Pharmaceutical interventions in antiretroviral therapy: systematic review and meta-analysis of randomized clinical trials.

WHAT IS KNOWN AND OBJECTIVE: High levels of adherence to antiretroviral therapy (ART) are needed to achieve the desired results. Because pharmaceutical care might contribute to improved adherence to treatment, the aim of this study was to assess the impact of pharmaceutical interventions on ART via a systematic review of randomized clinical trials (RCT). METHODS: Study selection, data extraction and risk-of-bias assessment were performed independently by two reviewers. RESULTS AND DISCUSSION: A total of 681 studies were located; only four of these met the inclusion criteria and were analysed. The summary measure corresponding to the outcome adherence to treatment was 1·47 (95% confidence interval [CI]: 0·81-2·65), and the measure corresponding to the outcome virologic suppression was 1·95 (95% CI: 0·61-6·25). WHAT IS NEW AND CONCLUSION: The results suggest that pharmaceutical interventions might contribute to improved adherence to ART and the achievement of virologic suppression, although the differences between the intervention and control groups were not statistically significant. Pharmaceutical interventions might be more efficacious in populations with low adherence to treatment and greater vulnerability.

Secular trends in nosocomial bloodstream infections: antibiotic-resistant bacteria increase the total burden of infection.

BACKGROUND: It is unknown whether rising incidence rates of nosocomial bloodstream infections (BSIs) caused by antibiotic-resistant bacteria (ARB) replace antibiotic-susceptible bacteria (ASB), leaving the total BSI rate unaffected. METHODS: We investigated temporal trends in annual incidence densities (events per 100 000 patient-days) of nosocomial BSIs caused by methicillin-resistant Staphylococcus aureus (MRSA), ARB other than MRSA, and ASB in 7 ARB-endemic and 7 ARB-nonendemic hospitals between 1998 and 2007. RESULTS: 33 130 nosocomial BSIs (14% caused by ARB) yielded 36 679 microorganisms. From 1998 to 2007, the MRSA incidence density increased from 0.2 to 0.7 (annual increase, 22%) in ARB-nonendemic hospitals, and from 3.1 to 11.7 (annual increase, 10%) in ARB-endemic hospitals (P = .2), increasing the incidence density difference between ARB-endemic and ARB-nonendemic hospitals from 2.9 to 11.0. The non-MRSA ARB incidence density increased from 2.8 to 4.1 (annual increase, 5%) in ARB-nonendemic hospitals, and from 1.5 to 17.4 (annual increase, 22%) in ARB-endemic hospitals (P < .001), changing the incidence density difference from -1.3 to 13.3. Trends in ASB incidence densities were similar in both groups (P = .7). With annual increases of 3.8% and 5.4% of all nosocomial BSIs in ARB-nonendemic and ARB-endemic hospitals, respectively (P < .001), the overall incidence density difference of 3.8 increased to 24.4. CONCLUSIONS: Increased nosocomial BSI rates due to ARB occur in addition to infections caused by ASB, increasing the total burden of disease. Hospitals with high ARB infection rates in 2005 had an excess burden of BSI of 20.6 per 100 000 patient-days in a 10-year period, mainly caused by infections with ARB.

Impact of hospital-wide infection rate, invasive procedures use and antimicrobial consumption on bacterial resistance inside an intensive care unit.

We performed a 30-month ecological study to determine the impact of hospital-wide antibiotic consumption, invasive procedure use and hospital-acquired infections (HAIs) on antibiotic resistance in an intensive care unit (ICU). Microbiological isolates from ICU patients with established diagnosis of hospital infection were monitored throughout the study. Overall hospital consumption per 100 patient-days of piperacillin-tazobactam, fluoroquinolones and cephalosporins increased from 1.9 to 2.3 defined daily doses (DDD) (P<0.01), from 4.7 to 10.3 DDD (P<0.01) and from 12.1 to 16.4 DDD (P<0.01), respectively. Bacterial multiresistance in ICU was identified in 31.3% (N=466) of isolates, with increasing resistance demonstrated for meropenem-resistant Klebsiella spp. (P=0.01) and meropenem-resistant Acinetobacter spp. (P=0.02). There was a positive correlation between multiresistance rate and DDD of cephalosporins (P<0.01) and fluoroquinolones (P=0.03). The rate of ceftazidime-resistant Klebsiella spp. correlated with DDD of fluoroquinolones and cephalosporins; the rate of ceftazidime-resistant Pseudomonas spp. correlated with consumption of cephalosporins, and rate of meticillin-resistant Staphylococcus aureus (MRSA) correlated with fluoroquinolone use. During the studied period, 36.9% (P<0.001) and 34.5% (P<0.01) of the changing multiresistance rate in ICU was associated with use of invasive procedures and overall HAI rate, respectively. Multiresistance rates in ICU are influenced by the variation in overall HAI rate, hospital-wide invasive procedures and antibiotic consumption outside the ICU.

Compliance with a critical pathway for the management of febrile neutropenia and impact on clinical outcomes.

Febrile neutropenia is associated with significant morbidity and mortality. Managing infectious in neutropenic patients remains a dynamic process, making necessary timely and efficient empirical antibiotic therapy. The implementation of critical pathways has been suggested as a strategy to improve clinical effectiveness. This study evaluated the compliance with an institutional critical pathway for the management of febrile neutropenia and the impact on clinical outcomes at Hospital de Clínicas de Porto Alegre, Brazil (HCPA). We performed a cohort study that prospectively included patients hospitalized from January 2004 to December 2005 and presented febrile neutropenia (190 episodes). Historical controls were selected from March 2001 to April 2003 (193 episodes) before the critical pathway was introduced. This study showed a low rate of full compliance (21.6%; 95% CI 15.7-27.5) with the critical pathway. In most cases, there was partial compliance (67.9%; 95% CI 61.3-74.5). Despite the moderate adherence observed, we recorded a decrease in in-hospital all-cause mortality in the sample studied after protocol implementation (from 24.4 to 14.4%; P = 0.017) and reduction in the length of use of cephalosporin and quinolones. In conclusion, implementation of a critical pathway seems to be an effective strategy to improve clinical outcomes in patients hospitalized with febrile neutropenia.