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Morquin D, Lejeune J, Agostini C, Godreuil S, Reynes J, Le Moing V, Lamy B. Time Is of the Essence: Achieving Prompt and Effective Antimicrobial Therapy of Bloodstream Infection With Advanced Hospital Information Systems. Clin Infect Dis 2024; 78:1434-1442. [PMID: 38059510 DOI: 10.1093/cid/ciad744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/28/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023] Open
Abstract
The early administration of appropriate antibiotic therapy is crucial for the survival of patients with bacteremia. Current research focuses on improving analytical times through technology, whereas there have been very few efforts to improve postanalytical times even though they represent 40% of the time between blood taking and appropriate treatment administration. One of the clues is the efficiency and appropriateness of the result communication system. Here, we review all delays in the entire process with the aim of improving time to appropriate treatment administration. We discuss causes for long times to adjust treatment once microbiological results are released. We argue that the pervasive health information system in this organization serves as both a bottleneck and a rigid framework. Finally, we explore how next-generation hospital information systems should be designed to effectively assist the doctors in treating patients with bacteremia.
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Affiliation(s)
- David Morquin
- Département des Maladies Infectieuses et Tropicales, CHU Montpellier, Montpellier, France
- Espace de Recherche et d'Intégration des Outils numériques en Santé (ERIOS), CHU Montpellier, Montpellier, France
| | - Jordan Lejeune
- Département des Maladies Infectieuses et Tropicales, CHU Montpellier, Montpellier, France
| | - Céline Agostini
- Département des Maladies Infectieuses et Tropicales, CHU Montpellier, Montpellier, France
| | - Sylvain Godreuil
- Laboratoire de bactériologie, CHU Montpellier, Université Montpellier, Montpellier, France
| | - Jacques Reynes
- Département des Maladies Infectieuses et Tropicales CHU, CHU Montpellier, Université Montpellier, Montpellier, France
| | - Vincent Le Moing
- Département des Maladies Infectieuses et Tropicales CHU, CHU Montpellier, Université Montpellier, Montpellier, France
| | - Brigitte Lamy
- UFR Médecine, Université Côte d'Azur, CHU de Nice, INSERM, C3M, Nice, France
- UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
- Service de Microbiologie, Assistance publique - Hopitaux de Paris (APHP), Hôpitaux Universitaires Paris Seine Saint-Denis (HUPSSD), Bobigny, France
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Rosenberg A, Dominy C, Bueno BT, Pasik S, Yeshoua B, Cho B, Arvind V, Valliani AA, Markowitz J, Kim JS, Cho SK. Weekend Admission Increases Risk of Readmissions Following Elective Thoracolumbar Spinal Fusion. Global Spine J 2024; 14:667-675. [PMID: 35969028 PMCID: PMC10802542 DOI: 10.1177/21925682221120788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective database study. OBJECTIVES The goal of this study was to assess the influence of weekend admission on patients undergoing elective thoracolumbar spinal fusion by investigating hospital readmission outcomes and analyzing differences in demographics, comorbidities, and postoperative factors. METHODS The 2016-2018 Nationwide Readmission Database was used to identify adult patients who underwent elective thoracolumbar spinal fusion. The sample was divided into weekday and weekend admission patients. Demographics, comorbidities, complications, and discharge status data were compiled. The primary outcomes were 30-day and 90-day readmission. Univariate logistic regression analyzed the relationship between weekday or weekend admission and 30- or 90-day readmission, and multivariate regression determined the impact of covariates. RESULTS 177,847 patients were identified in total, with 176,842 in the weekday cohort and 1005 in the weekend cohort. Multivariate regression analysis found that 30-day readmissions were significantly greater for the weekend cohort after adjusting for sex, age, Medicare or Medicaid status, and comorbidity status (OR 2.00, 95% CI: 1.60-2.48; P < .001), and 90-day readmissions were also greater for the weekend cohort after adjustment (OR 2.01, 95% CI: 1.68-2.40, P < .001). CONCLUSIONS Patients undergoing elective thoracolumbar spinal fusion surgery who are initially admitted on weekends are more likely to experience hospital readmission. These patients have increased incidence of deep vein thrombosis, postoperative infection, and non-routine discharge status. These factors are potential areas of focus for reducing the impact of the "weekend effect" and improving outcomes for elective thoracolumbar spinal fusion.
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Affiliation(s)
- Ashley Rosenberg
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Calista Dominy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian T. Bueno
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Pasik
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brandon Yeshoua
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varun Arvind
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aly A. Valliani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Markowitz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Davies PJB, Jones TPW, Macleod M. An assessment of the downstream implications of blood culture collection and transit. Eur J Clin Microbiol Infect Dis 2023:10.1007/s10096-023-04610-z. [PMID: 37131082 DOI: 10.1007/s10096-023-04610-z] [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: 02/02/2023] [Accepted: 04/21/2023] [Indexed: 05/04/2023]
Abstract
The implications of the variables within the pre-analytical phase of blood culture processing are poorly understood. This study aims to explore the effect of transit times (TT) and culture volume, on time to microbiological diagnosis and patient outcomes. Blood cultures received between 1st March and 31st July 2020/21 were identified. TT, time in incubator (TII), and for positive samples, request to positivity times (RPT) were calculated. Demographic details were recorded for all samples, and culture volume, length of stay (LoS), and 30-day mortality for patients with positive samples. Statistical analysis examined how culture volume and TT effected culture positivity and outcome; in the context of the 4-h national TT target. Totally, 14,375 blood culture bottles were received from 7367 patients; 988 (13.4%) were positive for organisms. There was no significant difference between TT of negative and positive samples. The RPT was significantly lower for samples with TT < 4 h (p < 0.001). Culture bottle volume did not affect RPT (p = 0.482) or TII (p = 0.367). A prolonged TT was associated with a longer length-of-stay in those with a bacteraemia with a significant organism (p = 0.001). We found shorter blood culture transportation time was associated with a significantly faster time of positive culture reporting, while optimal blood culture volume did not make a significant impact. Delays in reporting for significant organisms correspond to a prolonged LoS. Laboratory centralisation makes achieving the 4-h target a logistical challenge; however, this data suggests such targets have significant microbiological and clinical impacts.
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Affiliation(s)
- Peter J B Davies
- Department of Medical Microbiology, Glasgow Royal Infirmary, Glasgow, UK.
| | - Timothy P W Jones
- Department of Medical Microbiology, Glasgow Royal Infirmary, Glasgow, UK
- Department of Infectious Diseases, John Radcliffe Hospital, Oxford, UK
| | - Mairi Macleod
- Department of Medical Microbiology, Glasgow Royal Infirmary, Glasgow, UK
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Ren R, Dominy C, Bueno B, Pasik S, Markowitz J, Yeshoua B, Cho B, Arvind V, Valliani AA, Kim J, Cho S. Weekend Admission Increases Risk of Readmissions Following Elective Cervical Spinal Fusion. Neurospine 2023; 20:290-300. [PMID: 37016876 PMCID: PMC10080455 DOI: 10.14245/ns.2244816.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/10/2023] [Indexed: 04/03/2023] Open
Abstract
Objective: The “weekend effect” occurs when patients cared for during weekends versus weekdays experience worse outcomes. But reasons for this effect are unclear, especially amongst patients undergoing elective cervical spinal fusion (ECSF). Our aim was to analyze whether index weekend admission affects 30- and 90-day readmission rates post-ECSF.Methods: All ECSF patients > 18 years were retrospectively identified from the 2016–2018 Healthcare Cost and Utilization Project Nationwide Readmissions Database (NRD), using unique patient linkage codes and International Classification of Diseases, Tenth Revision codes. Patient demographics, comorbidities, and outcomes were analyzed. Univariate logistic regression analyzed primary outcomes of 30- and 90-day readmission rates in weekday or weekend groups. Multivariate regression determined the impact of complications on readmission rates.Results: Compared to the weekday group (n = 125,590), the weekend group (n = 1,026) held a higher percentage of Medicare/Medicaid insurance, incurred higher costs, had longer length of stay, and fewer routine home discharge (all p < 0.001). There was no difference in comorbidity burden between weekend versus weekday admissions, as measured by the Elixhauser Comorbidity Index (p = 0.527). Weekend admissions had higher 30-day (4.30% vs. 7.60%, p < 0.001) and 90-day (7.80% vs. 16.10%, p < 0.001) readmission rates, even after adjusting for sex, age, insurance status, and comorbidities. All-cause complication rates were higher for weekend admissions (8.62% vs. 12.7%, p < 0.001), specifically deep vein thrombosis, infection, neurological conditions, and pulmonary embolism.Conclusion: Index weekend admission increases 30- and 90-day readmission rates after ECSF. In patients undergoing ECSF on weekends, postoperative care for patients at risk for specific complications will allow for improved outcomes and health care utilization.
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Affiliation(s)
- Renee Ren
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Calista Dominy
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Bueno
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Pasik
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan Markowitz
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brandon Yeshoua
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varun Arvind
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aly A. Valliani
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun Kim
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Corresponding Author Samuel Cho Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, USA
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Chirio D, Demonchy E, Le Marechal M, Gaudart A, Lotte R, Carles M, Ruimy R. 24/7 workflow for bloodstream infection diagnostics in microbiology laboratories: the first step to improve clinical management. Clin Chem Lab Med 2023; 61:349-355. [PMID: 36326696 DOI: 10.1515/cclm-2022-0667] [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: 07/11/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We aimed to evaluate the impact of an uninterrupted workflow regarding blood cultures on turnaround time and antibiotic prescription. METHODS Monomicrobial episodes of bacteremia were retrospectively evaluated before and after a continuous 24/7 workflow was implemented in our clinical microbiology laboratory (pre- and post-intervention periods; PREIP and POSTIP). Primary outcome was the time from specimen collection to the first change in antibiotic therapy. Secondary outcomes included the time from specimen collection to effective antibiotic therapy and to antibiotic susceptibility testing results (or turnaround time), as well as hospital length of stay and all-cause mortality at 30 days. RESULTS A total of 548 episodes of bacteremia were included in the final analysis. There was no difference in PREIP and POSTIP regarding patient characteristics and causative bacteria. In POSTIP, the mean time to the first change in antibiotic therapy was reduced by 10.4 h (p<0.001). The time to effective antibiotic therapy and the turnaround time were respectively reduced by 4.8 h (p<0.001) and 5.1 h (p=0.006) in POSTIP. There was no difference in mean hospital length of stay or mortality between the two groups. CONCLUSIONS Around the clock processing of blood cultures allows for a reduction in turnaround time, which in turn reduces the delay until effective antibiotic therapy prescription.
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Affiliation(s)
- David Chirio
- Service de Maladies infectieuses et Tropicales, Hôpital l'Archet 1, CHU de Nice, Nice, France
- Université Côte d'Azur, Nice, France
| | - Elisa Demonchy
- Service de Maladies infectieuses et Tropicales, Hôpital l'Archet 1, CHU de Nice, Nice, France
| | - Marion Le Marechal
- Service de Maladies infectieuses et Tropicales, Hôpital l'Archet 1, CHU de Nice, Nice, France
- Département de santé publique, CHU de Nice, Nice, France
| | - Alice Gaudart
- Laboratoire de Bactériologie, CHU de Nice, Hôpital de l'Archet, Nice, France
| | - Romain Lotte
- Université Côte d'Azur, Nice, France
- Laboratoire de Bactériologie, CHU de Nice, Hôpital de l'Archet, Nice, France
- INSERM U1065, C3M, Equipe 6 "Virulence microbienne et signalisation inflammatoire", Bâtiment Universitaire Archimed, Nice, France
| | - Michel Carles
- Service de Maladies infectieuses et Tropicales, Hôpital l'Archet 1, CHU de Nice, Nice, France
- Université Côte d'Azur, Nice, France
| | - Raymond Ruimy
- Université Côte d'Azur, Nice, France
- Laboratoire de Bactériologie, CHU de Nice, Hôpital de l'Archet, Nice, France
- INSERM U1065, C3M, Equipe 6 "Virulence microbienne et signalisation inflammatoire", Bâtiment Universitaire Archimed, Nice, France
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Kotova EO, Domonova EA, Kobalava ZD, Shipulina OY, Karaulova YL, Pisaryuk AS. [Infective Endocarditis with Unknown Etiology: Possibilities of Conquering and Role of Microbiologistics]. ACTA ACUST UNITED AC 2021; 61:87-97. [PMID: 33706691 DOI: 10.18087/cardio.2021.1.n1218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/15/2020] [Accepted: 07/29/2020] [Indexed: 11/18/2022]
Abstract
Current infectious endocarditis (IE) is characterized by changes in its etiological and epidemiological profiles associated with increased incidence of IE of undetermined etiology. This requires a search for ways to enhance the effectivity of diagnosis. Microbiologistics along with high-tech methods becomes decisively important for identifying the pathogen by studying cultures of blood and tissues from the affected heart valve. This determines timely diagnosis and treatment to be introduced to medical practice as a component of personalized medicine. The article focuses on the validity and features of microbiological (cultural), immunochemical, and molecular biological [MALDI-TOF MS (matrix-activated laser desorption/ionization with time-of-flight mass spectrometry), polymerase chain reaction, sequencing] studies.
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Affiliation(s)
- E O Kotova
- Peoples' Friendship University of Russia (RUDN), Moscow
| | - E A Domonova
- Central Research Institute of Epidemiology" of The Federal Service on Customers' Rights Protection and Human Wellbeing Surveillance, Moscow
| | - Zh D Kobalava
- Peoples' Friendship University of Russia (RUDN), Moscow
| | - O Y Shipulina
- Central Research Institute of Epidemiology" of The Federal Service on Customers' Rights Protection and Human Wellbeing Surveillance, Moscow
| | - Y L Karaulova
- Peoples' Friendship University of Russia (RUDN), Moscow
| | - A S Pisaryuk
- Peoples' Friendship University of Russia (RUDN), Moscow; City Hospital named after V.V. Vinogradov, Moscow
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Elvy J, Walker D, Haremza E, Ryan K, Morris AJ. Blood culture quality assurance: what Australasian laboratories are measuring and opportunities for improvement. Pathology 2020; 53:520-529. [PMID: 33358375 DOI: 10.1016/j.pathol.2020.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/26/2020] [Accepted: 09/07/2020] [Indexed: 10/22/2022]
Abstract
Blood cultures are among the most important specimen types received and processed by the microbiology laboratory. Several publications list which variables should be measured to ensure quality. We undertook a qualitative structured questionnaire of Australian and New Zealand clinical microbiology laboratories to document current blood culture practices and to determine whether expected quality standards are being met. Questions included a wide range of pre-analytical, analytical, and post-analytical aspects of blood cultures from adults. The responses from 71 laboratories were analysed. Compliance was high for use of a biological safety cabinet (90%), incubating for 5 days (86%), and commenting on likely contaminants (85%). While Gram stains were reported within 2 hours during normal hours (93%), reporting was slower after hours (59%), p<0.001. The volume of blood collected for a clinical episode was poorly monitored with only 11% (n=8) of laboratories regularly auditing the number of blood culture sets and 3% (n=2) monitoring adequacy of fill. Most laboratories received blood cultures from off-site with just 34% (n=21) meeting guidance for loading bottles onto the analyser within 4 hours. More laboratories met standards for loading bottles onto the analyser during working hours than after hours: 87% vs 56%, p<0.001. Most laboratories did not monitor the contamination rate, 56% (n=40), and only 27% (n=19) knew their rate was below the guidance threshold of less than -3%. Considerable opportunities exist to improve quality assurance of blood culture practice in Australia and New Zealand, especially for the most critical aspect affecting culture sensitivity, the volume of blood collected.
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Affiliation(s)
- Juliet Elvy
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia; Department of Microbiology, Wellington Southern Community Laboratories, Wellington Hospital, Wellington, New Zealand; Department of Microbiology, Medlab Nelson Marlborough, Nelson, New Zealand.
| | - Debra Walker
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia
| | - Elizabeth Haremza
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia
| | - Katherine Ryan
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia
| | - Arthur J Morris
- The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP), Sydney, NSW, Australia; Clinical Microbiology Laboratory, LabPLUS, Auckland City Hospital, Auckland, New Zealand
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Laboratory and clinical impacts of an overnight laboratory service. Eur J Clin Microbiol Infect Dis 2020; 40:353-359. [PMID: 32960364 DOI: 10.1007/s10096-019-03737-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/06/2019] [Indexed: 01/02/2023]
Abstract
Delayed initiation of effective antimicrobial therapy for sepsis is associated with increased mortality. Whilst automated blood culture machines operate continuously, this does not align with conventional staff working hours and so turn-around-times (TAT) for reporting gram stains to clinicians are 3-7 times longer for blood cultures that flag positive overnight. We retrospectively compared laboratory TATs and clinical outcomes for blood cultures from 183 patients that flagged positive overnight during a 4-month period before and after the implementation of an overnight laboratory service. Enterobacterales and urinary tract infections were the most frequent pathogens and clinical syndrome respectively, and the prevalence of multi-resistant organisms was 15%. Compared with the pre-implementation period, the post-implementation period was associated with shorter median time from blood culture positivity to gram stain (7.4 vs 1.2 h), first genus level identification (7.2 vs 5.8 h) and first antimicrobial susceptibility result (24.1 vs 7.9 h). Similarly, the median time from blood culture positivity to clinicians first being informed was significantly shorter (9.2 vs 1.3 h). After removal of likely contaminants, 78% of patients were on effective empiric antimicrobials and for patients on ineffective empiric antimicrobials, effective therapy was initiated a median of 3.2 h sooner during the post-implementation period, without impact on mortality. Implementation of an overnight laboratory service was associated with significantly faster TAT for reporting blood culture results and more prompt initiation of effective antimicrobials for patients receiving ineffective empiric therapy, improving attainment of sepsis management goals.
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De Plato F, Fontana C, Gherardi G, Privitera GP, Puro V, Rigoli R, Viaggi B, Viale P. Collection, transport and storage procedures for blood culture specimens in adult patients: recommendations from a board of Italian experts. Clin Chem Lab Med 2020; 57:1680-1689. [PMID: 31348753 DOI: 10.1515/cclm-2018-1146] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 06/24/2019] [Indexed: 12/23/2022]
Abstract
Bloodstream infections (BSIs) remain a potentially life-threatening condition. The gold standard for the diagnosis of BSI is still blood cultures (BCs), and the diagnostic yield depends on clinical and technical factors that have an impact on collection and transportation. Hence, monitoring of the entire pre-analytical process from blood collection to transportation to the microbiology laboratory is critical. To optimize the clinical impact of the diagnostic and therapeutic procedures, a multidisciplinary approach and univocal protocols are mandatory. A board of specialists discussed the available evidence on the pre-analytical process and produced the present document to guide physicians and nurses on the ideal execution of BC: (1) timing and preparation for blood collection; (2) skin antisepsis; (3) blood volume; (4) sampling method and safety; (5) medium to be used; (6) time to BC transportation; and (7) quality assurance and quality management.
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Affiliation(s)
- Francesca De Plato
- Società Italiana Farmacologia Ospedaliera, Milan, Italy; and Local Health Authority ASL of Teramo, Teramo, Italy
| | - Carla Fontana
- Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy.,Microbiology and Virology Laboratory, Polyclinic of Tor Vergata, Rome, Italy
| | - Giovanni Gherardi
- Department of Medicine, Laboratory of Clinical Microbiology, University Campus Biomedico, Rome 00128, Italy
| | - Gaetano Pierpaolo Privitera
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.,University Hygiene and Epidemiology Complex Operative Unit and Clinical Risk Functional Area Coordinator, University Hospital Pisana, Pisa, Italy
| | - Vincenzo Puro
- National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
| | - Roberto Rigoli
- Department of Clinical Pathology, Local Health and Social Care Facility, No. 2, Marca Trevigiana, Treviso, Italy
| | - Bruno Viaggi
- Neuroanesthesia and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Lamy B, Sundqvist M, Idelevich EA. Bloodstream infections – Standard and progress in pathogen diagnostics. Clin Microbiol Infect 2020; 26:142-150. [DOI: 10.1016/j.cmi.2019.11.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022]
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Schwarzenbacher J, Kuhn SO, Vollmer M, Scheer C, Fuchs C, Rehberg S, Balau V, Hahnenkamp K, Bohnert JA, Gründling M. On-site blood culture incubation shortens the time to knowledge of positivity and microbiological results in septic patients. PLoS One 2019; 14:e0225999. [PMID: 31826003 PMCID: PMC6905563 DOI: 10.1371/journal.pone.0225999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 11/19/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction To determine whether on-site incubation of blood cultures at the intensive care unit (ICU) improves not only the time to incubation but also time to positivity, time to knowledge of positivity and time to results (identification and antibiotic susceptibility testing). Methods This observational single-centre study in ICU patients with severe sepsis and septic shock investigated the impact of blood culture incubation immediately on-site at the ICU (ICU group) by comparison with traditional processing in a remote laboratory (LAB group) on different time intervals of blood culture diagnostics from obtaining blood to clinician notification of final result. The effect of on-site incubation was evaluated in Kaplan-Meier estimates for the time to positivity, time to knowledge of positivity and time to microbiological results and a linear mixed model was built. Results A total of 3,549 blood culture sets from 657 ICU patients were analysed: 2,381 in the LAB group and 1,168 in the ICU group. Overall, 660 (18.6%) blood culture sets were positive and 2,889 (81.4%) sets remained negative. On-site incubation was associated with reduced time to knowledge of positivity (46.9 h [CI 43.4–50.8 h] vs. 28.0 h [CI 23.6–32.2 h], p < 0.001) and reduced time to result (61.4 h [CI 58.4–64.8 h] vs. 42.1 h [CI 39.1–47.5 h], p < 0.001). In blood cultures processed instantaneously at the ICU compared to incubation in the remote laboratory within 4 h, the time to microbiological result was significantly reduced by 8.5 h (p < 0.001). Pre-existing anti-infective therapy had no significant impact on diagnostic time intervals. Conclusions Instantaneous incubation of blood cultures in the ICU compared to incubation in a remote laboratory significantly improves time to knowledge to positivity and time to result. These effects are even more pronounced during off-hours of the microbiological laboratory. The results underline the importance of 24/7 diagnostics to provide round-the-clock processing of blood culture samples in patients with sepsis and septic shock and an immediate to communication of the results to the clinicians.
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Affiliation(s)
| | - Sven-Olaf Kuhn
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
- * E-mail:
| | - Marcus Vollmer
- Institute of Bioinformatics, University Medicine Greifswald, Greifswald, Germany
| | - Christian Scheer
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Christian Fuchs
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine and Pain Therapy, Protestant Hospital of the Bethel Foundation, Bielefeld, Germany
| | - Veronika Balau
- IMD Labor Greifswald, MVZ Labor Greifswald GmbH, Greifswald, Germany
| | - Klaus Hahnenkamp
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Jürgen A. Bohnert
- Friedrich Loeffler Institute of Microbiology, University Hospital Greifswald, Greifswald, Germany
| | - Matthias Gründling
- Department of Anesthesiology, University Hospital of Greifswald, Greifswald, Germany
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Mounsey LA, Chang PP, Sueta CA, Matsushita K, Russell SD, Caughey MC. In-Hospital and Postdischarge Mortality Among Patients With Acute Decompensated Heart Failure Hospitalizations Ending on the Weekend Versus Weekday: The ARIC Study Community Surveillance. J Am Heart Assoc 2019; 8:e011631. [PMID: 31319746 PMCID: PMC6761634 DOI: 10.1161/jaha.118.011631] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Hospital staffing is usually reduced on weekends, potentially impacting inpatient care and postdischarge coordination of care for patients with acute decompensated heart failure (ADHF). However, investigations of in‐hospital mortality on the weekend versus weekday, and post‐hospital outcomes of weekend versus weekday discharge are scarce. Methods and Results Hospitalizations for ADHF were sampled by stratified design from 4 US areas by the Community Surveillance component of the ARIC (Atherosclerosis Risk in Communities) study. ADHF was classified by a standardized computer algorithm and physician review of the medical records. Discharges or deaths on Saturday, Sunday, or national holidays were considered to occur on the “weekend.” In‐hospital mortality was compared between hospitalizations ending on a weekend versus weekday. Post‐hospital (28‐day) mortality was compared among patients discharged alive on a weekend versus weekday. From 2005 to 2014, 39 699 weighted ADHF hospitalizations were identified (19% terminating on a weekend). Demographics, comorbidities, length of stay, and guideline‐directed therapies were similar for patients with hospitalizations ending on a weekend versus weekday. In‐hospital death doubled on the weekend compared with weekday (12% versus 6%) and was not attenuated by adjustment for potential confounders (odds ratio, 2.37; 95% CI, 1.93–2.91). There was no association between weekend discharge and 28‐day mortality among patients discharged alive. Conclusions The risk of in‐hospital death among patients admitted with ADHF appears to be doubled on the weekends when hospital staffing is usually reduced. However, among patients discharged alive, hospital discharge on a weekend is not adversely associated with mortality. See Editorial Mehta and Pandey
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Affiliation(s)
| | | | - Carla A Sueta
- University of North Carolina School of Medicine Chapel Hill NC
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13
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Idelevich EA, Seifert H, Sundqvist M, Scudeller L, Amit S, Balode A, Bilozor A, Drevinek P, Kocak Tufan Z, Koraqi A, Lamy B, Mareković I, Miciuleviciene J, Müller Premru M, Pascual A, Pournaras S, Saegeman V, Schønheyder HC, Schrenzel J, Strateva T, Tilley R, Wiersinga WJ, Zabicka D, Carmeli Y, Becker K. Microbiological diagnostics of bloodstream infections in Europe-an ESGBIES survey. Clin Microbiol Infect 2019; 25:1399-1407. [PMID: 30980927 DOI: 10.1016/j.cmi.2019.03.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES High-quality diagnosis of bloodstream infections (BSI) is important for successful patient management. As knowledge on current practices of microbiological BSI diagnostics is limited, this project aimed to assess its current state in European microbiological laboratories. METHODS We performed an online questionnaire-based cross-sectional survey comprising 34 questions on practices of microbiological BSI diagnostics. The ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis (ESGBIES) was the primary platform to engage national coordinators who recruited laboratories within their countries. RESULTS Responses were received from 209 laboratories in 25 European countries. Although 32.5% (68/209) of laboratories only used the classical processing of positive blood cultures (BC), two-thirds applied rapid technologies. Of laboratories that provided data, 42.2% (78/185) were able to start incubating BC in automated BC incubators around-the-clock, and only 13% (25/192) had established a 24-h service to start immediate processing of positive BC. Only 4.7% (9/190) of laboratories validated and transmitted the results of identification and antimicrobial susceptibility testing (AST) of BC pathogens to clinicians 24 h/day. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry from briefly incubated sub-cultures on solid media was the most commonly used approach to rapid pathogen identification from positive BC, and direct disc diffusion was the most common rapid AST method from positive BC. CONCLUSIONS Laboratories have started to implement novel technologies for rapid identification and AST for positive BC. However, progress is severely compromised by limited operating hours such that current practice of BC diagnostics in Europe complies only partly with the requirements for optimal BSI management.
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Affiliation(s)
- E A Idelevich
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - H Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany; German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - M Sundqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - L Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS, Policlinico San Matteo Pavia Fondazione IRCCS, Pavia, Italy
| | - S Amit
- Department of Clinical Microbiology and Infectious Diseases, Hadassah Medical Centre, Jerusalem, Israel
| | - A Balode
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - A Bilozor
- Microbiology Laboratory, Diagnostic Clinic, East-Tallinn Central Hospital, Tallinn, Estonia
| | - P Drevinek
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Z Kocak Tufan
- Infectious Diseases and Clinical Microbiology Department, Medical School of Ankara Yildirim Beyazit University, Ankara, Turkey
| | - A Koraqi
- Clinical Microbiology Laboratory, University Hospital Centre 'Mother Theresa', Tirana, Albania
| | - B Lamy
- Laboratory of Clinical Microbiology, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, INSERM U1065 (C3M), Nice, France
| | - I Mareković
- Department of Clinical and Molecular Microbiology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - M Müller Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - A Pascual
- Unidad de Enfermedades Infecciosas, Microbiologia y Medicina Preventiva, Hospital Universitario Virgen Macarena, Departamento de Microbiología, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - S Pournaras
- Laboratory of Clinical Microbiology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - V Saegeman
- Department of Infection Control and Epidemiology, University Hospitals Leuven, Leuven, Belgium
| | - H C Schønheyder
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | - J Schrenzel
- Bacteriology Laboratory, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - T Strateva
- Department of Medical Microbiology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - R Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - W J Wiersinga
- Department of Infectious Diseases and Centre for Experimental Molecular Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - D Zabicka
- National Medicines Institute, Warsaw, Poland
| | - Y Carmeli
- Division of Epidemiology, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - K Becker
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany.
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Nannan Panday RS, Wang S, van de Ven PM, Hekker TAM, Alam N, Nanayakkara PWB. Evaluation of blood culture epidemiology and efficiency in a large European teaching hospital. PLoS One 2019; 14:e0214052. [PMID: 30897186 PMCID: PMC6428292 DOI: 10.1371/journal.pone.0214052] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 03/06/2019] [Indexed: 12/22/2022] Open
Abstract
Background Blood cultures remain the gold standard for detecting bacteremia despite their limitations. The current practice of blood culture collection is still inefficient with low yields. Limited focus has been given to the association between timing of specimen collection at different time points during admission and their yield. Methods We carried out a retrospective observational study by analyzing all 3,890 sets of cultures collected from the 1,962 admitted patients over the seven-month period of this study. We compared the blood culture yield between the early group (≤24 hours after admission) and the late group (> 24 hours of admission). We also investigated the effect of prehospital oral antibiotics and pre-analytical time on the first cultures in the emergency department. Epidemiology and efficiency of blood cultures were studied for each medical specialty. Results In total, 3,349(86.1%) blood cultures were negative and 541(13.9%) were positive for one or more microorganisms. After correcting for contamination, the overall yield was 290 (7.5%). The early group (n = 1,490) yielded significantly more true-positive cultures (10.1% versus 5.8%, P<0.001) than the late group (n = 2,400). The emergency department had a significantly higher yield than general wards, 11.2% versus 5.7% (p<0.001). Prehospital oral antibiotic use and pre-analytical time did not affect the yield of first cultures at the emergency department (p = 0.735 and 0.816 respectively). The number of tests needed to obtain one true-positive culture varied between departments, ranging from 7 to 45. Conclusion This study showed that blood cultures are inefficient in detecting bacteremia. Cultures collected during 24 hours after admission yielded more positive results than those collected later. Significant variations in blood culture epidemiology and efficiency per specialty suggest that guidelines should be reevaluated. Future studies should aim at improving blood culture yield, implementing educational programs to reduce contamination and cost-effective application of modern molecular diagnostic technologies.
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Affiliation(s)
- R. S. Nannan Panday
- Department of Internal Medicine, Section Acute Medicine, Amsterdam University Medical Centers, Location VU University Medical Center, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, Location VU University Medical Center and Location Academic Medical Center, Amsterdam, The Netherlands
| | - S. Wang
- Department of Internal Medicine, Section Acute Medicine, Amsterdam University Medical Centers, Location VU University Medical Center, Amsterdam, The Netherlands
| | - P. M. van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Centers, Location VU University Medical Center, Amsterdam, The Netherlands
| | - T. A. M. Hekker
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Centers, Location VU University Medical Center, Amsterdam, The Netherlands
| | - N. Alam
- Department of Internal Medicine, Section Acute Medicine, Amsterdam University Medical Centers, Location VU University Medical Center, Amsterdam, The Netherlands
| | - P. W. B. Nanayakkara
- Department of Internal Medicine, Section Acute Medicine, Amsterdam University Medical Centers, Location VU University Medical Center, Amsterdam, The Netherlands
- * E-mail:
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15
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Sánchez-Sánchez MM, Arias-Rivera S, Fraile-Gamo P, Jareño-Collado R, López-Román S, Vadillo-Obesso P, García-González S, Pulido-Martos MT, Sánchez-Muñoz EI, Cacho-Calvo J, Martín-Pellicer A, Panadero-Del Olmo L, Frutos-Vivar F. Effect of a training programme on blood culture contamination rate in critical care. ENFERMERIA INTENSIVA 2018; 29:121-127. [PMID: 29609850 DOI: 10.1016/j.enfi.2017.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 12/12/2017] [Accepted: 12/27/2017] [Indexed: 11/27/2022]
Abstract
Blood culture contamination can occur from extraction to processing; its rate should not exceed 3%. OBJECTIVE To evaluate the impact of a training programme on the rate of contaminated blood cultures after the implementation of sample extraction recommendations based on the best evidence. METHOD Prospective before-after study in a polyvalent intensive care unit with 18 beds. Two phases were established (January-June 2012, October 2012-October 2015) with a training period between them. Main recommendations: sterile technique, surgical mask, double skin disinfection (70° alcohol and 2% alcoholic chlorhexidine), 70° alcohol disinfection of culture flasks and injection of samples without changing needles. Including all blood cultures of patients with extraction request. VARIABLES demographic, severity, pathology, reason for admission, stay and results of blood cultures (negative, positive and contaminated). Basic descriptive statistics: mean (standard deviation), median (interquartile range) and percentage (95% confidence interval). Calculated contamination rates per 100 blood cultures extracted. Bivariate analysis between periods. RESULTS Four hundred and eight patients were included. Eight hundred and forty-one blood cultures were taken, 33 of which were contaminated. In the demographic variables, severity, diagnosis and stay of patients with contaminated samples, no differences were observed from those with uncontaminated samples. Pre-training vs post-training contamination rates: 14 vs 5.6 per 100 blood cultures extracted (P=.00003). CONCLUSION An evidence-based training programme reduced the contamination of samples. It is necessary to continue working on the planning of activities and care to improve the detection of pollutants and prevent contamination of samples.
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Affiliation(s)
- M M Sánchez-Sánchez
- Unidad de Cuidados Intensivos, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - S Arias-Rivera
- Enfermería de Investigación, Hospital Universitario de Getafe, Getafe, Madrid, España.
| | - P Fraile-Gamo
- Unidad de Cuidados Intensivos, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - R Jareño-Collado
- Unidad de Cuidados Intensivos, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - S López-Román
- Consultorio Local Moraleja de Enmedio, Moraleja de Enmedio, Madrid, España
| | | | - S García-González
- Unidad de Cuidados Intensivos, Hospital Universitario de Móstoles, Móstoles, Madrid, España
| | - M T Pulido-Martos
- Unidad de Cuidados Intensivos, Hospital Universitario 12 de Octubre, Madrid, España
| | - E I Sánchez-Muñoz
- Unidad de Cuidados Intensivos, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - J Cacho-Calvo
- Servicio de Microbiología, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - A Martín-Pellicer
- Área de Medicina Intensiva, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - L Panadero-Del Olmo
- Área de Medicina Intensiva, Hospital Universitario de Getafe, Getafe, Madrid, España
| | - F Frutos-Vivar
- Área de Medicina Intensiva, Hospital Universitario de Getafe, Getafe, Madrid, España
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How to: accreditation of blood cultures' proceedings. A clinical microbiology approach for adding value to patient care. Clin Microbiol Infect 2018; 24:956-963. [PMID: 29410246 DOI: 10.1016/j.cmi.2018.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/08/2018] [Accepted: 01/11/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Quality assurance and quality management are driving forces for controlling blood culture best practices but should not be disconnected from the end-point target, i.e. patient value. AIMS This article is intended to help microbiologists implement blood culture accreditation that is actually beneficial to patient management. SOURCES Experience from a nationwide taskforce for promoting quality assurance and competence in clinical microbiology laboratories, guidelines on blood culture. CONTENT Experience in blood culture accreditation according to International standard ISO 15189 standards is provided in this review, with a particular focus on critical points that are specific to blood culture (e.g. excluding strain identification or antimicrobial susceptibility testing). Blood culture test method verification is based on risk analysis, and evaluation of the test method's performance is based on the literature review and suppliers' data. In addition, blood culture performance relies largely on the quality of its pre-analytical phase, and the test method should be monitored based on key performance indicators such as the volume of blood cultured, the contamination rate and time to transportation. Other critical key indicators include the rate of false-positive signals, the rate of positive blood cultures, the ecology associated with positive results, and the timely communication of the results to the ward during the post-analytical phase. Finally, a critical analysis of quality controls and of the tools needed to improve blood culture monitoring in the future is provided. IMPLICATION Appropriate quality assurance should focus on patient value rather than technical details to provide an appropriate clinical service.
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17
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Wang V, Hsieh CC, Huang YL, Chen CP, Hsieh YT, Chao TH. Different utilization of intensive care services (ICSs) for patients dying of hemorrhagic and ischemic stroke, a hospital-based survey. Medicine (Baltimore) 2018; 97:e0017. [PMID: 29465539 PMCID: PMC5841996 DOI: 10.1097/md.0000000000010017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The intensive care service (ICS) saves lives and rescues the neurological function of stroke patients. We wondered the different utilization of ICS for patients with ischemic and hemorrhagic stroke, especially those who died within 30 days after stroke.Sixty-seven patients died during 2011 to 2015 due to acute stroke (42 due to intracranial hemorrhage [ICH]; 25 due to cerebral infarct [CI]). The durations of hospital stay (hospital staying days [HSDs]) and ICS staying days (ISDs) and codes of the do-not-resuscitate (DNR) were surveyed among these medical records. Statistics included chi-square and descriptive analyses.In this study, CI patients had a longer HSD (mean 14.3 days), as compared with ICH patients (mean 8.3 days); however, the ICH patients had a higher percentage of early entry within the first 24 hours of admission into ICS than CI group (95.1% vs 60.0%, P = .003). A higher rate of CI patients died in holidays or weekends than those with ICH (44.0% vs 21.4%, P = .051). DNR, requested mainly from direct descendants (children or grandchildren), was coded in all 25 CI patients (100.0%) and 38 ICH patients (90.5%). More cases with early DNR coded within 24 hours after admission occurred in ICH group (47%, 12% in CI patients, P = .003). None of the stroke patient had living wills. Withhold of endotracheal intubation (ETI) occurred among CI patients, more than for ICH patients (76.0% vs 18.4%, P < .005).In conclusion, CI patients longer HSD, ISD, higher mortality within holidays or weekends, and higher ETI withhold; but less percentage of ICS utilization expressed by a lower ISD/HSD ratio. This ICS utilization is a key issue of medical quality for stroke care.
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Affiliation(s)
- Vinchi Wang
- Department of Neurology, Cardinal Tien Hospital
- School of Medicine, College of Medicine, Fu-Jen Catholic University
- Medical Quality Management Center
| | | | | | - Chia-Ping Chen
- Information Technology Office, Yonghe Cardinal Tien Hospital, New Taipei City, Taiwan
| | | | - Tzu-Hao Chao
- Department of Neurology, Cardinal Tien Hospital
- School of Medicine, College of Medicine, Fu-Jen Catholic University
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Venturelli C, Righi E, Borsari L, Aggazzotti G, Busani S, Mussini C, Rumpianesi F, Rossolini GM, Girardis M. Impact of Pre-Analytical Time on the Recovery of Pathogens from Blood Cultures: Results from a Large Retrospective Survey. PLoS One 2017; 12:e0169466. [PMID: 28046040 PMCID: PMC5207733 DOI: 10.1371/journal.pone.0169466] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 12/16/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Prompt identification of bloodstream pathogens is essential for optimal management of patients. Significant changes in analytical methods have improved the turnaround time for laboratory diagnosis. Less attention has been paid to the time elapsing from blood collection to incubation and to its potential effect on recovery of pathogens. We evaluated the performance of blood cultures collected under typical hospital conditions in relation to the length of their pre-analytical time. METHODS We carried out a large retrospective study including 50,955 blood cultures collected, over a 30-month period, from 7,035 adult septic patients. Cultures were accepted by the laboratory only during opening time (Mon-Fri: 8am-4pm; Sat: 8am-2pm). Samples collected outside laboratory hours were stored at room temperature at clinical wards. All cultures were processed by automated culture systems. Day and time of blood collection and of culture incubation were known for all samples. RESULTS A maximum pre-analytical interval of 2 hours is recommended by guidelines. When the laboratory was open, 57% of cultures were processed within 2 h. When the laboratory was closed, 4.9% of cultures were processed within 2 h (P<0.001). Samples collected when the laboratory was closed showed pre-analytical times significantly longer than those collected when laboratory was open (median time: 13 h and 1 h, respectively, P<0.001). The prevalence of positive cultures was significantly lower for samples collected when the laboratory was closed compared to open (11% vs 13%, P<0.001). The probability of a positive result decreased of 16% when the laboratory was closed (OR:0.84; 95%CI:0.80-0.89, P<0.001). Further, each hour elapsed from blood collection to incubation resulted associated with a decrease of 0.3% (OR:0.997; 95%CI:0.994-0.999, P<0.001) in the probability of a positive result. DISCUSSION Delayed insertions of cultures into automated systems was associated with lower detection rates, with potentially important consequences for patients. In each hospital setting the logistic factors able to shorten pre-analytical time should be carefully investigated and specifically targeted.
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Affiliation(s)
- Claudia Venturelli
- Microbiology and Virology Laboratory, University Hospital of Modena, Modena, Italy
| | - Elena Righi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- * E-mail:
| | - Lucia Borsari
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gabriella Aggazzotti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Unit, University Hospital of Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Rumpianesi
- Microbiology and Virology Laboratory, University Hospital of Modena, Modena, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care Unit, University Hospital of Modena and University of Modena and Reggio Emilia, Modena, Italy
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Morton B, Mitsi E, Pennington SH, Reiné J, Wright AD, Parker R, Welters ID, Blakey JD, Rajam G, Ades EW, Ferreira DM, Wang D, Kadioglu A, Gordon SB. Augmented Passive Immunotherapy with P4 Peptide Improves Phagocyte Activity in Severe Sepsis. Shock 2016; 46:635-641. [PMID: 27488089 DOI: 10.1097/shk.0000000000000715] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Antimicrobial resistance threatens to undermine treatment of severe infection; new therapeutic strategies are urgently needed. Preclinical work shows that augmented passive immunotherapy with P4 peptide increases phagocytic activity and shows promise as a novel therapeutic strategy. Our aim was to determine ex vivo P4 activity in a target population of patients admitted to critical care with severe infection. METHODS We prospectively recruited UK critical care unit patients with severe sepsis and observed clinical course (≥3 months postdischarge). Blood samples were taken in early (≤48 h postdiagnosis, n = 54), latent (7 days postdiagnosis, n = 39), and convalescent (3-6 months postdiagnosis, n = 18) phases of disease. The primary outcome measure was killing of opsonized Streptococcus pneumoniae by neutrophils with and without P4 peptide stimulation. We also used a flow cytometric whole blood phagocytosis assay to determine phagocyte association and oxidation of intraphagosomal reporter beads. RESULTS P4 peptide increased neutrophil killing of opsonized pneumococci by 8.6% (confidence interval 6.35-10.76, P < 0.001) in all phases of sepsis, independent of infection source and microbiological status. This represented a 54.9% increase in bacterial killing compared with unstimulated neutrophils (15.6%) in early phase samples. Similarly, P4 peptide treatment significantly increased neutrophil and monocyte intraphagosomal reporter bead association and oxidation, independent of infection source. CONCLUSIONS We have extended preclinical work to demonstrate that P4 peptide significantly increases phagocytosis and bacterial killing in samples from a target patient population with severe sepsis. This study supports the rationale for augmented passive immunotherapy as a therapeutic strategy in severe sepsis.
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Affiliation(s)
- Ben Morton
- *Aintree University Hospital NHS Foundation Trust, Liverpool, UK †Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK ‡Clinical Infection, Microbiology and Immunology, Institute of Infection & Global Health, University of Liverpool, Liverpool, UK §Local Comprehensive Research Network, Northwest Coast, Liverpool, UK ||Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK ¶Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia #Clinical Infection, Microbiology and Immunology, Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
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20
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Datcu R, Boel J, Jensen IM, Arpi M. Comparison of BACTEC™ blood culture media for the detection of fungemia. Eur J Clin Microbiol Infect Dis 2016; 36:131-137. [PMID: 27677278 DOI: 10.1007/s10096-016-2781-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 09/05/2016] [Indexed: 02/05/2023]
Abstract
The aim of the present study was to investigate whether addition of the BACTEC™ Mycosis bottle to the standard BACTEC™ aerobic and anaerobic bottles contributed to a higher detection rate and a faster time to detection (TTD) of fungi. This was a retrospective cohort study of all patients with a positive blood culture with Candida species delivered to the Department of Clinical Microbiology, Herlev and Gentofte Hospital, Denmark in the 8-year period 2006 through 2014. The patients had at least one BACTEC™ aerobic and one Mycosis bottle sampled at the same time and at least one of the bottles yielded growth of fungi. Among 184 patients included, 173 were examined using BACTEC™ aerobic, anaerobic and Mycosis bottles. The anaerobic vial generally had the lowest detection rate and the longest TTD. The detection rate of BACTEC™ aerobic plus anaerobic with the BACTEC™ Mycosis bottle was significantly higher than the detection rate of BACTEC™ aerobic plus anaerobic without BACTEC™ Mycosis bottle for all species after 1-5 days, and specially for Candida glabrata at 2, 3, 4 and 5 days. TTD for C. glabrata was significantly shorter for BACTEC™ Mycosis than TTD for BACTEC™ aerobic or anaerobic bottles after ½ to 4 days. When combining "first or only" detection, the BACTEC™ Mycosis bottle had a significantly higher detection as compared to the aerobic bottle. Addition of the BACTEC™ Mycosis bottle to the standard BACTEC™ aerobic and anaerobic bottles significantly contributed to a higher detection rate and a faster TTD of fungemia.
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Affiliation(s)
- R Datcu
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark.
| | - J Boel
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - I M Jensen
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - M Arpi
- Department of Clinical Microbiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
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Aldridge C, Bion J, Boyal A, Chen YF, Clancy M, Evans T, Girling A, Lord J, Mannion R, Rees P, Roseveare C, Rudge G, Sun J, Tarrant C, Temple M, Watson S, Lilford R. Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. Lancet 2016; 388:178-86. [PMID: 27178476 PMCID: PMC4945602 DOI: 10.1016/s0140-6736(16)30442-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service. METHODS Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defined specialist intensity at each trust as the self-reported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for financial year 2013-14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile. FINDINGS 127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34,350 clinicians surveyed, 15,537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 [11%]) than on Wednesday (6105 [42%]). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5·74 h [SD 3·39] vs 3·97 h [3·31]); however, the median specialist intensity on Sunday was only 48% (IQR 40-58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0·7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1·10, 95% CI 1·08-1·11; p<0·0001). There was no significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r -0·042; p=0·654). INTERPRETATION This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing. FUNDING National Institute for Health Research Health Services and Delivery Research Programme.
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Affiliation(s)
| | | | - Amunpreet Boyal
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Mike Clancy
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Tim Evans
- Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | | | | | | | - Peter Rees
- Academy of Medical Royal Colleges Patient Liaison Group, London, UK
| | | | | | - Jianxia Sun
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Mark Temple
- Heart of England NHS Foundation Trust, Birmingham, UK
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Lamy B, Dargère S, Arendrup MC, Parienti JJ, Tattevin P. How to Optimize the Use of Blood Cultures for the Diagnosis of Bloodstream Infections? A State-of-the Art. Front Microbiol 2016; 7:697. [PMID: 27242721 PMCID: PMC4863885 DOI: 10.3389/fmicb.2016.00697] [Citation(s) in RCA: 201] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/26/2016] [Indexed: 11/13/2022] Open
Abstract
Bloodstream infection (BSI) is a major cause of death in developed countries and the detection of microorganisms is essential in managing patients. Despite major progress has been made to improve identification of microorganisms, blood culture (BC) remains the gold standard and the first line tool for detecting BSIs. Consensus guidelines are available to ensure optimal BSI procedures, but BC practices often deviate from the recommendations. This review provides an update on clinical and technical issues related to blood collection and to BC performance, with a special focus on the blood sample strategy to optimize the sensitivity and specificity of BCs.
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Affiliation(s)
- Brigitte Lamy
- Laboratoire de Bactériologie, CHU Montpellier Montpellier, France
| | | | - Maiken C Arendrup
- Unit for Mycology, Department of Microbiology & Infection Control, Statens Serum Institut Copenhagen, Denmark
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