Indirect impact of PCV10 children vaccination on the serotype distribution and antimicrobial resistance of Streptococcus pneumoniae causing invasive disease in adults over 50 in Colombia, 2005-2019: Observational analysis.

INTRODUCTION: The introduction of pneumococcal conjugate vaccine (PCV) into childhood vaccination programmes has reduced the prevalence of vaccine serotypes (VTs) that cause invasive pneumococcal disease (IPD) in children. In the elderly population, an impact has also been seen through indirect protection (herd effect). The aim of this study was to estimate the changes in serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae isolates recovered from adult IPD and to evaluate the indirect effect of immunization with PCV10 based on laboratory records by analyzing the period from 2005 to 2019 for six years before and eight years after the universal PCV10 administration to Colombian children. METHODS: A total of 2204 S. pneumoniae isolates from adults (≥50 years) with IPD were analyzed. The analysis examined the percentage changes in proportions (prevalence) and percentage variations in population rates (annual reported rates - ARR) of VTs between the pre-PCV10 (2005-2009) and post-PCV10 (2015-2019) periods. RESULTS: The findings were (1) evidence of a significant percentage decrease of pneumococcal VT10 causing IPD in adults (50% pre-PCV10 and 16% post-PCV10); (2) significant increase of serotype 19A (from 1.6% to 14.8%) and less important increase of serotype 3 (from 10.5% to 14.5%) and non-vaccine serotypes (NVT) (from 21.4% to 38.4%) non-significant; and (3) meningitis and non-meningitis multidrug resistant isolates associated with serotype 19A. An improvement in the surveillance system is associated with the immunization of children, as noted by the increased ARRs across the analysis period. CONCLUSIONS: Our results show the indirect impact of PCV10 vaccination in children on the VT10 distribution and antimicrobial resistance of S. pneumoniae causing IPD in Colombian adults over 50 when comparing the pre-PCV10 (2005-2009) and post-PCV10 (2015-2019) periods.

Trends in invasive bacterial diseases during the first 2 years of the COVID-19 pandemic: analyses of prospective surveillance data from 30 countries and territories in the IRIS Consortium.

BACKGROUND: The Invasive Respiratory Infection Surveillance (IRIS) Consortium was established to assess the impact of the COVID-19 pandemic on invasive diseases caused by Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, and Streptococcus agalactiae. We aimed to analyse the incidence and distribution of these diseases during the first 2 years of the COVID-19 pandemic compared to the 2 years preceding the pandemic. METHODS: For this prospective analysis, laboratories in 30 countries and territories representing five continents submitted surveillance data from Jan 1, 2018, to Jan 2, 2022, to private projects within databases in PubMLST. The impact of COVID-19 containment measures on the overall number of cases was analysed, and changes in disease distributions by patient age and serotype or group were examined. Interrupted time-series analyses were done to quantify the impact of pandemic response measures and their relaxation on disease rates, and autoregressive integrated moving average models were used to estimate effect sizes and forecast counterfactual trends by hemisphere. FINDINGS: Overall, 116 841 cases were analysed: 76 481 in 2018-19, before the pandemic, and 40 360 in 2020-21, during the pandemic. During the pandemic there was a significant reduction in the risk of disease caused by S pneumoniae (risk ratio 0·47; 95% CI 0·40-0·55), H influenzae (0·51; 0·40-0·66) and N meningitidis (0·26; 0·21-0·31), while no significant changes were observed for S agalactiae (1·02; 0·75-1·40), which is not transmitted via the respiratory route. No major changes in the distribution of cases were observed when stratified by patient age or serotype or group. An estimated 36 289 (95% prediction interval 17 145-55 434) cases of invasive bacterial disease were averted during the first 2 years of the pandemic among IRIS-participating countries and territories. INTERPRETATION: COVID-19 containment measures were associated with a sustained decrease in the incidence of invasive disease caused by S pneumoniae, H influenzae, and N meningitidis during the first 2 years of the pandemic, but cases began to increase in some countries towards the end of 2021 as pandemic restrictions were lifted. These IRIS data provide a better understanding of microbial transmission, will inform vaccine development and implementation, and can contribute to health-care service planning and provision of policies. FUNDING: Wellcome Trust, NIHR Oxford Biomedical Research Centre, Spanish Ministry of Science and Innovation, Korea Disease Control and Prevention Agency, Torsten Söderberg Foundation, Stockholm County Council, Swedish Research Council, German Federal Ministry of Health, Robert Koch Institute, Pfizer, Merck, and the Greek National Public Health Organization.

Fearing Pain at the End of Life: A Review of Advance Directives.

BACKGROUND: Patients, caregivers, and healthcare professionals often describe a "good death" as a pain-free process. However, many patients experience pain during their last weeks of life. Advance directives (ADs) are legally binding documents that allow individuals to express their wishes for end-of-life care which should include management of their pain. METHODS: An interprofessional team conducted a comprehensive analysis of ADs from all 50 states and the District of Columbia to assess the inclusion of language that reflects patients' wishes for pain relief at the end of life. RESULTS: Thirty-seven (73%) of the 51 entities examined reflected the prototypical directive, containing explicit instructions for withholding or withdrawing interventions that may prolong suffering rather than options for treating pain. Of these, 12 (24%) did not include the word "pain". Only 14 states (27%) provided clear guidance for managing pain. Unexpectantly, researchers found that 13 (25%) addressed the common fears of patients, caregivers, and healthcare teams when using opioids to relieve suffering, such as addiction, sedation, appetite, or respiratory suppression, and hastening death. CONCLUSION: The majority of ADs reviewed lacked clear and comprehensive measures for addressing pain relief. This deficiency may contribute to the undertreatment of pain and amplify the anxiety felt by patients, families, and healthcare providers when making end-of-life decisions. The results highlight the need for improvements in ADs to help ensure that patients' wishes regarding pain management are adequately addressed, documented and respected.

Distribution, frequency and clinical presentation of leptospirosis and coinfections: a systematic review protocol.

INTRODUCTION: Leptospirosis is a zoonotic disease with high prevalence in low-income and middle-income countries and tropical and subtropical regions. The clinical symptoms of the disease are similar to symptoms presented by other endemic infectious diseases that could be present simultaneously. Thus, leptospirosis could be masked by similar infections like dengue, malaria, hantavirus, melioidosis and borreliosis, among others. Therefore, leptospirosis could present itself as an under-reported infection or as a coinfection with another pathogen, as has been reported in the literature. However, there is a lack of documented evidence about the specific risk factors of leptospirosis infection, the symptoms, the coinfection's mortality and the frequency of coinfection. Additionally, leptospirosis coinfections have not been considered a neglected public health concern. Therefore, this systematic review aims to evaluate published articles that show the risk factors associated with leptospirosis infection and coinfection with other pathogens. METHODS AND ANALYSIS: The search process to identify eligible studies will be conducted including the LILACS, ProQuest, PubMed and Scopus databases with no restriction in terms of publication date. Also, grey literature will be included in the research. Authors will independently screen the title and abstracts of the articles identified from the search using Rayyan free software. Eligibility criteria include peer-reviewed research articles written in English or Spanish, including observational studies, cohorts, case-control, cross-sectional, ecological studies and report cases. The systematic review will include studies that report descriptions of leptospirosis cases with coinfection or co-occurrence. The search will be accomplished by articles from 1950 to May 2022. The data will be extracted in a standard extraction form using an Excel format. ETHICS AND DISSEMINATION: Results will be published in a peer-reviewed journal. Also, findings will be disseminated through scientific meetings. Ethical approval will not be required as this is a systematic review and primary data will be not collected or included. PROSPERO REGISTRATION NUMBER: CRD42021234754.

Laboratory-based surveillance of Shigella spp. from human clinical cases in Colombia, 1997-2018 / Vigilancia por el laboratorio de Shigella spp. aislada de casos clínicos humanos en Colombia, 1997-2018

INTRODUCTION: Shigellosis is endemic in low-and middle-income countries, causing approximately 125 million episodes of diarrhea and leading to approximately 160 .000 deaths annually one-third of which is associated with children. OBJECTIVE: To describe the characteristics and antimicrobial resistance profiles of Shigella species recovered in Colombia from 1997 to 2018. MATERIALS AND METHODS: We received isolates from laboratories in 29 Colombian departments. We serotyped with specific antiserum and determined antimicrobial resistance and minimal inhibitory concentrations for ten antibiotics with Kirby-Bauer tests following the Clinical and Laboratory Standards Institute recommendations. RESULTS: We analyzed 5,251 isolates of Shigella spp., most of them obtained from stools (96.4%); 2,511 (47.8%) were from children under five years of age. The two most common species were S. sonnei (55.1%) and S. flexneri (41.7%). The highest resistance rate was that of tetracycline (88.1%) followed by trimethoprim-sulfamethoxazole (79.3%) and ampicillin (65.5%); 50.8% of isolates were resistant to chloramphenicol, 43.6% to amoxicillin/clavulanic acid, and less than 1% to cefotaxime, ceftazidime, gentamicin, and ciprofloxacin. In S. sonnei, the most common resistance profile corresponded to trimethoprim-sulfamethoxazole (92%) whereas in S. flexneri the most common antibiotic profiles were multidrug resistance. CONCLUSIONS: In Colombia, children under five years are affected by all Shigella species. These findings should guide funders and public health officials to make evidence based decisions for protection and prevention measures. The antimicrobial resistance characteristics found in this study underline the importance of combating the dissemination of the most frequently isolated species, S. sonnei and S. flexneri.

Introducción. La shigelosis es endémica en los países de ingresos bajos y medios y ocasiona aproximadamente 125 millones de episodios de diarrea y 160.000 muertes al año, un tercio de los cuales se presenta en niños. Objetivo. Describir las características y los perfiles de resistencia antimicrobiana en aislamientos de Shigella spp. recuperados en Colombia entre 1997 y 2018. Materiales y métodos. Los aislamientos provenían de laboratorios en 29 departamentos de Colombia. La serotipificación se hizo con antisueros específicos de Shigella spp. y, la determinación de los perfiles de resistencia y la concentración inhibitoria mínima de diez antibióticos, por Kirby-Bauer. Resultados. Se estudiaron 5.251 aislamientos de Shigella spp. obtenidos de materia fecal (96,4 %); el 47,8 % de ellos correspondía a niños menores de cinco años. Las especies más frecuentes fueron S. sonnei (55,1 %) y S. flexneri (41,7 %). Se presentó resistencia a tetraciclina (88,1 %), trimetoprim-sulfametoxasol (79,3 %), ampicilina (65,5 %), cloranfenicol (50,8 %) y amoxicilina-acido clavulánico (43,6 %). La resistencia no superó el 1 % contra cefotaxime, ceftazidima, gentamicina y ciprofloxacina. Para S. sonnei, el perfil de resistencia más frecuente correspondió a trimetoprim-sulfametoxasol, en contraste con S. flexneri, cuyos perfiles fueron todos multirresistentes. Conclusiones. Los niños menores de cinco años se vieron afectados por todas las especies de Shigella spp., aspecto que los legisladores en salud pública deben considerar a la hora de tomar decisiones en torno a las medidas de prevención y protección frente a esta enfermedad. Las características de resistencia antimicrobiana de los aislamientos de Shigella spp. en Colombia ponen de manifiesto la importancia de combatir la diseminación de las dos especies más frecuentes en casos clínicos, S. sonnei y S. flexneri.

Laboratory-based surveillance of Shigella spp. from human clinical cases in Colombia, 1997-2018 / Vigilancia por el laboratorio de Shigella spp. aislada de casos clínicos humanos en Colombia, 1997-2018

Abstract | Introduction: Shigellosis is endemic in low-and middle-income countries, causing approximately 125 million episodes of diarrhea and leading to approximately 160.000 deaths annually one-third of which is associated with children. Objective: To describe the characteristics and antimicrobial resistance profiles of Shigella species recovered in Colombia from 1997 to 2018. Materials and methods: We received isolates from laboratories in 29 Colombian departments. We serotyped with specific antiserum and determined antimicrobial resistance and minimal inhibitory concentrations for ten antibiotics with Kirby-Bauer tests following the Clinical and Laboratory Standards Institute recommendations. Results: We analyzed 5,251 isolates of Shigella spp., most of them obtained from stools (96.4%); 2,511 (47.8%) were from children under five years of age. The two most common species were S. sonnei (55.1%) and S. fbxneri (41.7%). The highest resistance rate was that of tetracycline (88.1%) followed by trimethoprim-sulfamethoxazole (79.3%) and ampicillin (65.5%); 50.8% of isolates were resistant to chloramphenicol, 43.6% to amoxicillin/clavulanic acid, and less than 1% to cefotaxime, ceftazidime, gentamicin, and ciprofloxacin. In S. sonnei, the most common resistance profile corresponded to trimethoprim-sulfamethoxazole (92%) whereas in S. fbxneri the most common antibiotic profiles were multidrug resistance. Conclusions. In Colombia, children under five years are affected by all Shigella species. These findings should guide funders and public health officials to make evidence-based decisions for protection and prevention measures. The antimicrobial resistance characteristics found in this study underline the importance of combating the dissemination of the most frequently isolated species, S. sonnei and S. ftexneri.

Resumen | Introducción. La shigelosis es endémica en los países de ingresos bajos y medios y ocasiona aproximadamente 125 millones de episodios de diarrea y 160.000 muertes al año, un tercio de los cuales se presenta en niños. Objetivo. Describir las características y los perfiles de resistencia antimicrobiana en aislamientos de Shigella spp. recuperados en Colombia entre 1997 y 2018. Materiales y métodos. Los aislamientos provenían de laboratorios en 29 departamentos de Colombia. La serotipificación se hizo con antisueros específicos de Shigella spp. y, la determinación de los perfiles de resistencia y la concentración inhibitoria mínima de diez antibióticos, por Kirby-Bauer. Resultados. Se estudiaron 5.251 aislamientos de Shigella spp. obtenidos de materia fecal (96,4 %); el 47,8 % de ellos correspondía a niños menores de cinco años. Las especies más frecuentes fueron S. sonnei (55,1 %) y S. ftexneri (41,7 %). Se presentó resistencia a tetraciclina (88,1 %), trimetoprim-sulfametoxasol (79,3 %), ampicilina (65,5 %), cloranfenicol (50,8 %) y amoxicilina-acido clavulánico (43,6 %). La resistencia no superó el 1 % contra cefotaxime, ceftazidima, gentamicina y ciprofloxacina. Para S. sonnei, el perfil de resistencia más frecuente correspondió a trimetoprim-sulfametoxasol, en contraste con S. ftexneri, cuyos perfiles fueron todos multirresistentes. Conclusiones. Los niños menores de cinco años se vieron afectados por todas las especies de Shigella spp., aspecto que los legisladores en salud pública deben considerar a la hora de tomar decisiones en torno a las medidas de prevención y protección frente a esta enfermedad. Las características de resistencia antimicrobiana de los aislamientos de Shigella spp. en Colombia ponen de manifiesto la importancia de combatir la diseminación de las dos especies más frecuentes en casos clínicos, S. sonnei y S. ftexneri.

Genomic Diversity of Burkholderia pseudomallei Isolates, Colombia.

We report an analysis of the genomic diversity of isolates of Burkholderia pseudomallei, the cause of melioidosis, recovered in Colombia from routine surveillance during 2016-2017. B. pseudomallei appears genetically diverse, suggesting it is well established and has spread across the region.

Prenatal alcohol exposure prevalence as measured by direct ethanol metabolites in meconium in a Native American tribe of the southwest.

BACKGROUND: Although fetal alcohol spectrum disorders represent a significant public health problem, Native Americans are underrepresented in population and targeted screening programs. Prior reports suggest that Native American tribal communities may have a higher prevalence of alcohol use during pregnancy; however, systematic examination using ethanol biomarkers is lacking. METHODS: This study utilized data collected through the Navajo Birth Cohort Study (NBCS)-a birth cohort study of a Southwestern tribal community. Prevalence of prenatal alcohol exposure (PAE) was assessed by a battery of meconium biomarkers among 333 NBCS participants. Meconium samples were analyzed for nine individual fatty acid ethyl ester (FAEE) species, ethyl glucuronide (EtG), and ethyl sulfate (EtS) by LC-MS/MS. RESULTS: Participants were recruited from five hospitals at the Navajo Nation located in Arizona (Chinle, Tséhootsooí, Tuba City) and New Mexico (Gallup, Shiprock). All participants identified as Native American; most reported a personal income of <$20,000 per year (71.3%), and ≤high school education (55.3%). The most prevalent biomarker was EtS (7.8%) followed by ethyl oleate (6.9%); 5.4% of the sample were positive for at least two biomarkers. CONCLUSIONS: Results of this study on the prevalence of PAE in the Navajo Nation, obtained for the first time with an objective comprehensive panel of meconium biomarkers, indicate that the rates in the NBCS may be comparable to the general U.S. population and are in accord with recent U.S. national survey estimates. Our findings emphasize that drinking behaviors among Native American communities in the United States can vary, and generalization across all Native American populations is not warranted.

Barriers and facilitators to dispensing of intranasal naloxone by pharmacists.

BACKGROUND: Although misuse of prescription opioids has reached epidemic proportions, pharmacy-based preventive services to combat this epidemic are limited. The aims of this study were to identify barriers and facilitators to the dispensing of intranasal naloxone (INN) by pharmacists in New Mexico. METHODS: For this mixed-methods study, a qualitative component (focus group) informed the development of a quantitative component (electronic survey) distributed to all pharmacists registered with the New Mexico Board of Pharmacy and practicing in the state. A 46-item survey included questions about pharmacists' concerns regarding dispensing INN, barriers and facilitators to dispensing INN, efforts needed to increase availability and utilization of pharmacist-dispensed INN, and characteristics of respondents and their pharmacies. RESULTS: Pharmacists from all geographical regions and all types of pharmacy settings were represented in the sample (final N = 390, participation rate 23.5%, including a subset of 182 community pharmacists). The main barriers identified were (1) out-of-pocket costs for patients; (2) time constraints for pharmacists; and (3) inadequate reimbursement for pharmacists. The main facilitators were (1) increased awareness among opioid-using patients and family members about the need for INN; (2) additional education to the general public; and (3) additional training for pharmacists on how to initiate discussions about INN with high-risk patients. Some community pharmacists were concerned that INN dispensing would promote opioid abuse (16.5%) and attract undesirable clientele (14.3%). In a multivariable logistic regression analysis of a community pharmacy subset, a higher number of concerns about INN (odds ratio [OR] = 0.87; 95% confidence interval [CI]: 0.82-0.93) and a pharmacy setting in a chain grocery or a "big box" store (OR = 0.38; 95% CI: 0.16-0.92) were associated with decreased odds of dispensing INN. CONCLUSIONS: Effective intervention strategies for increasing dispensing of intranasal naloxone by pharmacists should focus on pharmacists' concerns, include education to multiple audiences, and address provider-level, system-level, and society-level barriers.

Laboratory surveillance of Salmonella enterica from human clinical cases in Colombia 2005-2011. / Vigilancia por laboratorio de Salmonella enterica en casos clínicos humanos en Colombia 2005 a 2011.

INTRODUCTION: Salmonella is an enteropathogen acquired through contaminated food or water. In Colombia, Salmonella spp. is included in the national surveillance of Acute Diarrhoeal Diseases and typhoid fever initiated in 1997. This report shows the phenotype and genotype results obtained from 2005 to 2011. METHODS: A total of 4010 isolates of Salmonella enterica were analysed by serotyping with Kauffmann-White-LeMinor, antimicrobial resistance patterns, and pulse-field gel electrophoresis (PFGE). RESULTS: A total of 93 serovars were identified, of which, Typhimurium, Enteritidis, Typhi, Dublin, Panama, Derby, Braenderup, Saintpaul, and Uganda were prominent. The highest levels of resistance were found for tetracycline and nalidixic acid. Susceptibility was observed in 52.4% (2101/4010) of the isolates. Multi-resistance was recorded in 54.9% of Typhimurium isolates, with 81 different combinations. Using PFGE, 51.9% (2083/4010) isolates were analysed in 34 serovars, and 828 electrophoretic patterns were obtained. From these, 8 patterns were found in at least two Latin-American countries. CONCLUSION: The surveillance of Salmonella spp. provides information on the serovar distribution, antimicrobial resistance, and clonal distribution in Colombia, as well as information to treat this disease and control the spread of antimicrobial bacterial resistance.

Caracterización molecular de aislamientos de Shigella sonnei recuperados en el programa de vigilancia por el laboratorio de la enfermedad diarreica aguda en Colombia / Molecular characterization of Shigella sonnei isolates recovered by the Laboratory Surveillance Program for Acute Diarrheal Disease in Colombia

Introducción. En Colombia, Shigella sonnei es uno de los serotipos más frecuentemente aislados (53,4 %) de muestras clínicas humanas asociadas a la enfermedad diarreica aguda. La identificación de patrones de restricción del ADN mediante electroforesis en gel de campo pulsado constituye la base de la vigilancia molecular de S. sonnei . Objetivo. Establecer la base de la vigilancia molecular de S. sonnei en Colombia mediante electroforesis en gel de campo pulsado. Materiales y métodos. Se estudiaron 102 de los 2.048 aislamientos de S. sonnei remitidos por la Red Nacional de Laboratorios entre 1997 y marzo del 2013; la selección se hizo de acuerdo con el patrón de resistencia antimicrobiana, el origen de la muestra y la relación con brotes. Se determinó el patrón genético mediante electroforesis en gel de campo pulsado con las enzimas de restricción XbaI y Blnl, según el protocolo de la red PulseNet International. El análisis de los patrones electroforéticos se hizo con el programa GelCompar II, versión 4.0. Resultados. Se obtuvieron 42 patrones electroforéticos con una similitud de 70 a 100 %. El patrón más frecuente fue COIN08J16X01.0017 (17,6 %), seguido por los patrones COIN04J16X01.0004 (9,8 %) y COIN02J16X01.0002 (5,8 %), y el 66,8 % restante se asoció con otros patrones electroforéticos. El análisis de brotes demostró la relación genética de cada brote con 100 % de similitud en la identificación; el patrón más frecuente en los brotes fue el COIN08J16X01.0017 (17,1 %). Conclusión. Se estableció la base de datos genotípicos de aislamientos de S. sonnei a nivel nacional mediante electroforesis en gel de campo pulsado; se incluyeron los 42 patrones únicos identificados en este estudio.

Introduction: In Colombia, Shigella sonnei is one of the most frequently isolated serotypes (53.4%) in human clinical samples associated with diarrheal acute disease. The identification of DNA restriction patterns by pulsed field gel electrophoresis is the basis for the molecular surveillance of S. sonnei . Objective: To establish the basis for the molecular surveillance of S. sonnei in Colombia using pulsed-field gel electrophoresis. Materials and methods: We studied 102 of 2,048 S. sonnei isolates referred by the National Laboratory Network between 1997 and March, 2013; the selection was made according to the antimicrobial multiresistance profile, the source of samples, and the relation to outbreaks. The genetic profile was determined by pulsed field gel electrophoresis using the restriction enzymes XbaI and BlnI in accordance with the PulseNet International protocol. The electrophoretic patterns were analyzed with the GelCompare II, version 4.0 software. Results: We obtained 42 electrophoretic patterns with a 70% to 100% similarity. The most frequent pattern was COIN08J16X01.0017 with 17.6%, followed by patterns COIN04J16X01.0004 with 9.8%, and COIN02J16X01.0002 with 5.8%, while the remaining 66.8% was associated with other electrophoretic patterns. The analysis of 10 outbreaks demonstrated their genetic relation with a 100% of similarity; the most frequent pattern in outbreaks was COIN08J16X01.0017 with 17.1%. Conclusion: The genotypic database for Shigella sonnei isolates was established using pulsed field gel electrophoresis including the 42 unique patterns identified in this study.

[Molecular characterization of Shigella sonnei isolates recovered by the Laboratory Surveillance Program for Acute Diarrheal Disease in Colombia]. / Caracterización molecular de aislamientos de Shigella sonnei recuperados en el programa de vigilancia por el laboratorio de la enfermedad diarreica aguda en Colombia.

INTRODUCTION: In Colombia, Shigella sonnei is one of the most frequently isolated serotypes (53.4%) in human clinical samples associated with diarrheal acute disease. The identification of DNA restriction patterns by pulsed field gel electrophoresis is the basis for the molecular surveillance of S. sonnei . OBJECTIVE: To establish the basis for the molecular surveillance of S. sonnei in Colombia using pulsed-field gel electrophoresis. MATERIALS AND METHODS: We studied 102 of 2,048 S. sonnei isolates referred by the National Laboratory Network between 1997 and March, 2013; the selection was made according to the antimicrobial multiresistance profile, the source of samples, and the relation to outbreaks. The genetic profile was determined by pulsed field gel electrophoresis using the restriction enzymes XbaI and BlnI in accordance with the PulseNet International protocol. The electrophoretic patterns were analyzed with the GelCompare II, version 4.0 software. RESULTS: We obtained 42 electrophoretic patterns with a 70% to 100% similarity. The most frequent pattern was COIN08J16X01.0017 with 17.6%, followed by patterns COIN04J16X01.0004 with 9.8%, and COIN02J16X01.0002 with 5.8%, while the remaining 66.8% was associated with other electrophoretic patterns. The analysis of 10 outbreaks demonstrated their genetic relation with a 100% of similarity; the most frequent pattern in outbreaks was COIN08J16X01.0017 with 17.1%. CONCLUSION: The genotypic database for Shigella sonnei isolates was established using pulsed field gel electrophoresis including the 42 unique patterns identified in this study.

Warfarin anticoagulation after total hip or total knee replacement: clinical and resource-utilization outcomes in a university-based antithrombosis clinic.

PURPOSE: Clinical and resource-utilization outcomes associated with warfarin anticoagulation after major orthopedic surgery were evaluated. METHODS: Consecutive patients who received postsurgical prophylaxis with warfarin within 24 hours of total knee replacement (TKR) or total hip replacement (THR) surgery and who were referred to and had outpatient follow-up for anticoagulation management in a single-center, university-based antithrombosis clinic from January 1, 1998, to January 1, 2009, were included in the study. Data were obtained from existing inpatient and outpatient medical records and retrospectively reviewed. Patient follow-up and data collection were conducted from the time of admission until 90 days after surgery. RESULTS: A total of 400 patients were included in the study; 179 (44.8%) underwent THR and 221 (55.3%) underwent TKR. The mean length of hospital stay was 5.0 ± 1.9 days, and the mean length of warfarin therapy was 50 ± 21 days. The mean time required to reach the target International Normalized Ratio (INR) of 2.0-3.0 was 10.0 ± 9.1 days. The within-patient percentage of INR levels spent in the target range was 28% ± 18%. Objectively confirmed symptomatic venous thromboembolism (VTE) occurred in 16 patients (4%), with 14 events (87.5%) occurring with INR values of ≤2.0 and 2 events (12.5%) occurring with INR values of >2.0. CONCLUSION: THR and TKR surgical patients at one institution who were receiving postsurgical VTE prophylaxis with warfarin spent a substantial proportion of time with their INR below the target range and had a high rate of symptomatic VTE.

The validity of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for identifying patients hospitalized for COPD exacerbations.

BACKGROUND: Acute exacerbations of COPD (AE-COPD) are a leading cause of hospitalizations in the United States. To estimate the burden of disease (eg, prevalence and cost), identify opportunities to improve care quality (eg, performance measures), and conduct observational comparative effectiveness research studies, various algorithms based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes have been used to identify patients with COPD. However, the validity of these algorithms remains unclear. METHODS: We compared the test characteristics (sensitivity, specificity, positive predictive value, and negative predictive value) of four different coding algorithms for identifying patients hospitalized for an exacerbation of COPD with chart review (reference standard) using a stratified probability sample of 200 hospitalizations at two urban academic medical centers. Sampling weights were used when calculating prevalence and test characteristics. RESULTS: The prevalence of COPD exacerbations (based on the reference standard) was 7.9% of all hospitalizations. The sensitivity of all ICD-9-CM algorithms was very low and varied by algorithm (12%-25%), but the negative predictive value was similarly high across algorithms (93%-94%). The specificity was > 99% for all algorithms, but the positive predictive value varied by algorithm (81%-97%). CONCLUSIONS: Algorithms based on ICD-9-CM codes will undercount hospitalizations for AE-COPD, and as many as one in five patients identified by these algorithms may be misidentified as having a COPD exacerbation. These findings suggest that relying on ICD-9-CM codes alone to identify patients hospitalized for AE-COPD may be problematic.

Hospitalizations for acute exacerbations of chronic obstructive pulmonary disease: how you count matters.

ICD-9-CM diagnosis codes are increasingly used to estimate the burden of disease, as well as to evaluate the quality of care and outcomes of various conditions. Acute exacerbations of COPD (AE-COPD) are common and associated with substantial health and financial burden in the U.S. Whether published algorithms that employ different combinations of ICD-9-CM codes to identify patients hospitalized for AE-COPD yield similar or different estimates of disease burden is unclear. In this study, the Nationwide Inpatient Sample from years 2000-2006 was used to identify and compare the number of hospitalizations, healthcare utilization, and outcomes for patients hospitalized for AE-COPD in the U.S. AE-COPD was identified using five different published ICD-9-CM algorithms. Estimates of the annual number of hospitalizations for AE-COPD in the U.S. varied more than 2-fold (e.g., 421,000 to 870,000 in 2006). Outcomes and healthcare utilization of patients hospitalized for AE-COPD varied substantially, depending on the algorithm used (e.g., in-hospital mortality 2.0% to 5.1%, total hospital days 2.0 to 5.1 million in 2006). Observed trends in the number of hospitalizations over the 7-year period varied depending on which algorithm was used. In conclusion, the estimated health burden and trends in hospitalizations for AE-COPD in the United States differ, depending on which ICD-9-CM algorithm is used. To improve our understanding of the burden of AE-COPD and to ensure that quality of care initiatives are not misdirected, a validated approach to identifying patients hospitalized for AE-COPD is needed.