This is a concurrent mixed methodology study using questionnaires and semi-directive individual interviews with nursing homes residents, nurses, and doctors practicing in these facilities. The questionnaires analyzed were collected from 35 residents (24.3%) and 109 nurses (75.7%). The qualitative interview involved 26 of total participants that agreed to be interviewed. We noticed misconceptions being held by the residents regarding the antibiotic resistance phenomenon. Additionally, nurses were not considered as a source of information about antibiotics. Nurses and residents had conflicting opinions about residents requesting antibiotics, and the findings depict a stereotypical view of the nurse profession as a reflection of a cognitive representation. The authors conclude that, despite many campaigns, further efforts are needed to tackle antimicrobial resistance. Initiatives could include raising awareness about antimicrobial resistance, clarifying the role of nurses, and communicating well with residents about their needs in nursing homes.
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Seynaeve D, Augusseau-Rivière B, Couturier P, Morel-Baccard C, Landelle C, Bosson JL, Gavazzi G, Mallaret MR. Outbreak of Human Metapneumovirus in a Nursing Home: A Clinical Perspective. J Am Med Dir Assoc 2019; 21:104-109.e1. [PMID: 31101588 PMCID: PMC7105973 DOI: 10.1016/j.jamda.2019.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 01/26/2023]
Abstract
Objectives To describe a human metapneumovirus (hMPV) outbreak occurring in a nursing home for older adults and to identify the risk factors associated with the clinical infection. Design A retrospective, case-controlled study. Setting and participants A French nursing home for older adults between December 27, 2014 and January 20, 2015. Probable cases were residents presenting at least 1 respiratory symptom or 1 constitutional symptom. Confirmed cases identified in the same way as probable cases but with a positive RT-PCR test for hMPV. Controls were residents with no symptoms of respiratory infection. Measures Identification of hMPV was realized on nasal swab samples by RT-PCR. Results Seventy-eight older people were resident at the time of the outbreak. Three of the 4 tested were positive for hMPV by RT-PCR and negative for 13 other viruses or bacteria. All probable infected residents presented cough; other symptoms were scarcer. An inflammatory response was present, with median C-reactive protein at 50 mg/L. The median duration of the illness was 7 days. The rate of infection among residents was high (51%), with 5 hospitalizations (12.5%) and 1 death (2.5%). In multivariate analysis, vaccination against influenza virus appeared to emerge as associated with a probable hMPV infection, but this might be an artifact, as the proportion of unvaccinated residents was low (15%). A clear infected population profile was hard to define, although limited autonomy and low ADL score may play a role. Basic hygiene precautions were reinforced, but droplet precautions seemed difficult to apply rigorously to this population. Conclusions/Implications Clinical and biological presentations were nonspecific. The rate of infection was high, highlighting the need for the rapid introduction of strict precautions to contain the infection.
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Affiliation(s)
- Damien Seynaeve
- Service d'Hygiène Hospitalière et de Gestion des Risques, CHU Grenoble Alpes, Grenoble Cedex, France.
| | | | - Pascal Couturier
- Clinique Universitaire de Médecine Gériatrique, CHU Grenoble Alpes, Grenoble Cedex, France
| | | | - Caroline Landelle
- Service d'Hygiène Hospitalière et de Gestion des Risques, CHU Grenoble Alpes, Grenoble Cedex, France; Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble Cedex, France
| | - Jean-Luc Bosson
- Pôle de Santé Publique, CHU Grenoble Alpes, Grenoble Cedex, France; Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble Cedex, France
| | - Gaëtan Gavazzi
- Clinique Universitaire de Médecine Gériatrique, CHU Grenoble Alpes, Grenoble Cedex, France; Université Grenoble Alpes, GREPI EA 7408, Grenoble Cedex, France
| | - Marie-Reine Mallaret
- Service d'Hygiène Hospitalière et de Gestion des Risques, CHU Grenoble Alpes, Grenoble Cedex, France; Université Grenoble Alpes, CNRS, Grenoble INP, TIMC-IMAG, Grenoble Cedex, France
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Romano AD, Lo Buglio A, Bellanti F, Villani R, Serviddio G, Vendemiale G. Diagnostic reliability of the procalcitonin serum marker in septic frail patient. Aging Clin Exp Res 2019; 31:727-732. [PMID: 30132205 DOI: 10.1007/s40520-018-1020-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/03/2018] [Indexed: 02/05/2023]
Abstract
AIM Aging is associated with increased inflammation, particularly in frailty. Indeed, such patient presents increased serum inflammatory markers, such as C-reactive protein and interleukin-6. Interleukin-6 is an important stimulating factor for the production of procalcitonin. The aim of this study is to evaluate the diagnostic reliability of serum PCT in the diagnosis of sepsis in frail elderly patients. METHODS Using Fried's criteria for frailty, 140 older patients hospitalized for any cause were consecutively enrolled and divided in two groups: no-frail (60 patients) and frail (80 patients). Patients were further categorized on the basis of the presence/absence of sepsis. Interleukin-6, procalcitonin and inflammatory indices were sampled at hospital admission. RESULTS Septic patients from frail and no-frail groups showed higher values of interleukin-6 and procalcitonin. However, focusing on groups without sepsis, a statistically significant difference of interleukin-6 and procalcitonin values among frail and no-frail groups was seen at the post-hoc analysis. In frail group, procalcitonin cut-off of 0.5 ng/ml had a sensibility and specificity, respectively, of 100 and 22%. Through receiver operating characteristic curve (ROC) analysis, we found that procalcitonin serum value of 1.4 ng/ml had better sensibility and specificity (respectively, 93.8 and 84.4%, AUC 0.965). CONCLUSIONS In our study, we confirm the diagnostic reliability of procalcitonin in frail elderly patients for the diagnosis of sepsis. We found that 1.4 ng/ml was the best cut-off in this population.
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Affiliation(s)
- Antonino Davide Romano
- Department of Medical and Surgical Sciences, Ce.R.M.I.-Centre for Aging Research, University of Foggia, Viale Pinto 1, 71121, Foggia, Italy.
| | - Aurelio Lo Buglio
- Department of Medical and Surgical Sciences, Ce.R.M.I.-Centre for Aging Research, University of Foggia, Viale Pinto 1, 71121, Foggia, Italy
| | - Francesco Bellanti
- Department of Medical and Surgical Sciences, Ce.R.M.I.-Centre for Aging Research, University of Foggia, Viale Pinto 1, 71121, Foggia, Italy
| | - Rosanna Villani
- Department of Medical and Surgical Sciences, Ce.R.M.I.-Centre for Aging Research, University of Foggia, Viale Pinto 1, 71121, Foggia, Italy
| | - Gaetano Serviddio
- Department of Medical and Surgical Sciences, Ce.R.M.I.-Centre for Aging Research, University of Foggia, Viale Pinto 1, 71121, Foggia, Italy
| | - Gianluigi Vendemiale
- Department of Medical and Surgical Sciences, Ce.R.M.I.-Centre for Aging Research, University of Foggia, Viale Pinto 1, 71121, Foggia, Italy
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Ordóñez-Mena JM, Fanshawe TR, McCartney D, Shine B, Van den Bruel A, Lasserson D, Hayward G. C-reactive protein and neutrophil count laboratory test requests from primary care: what is the demand and would substitution by point-of-care technology be viable? J Clin Pathol 2019; 72:474-481. [PMID: 30992343 DOI: 10.1136/jclinpath-2018-205688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/05/2019] [Accepted: 04/03/2019] [Indexed: 11/04/2022]
Abstract
AIMS : C-reactive protein (CRP) and neutrophil count (NC) are important diagnostic indicators of inflammation. Point-of-care (POC) technologies for these markers are available but rarely used in community settings in the UK. To inform the potential for POC tests, it is necessary to understand the demand for testing. We aimed to describe the frequency of CRP and NC test requests from primary care to central laboratory services, describe variability between practices and assess the relationship between the tests. METHODS We described the number of patients with either or both laboratory tests, and the volume of testing per individual and per practice, in a retrospective cohort of all adults in general practices in Oxfordshire, 2014-2016. RESULTS 372 017 CRP and 776 581 NC tests in 160 883 and 275 093 patients, respectively, were requested from 69 practices. CRP was tested mainly in combination with NC, while the latter was more often tested alone. The median (IQR) of CRP and NC tests/person tested was 1 (1-2) and 2 (1-3), respectively. The median (IQR) tests/practice/week was 36 (22-52) and 72 (50-108), and per 1000 persons registered/practice/week was 4 (3-5) and 8 (7-9), respectively. The median (IQR) CRP and NC concentrations were 2.7 (0.9-7.9) mg/dL and 4.1 (3.1-5.5)×109/L, respectively. CONCLUSIONS The high demand for CRP and NC testing in the community, and the range of results falling within the reportable range for current POC technologies highlight the opportunity for laboratory testing to be supplemented by POC testing in general practice.
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Affiliation(s)
- José M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK .,NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David McCartney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian Shine
- Biochemistry, Oxford University Hospitals, Oxford, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,Academic Centre for Primary Care, KU Leuven, Leuven, Belgium
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Gbinigie OA, Ordóñez-Mena JM, Fanshawe T, Plüddemann A, Heneghan CJ. Limited evidence for diagnosing bacterial skin infections in older adults in primary care: systematic review. BMC Geriatr 2019; 19:45. [PMID: 30777025 PMCID: PMC6380032 DOI: 10.1186/s12877-019-1061-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/11/2019] [Indexed: 11/29/2022] Open
Abstract
Background Older adults with bacterial skin infections may present with atypical symptoms, making diagnosis difficult. There is limited authoritative guidance on how older adults in the community present with bacterial skin infections. To date there have been no systematic reviews assessing the diagnostic value of symptoms and signs in identifying bacterial skin infections in older adults in the community. Methods We searched Medline and Medline in process, Embase and Web of Science, from inception to September 2017. We included cohort and cross-sectional studies assessing the diagnostic accuracy of symptoms and signs in predicting bacterial skin infections in adults in primary care aged over 65 years. The QUADAS-2 tool was used to assess study quality. Results We identified two observational studies of low-moderate quality, with a total of 7991 participants, providing data to calculate the diagnostic accuracy of 5 unique symptoms in predicting bacterial skin infections. The presence of wounds [LR+: 7.93 (CI 4.81–13.1)], pressure sores [LR+: 4.85 (CI 2.18–10.8)] and skin ulcers [LR+: 6.26 (CI 5.49–7.13)] help to diagnose bacterial skin infections. The presence of urinary incontinence does not help to predict bacterial skin infections (LR + ‘s of 0.99 and 1.04; LR-‘s of 0.96 and 1.04). Conclusions Currently, there is insufficient evidence to inform the diagnosis of bacterial skin infections in older adults in the community; clinicians should therefore rely upon their clinical judgement and experience. Evidence from high quality primary care studies in older adults, including studies assessing symptoms traditionally associated with bacterial skin infections (e.g. erythema and warmth), is urgently needed to guide practice. Electronic supplementary material The online version of this article (10.1186/s12877-019-1061-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Oghenekome A Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - José M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Thomas Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Annette Plüddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Carl J Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Gbinigie OA, Ordóñez-Mena JM, Fanshawe TR, Plüddemann A, Heneghan C. Diagnostic value of symptoms and signs for identifying urinary tract infection in older adult outpatients: Systematic review and meta-analysis. J Infect 2018; 77:379-390. [PMID: 29964141 PMCID: PMC6203890 DOI: 10.1016/j.jinf.2018.06.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 06/22/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To critically appraise and evaluate the diagnostic value of symptoms and signs in identifying UTI in older adult outpatients, using evidence from observational studies. METHODS We searched Medline and Medline in process, Embase and Web of Science, from inception up to September 2017. We included studies assessing the diagnostic accuracy of symptoms and/or signs in predicting UTI in outpatients aged 65 years and above. Study quality was assessed using the QUADAS-2 tool. RESULTS We identified 15 eligible studies of variable quality, with a total of 12,039 participants (range 65-4259), and assessed the diagnostic accuracy of 66 different symptoms and signs in predicting UTI. A number of symptoms and signs typically associated with UTI, such as nocturia, urgency and abnormal vital signs, were of limited use in older adult outpatients. Inability to perform a number of acts of daily living were predictors of UTI: For example, disability in feeding oneself, + ve LR: 11.8 (95% CI 5.51-25.2) and disability in washing one's hands and face, + ve LR: 6.84 (95% CI 4.08-11.5). CONCLUSIONS The limited evidence of varying quality shows that a number of symptoms and signs traditionally associated with UTI may have limited diagnostic value in older adult outpatients.
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Affiliation(s)
- Oghenekome A Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, United Kingdom.
| | - José M Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, United Kingdom.
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, United Kingdom.
| | - Annette Plüddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, United Kingdom.
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, United Kingdom.
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Falcone M, Paul M, Yahav D, Orlando G, Tiseo G, Prendki V, Güerri-Fernández R, Gavazzi G, Mutters NT, Cookson B, Tinelli Marco M. Antimicrobial consumption and impact of antimicrobial stewardship programmes in long-term care facilities. Clin Microbiol Infect 2018; 25:562-569. [PMID: 30076978 DOI: 10.1016/j.cmi.2018.07.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/13/2018] [Accepted: 07/19/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Antimicrobials are among the most frequently prescribed drugs in long-term care facilities (LTCFs). Implementation of antimicrobial stewardship programmes (ASPs) is often challenging because of scarce data in this setting. OBJECTIVES This narrative review aimed to provide data about antibiotic consumption in LTCFs and the need, implementation, and organization of ASPs in this setting. SOURCE PubMed was searched for studies assessing antimicrobial consumption and implementation of ASPs in LTCFs. The search was restricted to articles published in English in the last 10 years. Experts belonging to the ESCMID Study Group for Infections in the Elderly (ESGIE) reviewed the selected studies and evaluated the studies on ASPs according to the GRADE approach. Moreover, the quality of reporting has been assessed according to TREND and CONSORT checklists for quasi-experimental and cluster randomized clinical trials (cRCT), respectively. CONTENT Data on antibiotic consumption in LTCFs show great variability in LTCFs across and within countries. Reasons for this variability are difficult to analyse because of the differences in the types of LTCFs, their organization, and the population cared-for in the different LTCFs. However, studies show that the use of antibiotics among elderly patients in LTCFs, especially in cases of asymptomatic bacteriuria and influenza-like syndromes, is often inappropriate. High-quality cRCTs and low to moderate quality quasi-experimental studies show that educational interventions direct at nurse and physicians are effective in reducing unnecessary antibiotic prescriptions. IMPLICATIONS There is an urgent need for ASPs tailored for LTCFs. Multifaceted organized educational interventions, involving both clinicians and nursing staff, should be advocated and require institutional intervention by health authorities. Future studies assessing the impact of well-defined ASPs in LTCFs should produce compelling evidence in this setting.
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Affiliation(s)
- M Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Italy.
| | - M Paul
- Infectious Diseases Institute, Rambam Health Care Campus, The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - D Yahav
- Infectious Diseases Unit, Rabin Medical Centre, Beilinson Hospital, Petah-Tikva, Israel
| | - G Orlando
- Clinic of Infectious Diseases, University Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - G Tiseo
- Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Rome, Italy
| | - V Prendki
- Internal Medicine and Rehabilitation Unit, Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - R Güerri-Fernández
- Infectious Diseases, Hospital Del Mar Medical Research Institute, Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - G Gavazzi
- University of Grenoble-Alpes and Clinic of Geriatrics, University Hospital of Grenoble-Alpes, Grenoble, France
| | - N T Mutters
- Institute for Infection Prevention and Hospital Epidemiology, Medical Centre - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - B Cookson
- Division of Infection and Immunity, University College London, Gower Street, London, WCl E 68T, UK
| | - M Tinelli Marco
- Long Term Care Facility "Pio Albergo Trivulzio", Milan, Italy
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Toyas Miazza C, Martínez-Álvarez RM, Díez-Manglano J, Ezpeleta Galindo AI, Laín Miranda ME, Aspiroz Sancho C. [Limitation of therapeutic effort in patients with bacteremia]. Rev Esp Geriatr Gerontol 2018; 53:262-267. [PMID: 29605450 DOI: 10.1016/j.regg.2018.02.005] [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: 10/02/2017] [Revised: 02/12/2018] [Accepted: 02/16/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The limitation of therapeutic effort (LTE) depends on medical, ethical and individual factors. We describe the characteristics of patients with bacteremia in which it was decided to limit the therapeutic effort. METHOD Prospective study of bacteremia in a community hospital in 2011. We collected information regarding patient variable (age, sex, Barthel index, comorbidities, Charlson Index and exogenous factors) as well as regarding the infectious episode (etiology, focus, place of adquisition, clinical expressivity, LTE and hospital mortality). The group in which LTE was performed was compared to the one that was not. RESULTS We collected 233 episodes of bacteremia in 227 patients. We performed LTE in 19 patients (8.2%). Patients with LTE were older (80.7 vs. 72.6 years, p=.014), had more comorbidity (Charlson index 4.6 vs. 2.1, p<.001 and most frequently were severe dependents (57.9% vs. 18.8%, p<.001). We found no association with sex, place of adquisition or clinical expressivity. The commonest clinical focus in patients with LTE was the urinary (42.1%) and there was a predominance of gram positive bacteria (63.2%). The empirical treatment was started early in 73.7% of cases. All patients except one died. CONCLUSION LTE is considered in an important number of patients with bacteremia. They usually are older, with more comorbidity and functional dependence, bad functional basal status and important comorbidity. Knowing their differential characteristics allow us to understand this decision.
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Affiliation(s)
- Carla Toyas Miazza
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - Rosa María Martínez-Álvarez
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Jesús Díez-Manglano
- Servicio de Mecicina Interna, Hospital Universitario Miguel Servet, Zaragoza, España
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Pollock N, Dhiman R, Daifalla N, Farhat M, Campos-Neto A. Discovery of a unique Mycobacterium tuberculosis protein through proteomic analysis of urine from patients with active tuberculosis. Microbes Infect 2018; 20:228-235. [PMID: 29306028 PMCID: PMC5946903 DOI: 10.1016/j.micinf.2017.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/06/2017] [Accepted: 12/15/2017] [Indexed: 11/29/2022]
Abstract
Identification of pathogen-specific biomarkers present in patients' serum or urine samples can be a useful diagnostic approach. In efforts to discover Mycobacterium tuberculosis (Mtb) biomarkers we identified by mass spectroscopy a unique 21-mer Mtb peptide sequence (VVLGLTVPGGVELLPGVALPR) present in the urines of TB patients from Zimbabwe. This peptide has 100% sequence homology with the protein TBCG_03312 from the C strain of Mtb (a clinical isolate identified in New York, NY, USA) and 95% sequence homology with Mtb oxidoreductase (MRGA423_21210) from the clinical isolate MTB423 (identified in Kerala, India). Alignment of the genes coding for these proteins show an insertion point mutation relative to Rv3368c of the reference H37Rv strain, which generated a unique C-terminus with no sequence homology with any other described protein. Phylogenetic analysis utilizing public sequence data shows that the insertion mutation is apparently a rare event. However, sera from TB patients from distinct geographical areas of the world (Peru, Vietnam, and South Africa) contain antibodies that recognize a purified recombinant C-terminus of the protein, thus suggesting a wider distribution of isolates that produce this protein.
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Affiliation(s)
- Nira Pollock
- Boston Children's Hospital and Harvard Medical School, Boston MA, USA
| | | | | | - Maha Farhat
- Harvard Medical School, and Massachusetts General Hospital, Boston, MA, USA
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Abstract
Identifying sources of infection and establishing source control is an essential component of the workup and treatment of sepsis. Investigation with history, physical examination, laboratory tests, and imaging can in identifying sources of infection. All organ systems have the potential to develop sources of infection. However, there are inherent difficulties presented by some that require additional diligence, namely, urinalysis, chest radiographs, and intraabdominal infections. Interventions include administration of antibiotics and may require surgical or other specialist intervention. This is highlighted by the Surviving Sepsis Campaign with specific recommendations for time to antibiotics and expeditious time to surgical source control.
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Affiliation(s)
- Zeke P Oliver
- Emergency Medicine, Department of Emergency Medicine, Carilion Clinic Virginia Tech School of Medicine, 1 Riverside Circle, 4th Floor, Roanoke, VA 24014, USA.
| | - Jack Perkins
- Emergency Medicine, Department of Emergency Medicine, Carilion Clinic Virginia Tech School of Medicine, 1 Riverside Circle, 4th Floor, Roanoke, VA 24014, USA
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Bacteraemic urinary tract infections may mimic respiratory infections: a nested case-control study. Eur J Clin Microbiol Infect Dis 2016; 35:1601-5. [PMID: 27272327 DOI: 10.1007/s10096-016-2697-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
Abstract
Daily practice suggests that respiratory signs may be observed in bacteraemic urinary infections (BUI). Our objective was to search for an association between the presence of respiratory symptoms and the bacteraemic nature of urinary tract infections (UTI). A nested case-control study was carried out based on our computerised dashboard from January 2011 to June 2015. Cases were defined as patients with a BUI due to Enterobacteriaceae species, identified in blood and urine cultures. Controls had fever and a positive urinary sample but sterile blood cultures (NBUI) and a final diagnosis of urinary infection. Patients from the BUI group were 1:1 matched to the NBUI group according to four parameters: age, gender, cardiovascular and pulmonary comorbid conditions. Subjects with cognitive impairment limiting clinical accuracy and those with healthcare-associated infections were excluded. We compared systematically recorded respiratory and urinary symptoms between groups: signs on auscultation, dyspnoea, chest pain, cough and sputum, dysuria with burning, pollakiuria, flank or costovertebral angle tenderness and ischuria. One hundred BUI were compared to 100 NBUI, both groups exhibiting a similar rate for all considered comorbid conditions. In the BUI group, 58 % showed at least one respiratory sign vs. 20 % in the NBUI group, p < 0.001, while urinary signs were less frequent: 54 % vs. 71 %, p = 0.013. In the multivariate analysis, BUI was associated with the presence of abnormal pulmonary auscultation [adjusted odds ratio (AOR), 5.91; p < 0.001] and a trend towards less urinary symptoms (AOR, 1.58; p = 0.058). Patients with BUI presented with significantly more respiratory signs, which overshadowed urinary symptoms, compared to those with non-bacteraemic UTI. Such observations impact clinical decision-making.
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Clifford KM, Dy-Boarman EA, Haase KK, Maxvill K, Pass SE, Alvarez CA. Challenges with Diagnosing and Managing Sepsis in Older Adults. Expert Rev Anti Infect Ther 2016; 14:231-41. [PMID: 26687340 DOI: 10.1586/14787210.2016.1135052] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sepsis in older adults has many challenges that affect rate of septic diagnosis, treatment, and monitoring parameters. Numerous age-related changes and comorbidities contribute to increased risk of infections in older adults, but also atypical symptomatology that delays diagnosis. Due to various pharmacokinetic/pharmacodynamic changes in the older adult, medications are absorbed, metabolized, and eliminated at different rates as compared to younger adults, which increases risk of adverse drug reactions due to use of drug therapy needed for sepsis management. This review provides information to aid in diagnosis and offers recommendations for monitoring and treating sepsis in the older adult population.
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Affiliation(s)
- Kalin M Clifford
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Eliza A Dy-Boarman
- b Department of Clinical Sciences , Drake University , Des Moines , IA , USA
| | - Krystal K Haase
- c Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Amarillo , TX , USA
| | - Kristen Maxvill
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Steven E Pass
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas , TX , USA
| | - Carlos A Alvarez
- a Department of Pharmacy Practice , Texas Tech University Health Sciences Center , Dallas , TX , USA.,d Department of Clinical Sciences , University of Texas Southwestern , Dallas , TX , USA
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Abstract
Bloodstream infections (BSIs) are both common and fatal in older patients. We describe data from studies evaluating older patients hospitalized with BSIs. Most older patients with BSIs present "typically" with either fever or leukocytosis. The most common source of BSI in older patients is the urinary tract, and accordingly, Gram-negative organisms predominate. A significant part of these BSIs may thus be preventable by removal of unnecessary urinary catheters. Increased long term mortality is reported following BSIs in older patients, however, data on other long-term outcomes, including functional capacity, cognitive decline and others are lacking. Management of BSIs may include less invasive procedures due to the fragility of older patients. This approach may delay the diagnosis and treatment in some cases. Older patients are probably under-represented in clinical trials assessing treatment of bacteremia. Physicians treating older patients should consider the relevance of these studies' outcomes.
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Affiliation(s)
- Dafna Yahav
- a Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital , Petah-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Ramat-Aviv , Israel
| | - Noa Eliakim-Raz
- a Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital , Petah-Tikva , Israel.,b Sackler Faculty of Medicine, Tel Aviv University , Ramat-Aviv , Israel
| | - Leonard Leibovici
- b Sackler Faculty of Medicine, Tel Aviv University , Ramat-Aviv , Israel.,c Department of Medicine E , Rabin Medical Center, Beilinson Hospital , Petah-Tikva , Israel
| | - Mical Paul
- b Sackler Faculty of Medicine, Tel Aviv University , Ramat-Aviv , Israel.,d Unit of Infectious Diseases, Rambam Hospital , Haifa , Israel
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Antibiotic prescription evaluation in the rehabilitation ward of a geriatric hospital. Med Mal Infect 2015; 45:427-35. [DOI: 10.1016/j.medmal.2015.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/16/2015] [Indexed: 11/19/2022]
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Carey AJ, Tan CK, Ipe DS, Sullivan MJ, Cripps AW, Schembri MA, Ulett GC. Urinary tract infection of mice to model human disease: Practicalities, implications and limitations. Crit Rev Microbiol 2015; 42:780-99. [PMID: 26006172 DOI: 10.3109/1040841x.2015.1028885] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Urinary tract infections (UTIs) are among the most common bacterial infections in humans. Murine models of human UTI are vital experimental tools that have helped to elucidate UTI pathogenesis and advance knowledge of potential treatment and infection prevention strategies. Fundamentally, several variables are inherent in different murine models, and understanding the limitations of these variables provides an opportunity to understand how models may be best applied to research aimed at mimicking human disease. In this review, we discuss variables inherent in murine UTI model studies and how these affect model usage, data analysis and data interpretation. We examine recent studies that have elucidated UTI host-pathogen interactions from the perspective of gene expression, and review new studies of biofilm and UTI preventative approaches. We also consider potential standards for variables inherent in murine UTI models and discuss how these might expand the utility of models for mimicking human disease and uncovering new aspects of pathogenesis.
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Affiliation(s)
- Alison J Carey
- a Menzies Health Institute Queensland & School of Medical Sciences, Griffith University , Gold Coast , Australia
| | - Chee K Tan
- a Menzies Health Institute Queensland & School of Medical Sciences, Griffith University , Gold Coast , Australia
| | - Deepak S Ipe
- a Menzies Health Institute Queensland & School of Medical Sciences, Griffith University , Gold Coast , Australia
| | - Matthew J Sullivan
- a Menzies Health Institute Queensland & School of Medical Sciences, Griffith University , Gold Coast , Australia
| | - Allan W Cripps
- b Menzies Health Institute Queensland, Griffith University , Gold Coast , Australia , and
| | - Mark A Schembri
- c School of Chemistry and Molecular Biosciences, University of Queensland , Brisbane , Australia
| | - Glen C Ulett
- a Menzies Health Institute Queensland & School of Medical Sciences, Griffith University , Gold Coast , Australia
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Gómez-Cerquera JM, Daroca-Pérez R, Baeza-Trinidad R, Casañas-Martinez M, Mosquera-Lozano JD, Ramalle-Gómara E. Validity of procalcitonin for the diagnosis of bacterial infection in elderly patients. Enferm Infecc Microbiol Clin 2014; 33:521-4. [PMID: 25541006 DOI: 10.1016/j.eimc.2014.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 10/18/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION PCT has been consolidated as a key tool in the diagnosis of bacterial infections in general population. Few studies have been conducted to determine the applicability of this test in elderly patients. METHODS Study of validity of PCT on elderly patients. Two groups were formed; the first group was formed by patients aged 75 years or older, under bacterial infection criteria and PCT on the initial Lab test. The second group was formed by patients aged 75 years or older with any noninfectious disease; these patients were asked PCT in the initial Lab test. Sensitivity, specificity, positive and negative likelihood ratio were calculated. RESULTS 161 patients were included, 95 with probable bacterial infection and 66 without infection. Patients with probable bacterial infection criteria, 72% of them had PCT >0.5 ng/mL. Patients without infection, 8% of the patients had PCT >0.5 ng/mL. Sensitivity and specificity of PCT to bacterial infection with the cutoff value of 0.5 ng/mL was 72% and 92%, respectively. CONCLUSION PCT can be used in elderly patients to diagnose bacterial infections because it has proved good sensitivity and high specificity.
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Blakiston M, Zaman S. Nosocomial bacteriuria in elderly inpatients may be leading to considerable antibiotic overuse: an audit of current management practice in a secondary level care hospital in New Zealand. Infect Drug Resist 2014; 7:301-8. [PMID: 25419149 PMCID: PMC4235501 DOI: 10.2147/idr.s66036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Bacteriuria in the form of symptomatic urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) is common in the elderly. There is no clinical benefit obtained by treating elderly individuals with ASB. However, its high prevalence leads to the overdiagnosis of UTI and unnecessary antibiotic use, which can result in adverse events, including Clostridium difficile diarrhea and reinfection with antibiotic-resistant organisms. Methods This was a retrospective audit that assessed the management of nosocomial bacteriuria in elderly patients admitted to the over-65 years rehabilitation unit of a secondary level care hospital in New Zealand. Identified bacteriuria episodes had the timing of sample collection relative to admission, microbial etiology, antibiotic susceptibility profile, inflammatory marker level, and treatment determined. Episodes were classified into six different clinical groups based on the presence or absence of signs and symptoms, urinary catheter status, and systemic inflammatory response. The proportion of bacteriuria episodes by clinical grouping and the level of treatment by clinical group were determined, followed by assessment of the amount of overtreatment in terms of the number of unnecessary antibiotic courses and unnecessary antibiotic treatment days. Results Significant bacteriuria was identified in 30% of patients, with 35% of urine samples collected in the immediate postadmission period. Fifty-four percent of the bacteriuria episodes were ASB or catheter-associated ASB (CA-ASB) without an inflammatory response, 24% were ASB or CA-ASB with raised inflammatory markers, and 22% were UTI or CA-UTI. The most common cause of bacteriuria was Escherichia coli, although the etiology was diverse, especially after prolonged hospitalization or in catheterized patients. A large proportion of organisms were resistant to one or more of the commonly used oral antibiotics. Treatment of ASB and CA-ASB accounted for 43% of all antibiotic courses received. Furthermore, treatment of ASB and CA-ASB combined with unnecessarily prolonged treatment days for clinically relevant infections accounted for 55% of all antibiotic treatment days received. Conclusion The results suggest that inappropriate urine screening was occurring and that 43% of antibiotic courses and 55% of all antibiotic treatment days were unnecessary. Current practice is amenable to improvement by performing urine culture only when clinically indicated, focusing on clinical signs and symptoms to diagnose clinically significant UTI rather than a positive culture, and using, where possible, the ecologically least damaging antibiotic for the shortest duration required.
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Affiliation(s)
- Matthew Blakiston
- Department of Medicine, MidCentral District Health Board, Palmerston North, New Zealand
| | - Syed Zaman
- Department of Medicine, MidCentral District Health Board, Palmerston North, New Zealand
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