A retrospective review of a tertiary Hospital's isolation and de-isolation policy for suspected pulmonary tuberculosis

BACKGROUND

Effective protocols for the isolation and de-isolation of patients with suspected pulmonary tuberculosis (PTB) are essential determinants of health-care costs. Early de-isolation needs to be balanced with the need to prevent nosocomial transmission of PTB. The aim of our study was to evaluate the efficiency of our hospital's current protocol for isolating and de-isolating patients with suspected PTB, in particular assessing the timeliness to de-isolation of patients with AFB smear negative respiratory samples.

METHODS

We retrospectively reviewed 121 patients with suspected PTB who were admitted to our hospital's isolation ward. We analyzed the time spent in isolation, the total number of respiratory samples that were collected for each patient and the time taken from collection of the first respiratory sample to release of the result of third respiratory sample for acid-fast bacilli (AFB) smear. We also calculated the direct cost of isolation for each patient.

RESULTS

The mean and median number of AFB smears for each patient was three. Thirty percent of patients had four or more AFB smears taken and 20% were de-isolated before the results of three negative AFB smears were obtained. The mean duration of isolation was significantly shorter in patients who had fewer than three negative AFB smears compared to those who had three or more negative AFB smears (three days vs. five days, p <0.01). The mean cost in patients who were de-isolated before three negative smears were obtained was USD 947 compared to USD 1,636 in those were only de-isolated after three negative AFB smears (p <0.01).

CONCLUSIONS

Our study suggests that our institution's current infection control policy for the isolation of patients with suspected PTB is fairly satisfactory, but may need to be tightened further to prevent true cases of PTB being de-isolated prematurely. However, there may be instances when patients could potentially be de-isolated more quickly without risk to others, thus saving on the use of limited resources and costs to patients.

Vancomycin versus daptomycin for the treatment of methicillin-resistant Staphylococcus aureus bacteremia due to isolates with high vancomycin minimum inhibitory concentrations: study protocol for a phase IIB randomized controlled trial

BACKGROUND

Vancomycin is the standard first-line treatment for methicillin-resistant Staphylococcus aureus bacteremia. However, recent consensus guidelines recommend that clinicians consider using alternative agents such as daptomycin when the vancomycin minimum inhibitory concentration is greater than 1 ug/ml. To date however, there have been no head-to-head randomized trials comparing the safety and efficacy of daptomycin and vancomycin in the treatment of such infections. The primary aim of our study is to compare the efficacy of daptomycin versus vancomycin in the treatment of bloodstream infections due to methicillin-resistant Staphylococcus aureus isolates with high vancomycin minimum inhibitory concentrations (greater than or equal to 1.5 ug/ml) in terms of reducing all-cause 60-day mortality.

METHODS/DESIGN

The study is designed as a multicenter prospective open label phase IIB pilot randomized controlled trial. Eligible participants will be inpatients over 21-years-old with a positive blood culture for methicillin-resistant Staphylococcus aureus with vancomycin minimum inhibitory concentration of greater than or equal to 1.5 ug/ml. Randomization into intervention or active control arms will be performed with a 1:1 allocation ratio. We aim to recruit 50 participants over a period of two years. Participants randomized to the active control arm will receive vancomycin dose-while those randomized to the intervention arm will receive daptomycin. Participants will receive a minimum of 14 days study treatment.The primary analysis will be conducted on the intention-to-treat principle. The Fisher's exact test will be used to compare the 60-day mortality rate from index blood cultures (primary endpoint) between the two treatment arms, and the exact two-sided 95% confidence interval will be calculated using the Clopper and Pearson method. Primary analysis will be conducted using a two sided alpha of 0.05.

DISCUSSION

If results from this pilot study suggest that daptomycin shows significant efficacy in the treatment of bloodstream infections due to methicillin-resistant Staphylococcus aureus isolates with high vancomycin minimum inhibitory concentrations, we aim to proceed with a larger scale confirmatory study. This would help guide clinicians and inform practice guidelines on the optimal treatment for such infections.

TRIAL REGISTRATION

The trial is listed on clinicaltrials.gov (NCT01975662, date of registration: 29 October 2013).

Severe Infection with H1N1 Requiring Intensive Care – Lessons for Preparedness Programmes

Introduction: The influenza pandemic has generated much interest in the press and the medical world. We report our experience with 15 cases of severe novel influenza A H1N1 (2009) infections requiring intensive care. The aim of this review is to improve our preparedness for epidemics and pandemics by studying the most severely affected patients. Clinical Picture: During the epidemic, hospitals were required to provide data on all confirmed H1N1 cases admitted to an intensive care unit (ICU) to the Ministry of Health. We abstracted information from this dataset for this report. To highlight learning points, we reviewed the case notes of, and report, the five most instructive cases. Treatment: There were 15 cases admitted to an ICU from July 4, 2009 to August 30, 2009. Two patients died. Conclusions: The lessons we wish to share include the following: preparedness should include having intermediate-care facilities that also provide single room isolation and skilled nursing abilities, stringent visitor screening should be implemented and influenza may trigger an acute myocardial infarction in persons with risk factors. Key words: Influenza pandemic, Preparedness for epidemic, Visitor screening

Independent Predictors for Mortality in Patients with Positive Stenotrophomonas maltophilia Cultures

Introduction: Stenotrophomonas maltophilia is an emerging pathogen in nosocomial infections that may result in high mortality. S. maltophilia often present as part of a polymicrobial culture and it is not well established when treatment is indicated. We aimed to identify predictors of mortality in patients with positive cultures of S. maltophilia. Materials and Methods: A retrospective cohort study in a tertiary care medical centre was performed in 150 adult patients with positive cultures of S. maltophilia. Patients’ demographics, underlying diseases, severity of illness, length of hospitalisation, prior antibiotic exposure, number/types of indwelling catheters, culture sites, and appropriateness of empiric therapy were collected. Logistic regression was used to determine the independent risk factor(s) for infection-attributed mortality. Results: Ninetynine males and 51 females were studied. The mean (SD) age and APACHE II score of the patients were 61.9 (16.0) and 14.0 (6.1), respectively. The respiratory tract was the most frequent site (55.3%) where S. maltophilia was isolated. Infection-attributed mortality was observed in 22 of the 150 patients (14.7 %). Admission to ICU [Odds ratio (OR), 3.767; 95% confidence interval (CI), 1.277-11.116, P = 0.016], and delayed effective treatment (OR, 18.684; 95% CI, 4.05086.188; P <0.001) were identified as independent risk factors for mortality. Conclusions: Predictors of mortality in patients with positive cultures of S. maltophilia were identified, which may guide clinicians in patient assessment and devising therapeutic decisions. Further studies are needed to validate our results. Key words: Outcomes, Predictors, Stenotrophomonas maltophilia