RESUMO
BACKGROUND: Although disparities in COVID-19 outcomes have been observed, factors contributing to these differences are not well understood. OBJECTIVE: To determine whether COVID-19 hospitalization outcomes are related to neighborhood-level social vulnerability, independent of patient-level clinical factors. DESIGN: Pooled cross-sectional study of prospectively collected data. SETTING: 38 Michigan hospitals. PATIENTS: Adults older than 18 years hospitalized for COVID-19 in a participating site between March and December 2020. MEASUREMENTS: COVID-19 outcomes included acute organ dysfunction, organ failure, invasive mechanical ventilation, intensive care unit stay, death, and discharge disposition. Social vulnerability was measured by the social vulnerability index (SVI), a composite measure of social disadvantage. RESULTS: Compared with patients in low-vulnerability ZIP codes, those living in high-vulnerability ZIP codes were more frequently treated in the intensive care unit (29.0% vs. 24.5%); more frequently received mechanical ventilation (19.3% vs. 14.2%); and experienced higher rates of organ dysfunction (51.9% vs. 48.6%), organ failure (54.7% vs. 51.6%), and in-hospital death (19.4% vs. 16.7%). In mixed-effects regression analyses accounting for age, sex, and comorbid conditions, an increase in a patient's neighborhood SVI by 0.25 (1 quartile) was associated with greater likelihood of mechanical ventilation (increase of 2.1 percentage points), acute organ dysfunction (increase of 2.8 percentage points), and acute organ failure (increase of 2.8 percentage points) but was not associated with intensive care unit stay, mortality, or discharge disposition. LIMITATION: Observational data focused on hospitalizations in a single state. CONCLUSION: Hospitalized patients with COVID-19 from socially vulnerable neighborhoods presented with greater illness severity and required more intensive treatment, but once hospitalized they did not experience differences in hospital mortality or discharge disposition. Policies that target socially vulnerable neighborhoods and access to COVID-19 care may help ameliorate health disparities. PRIMARY FUNDING SOURCE: Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships Program, the Michigan Public Health Institute, and the Michigan Department of Health & Human Services.
Assuntos
COVID-19 , Adulto , COVID-19/epidemiologia , COVID-19/terapia , Estudos Transversais , Mortalidade Hospitalar , Hospitalização , Humanos , Insuficiência de Múltiplos Órgãos , Estudos Retrospectivos , SARS-CoV-2RESUMO
BACKGROUND: The risk of peripherally inserted central catheter (PICC)-related complications in patients hospitalized with solid tumors remains unclear. Existing studies are limited by single-center, outpatient designs and include heterogenous patients. METHODS: A retrospective cohort study was designed and included adult patients with solid organ cancers who were admitted to a general medicine ward or intensive care unit and received a PICC. Data were collected from November 2013 to December 2019 at 50 Michigan hospitals. Major complications were defined as central line-associated bloodstream infection, deep vein thrombosis, pulmonary embolism, and catheter occlusion. Hospital variation in PICC use and outcomes was examined. RESULTS: Data included 3235 hospitalized patients with solid tumors who had PICCs placed for 51,047 catheter days. Most catheters were double-lumen devices (57.0%). Notably, 17.5% of patients had another central venous catheter at the time of PICC insertion. The most common indications for PICC use were antibiotics (34.5%) and difficult access or blood draws (21.6%); chemotherapy was the primary indication in only 15.7% of patients. A major PICC-related complication occurred in 491 patients (15.2%); catheter occlusion was the most prevalent complication (n = 322; 10.0%) followed by deep vein thrombosis (n = 116; 3.6%), central line-associated bloodstream infection (n = 82; 2.5%), and pulmonary embolism (n = 20; 0.6%). Significant variation in indications for PICC use, device characteristics, and frequency of major complications across hospitals was observed (p < .001). CONCLUSIONS: PICCs were associated with significant complications in hospitalized patients who had solid malignancies and were often used for reasons other than chemotherapy. Policies and guidance for the appropriate use of PICCs in oncologic patients appear necessary. LAY SUMMARY: Peripherally inserted central catheters (PICCs) are devices placed in peripheral veins to deliver medication to large veins near the heart. PICCs are used frequently in oncology. The objective of this report was to describe PICC-associated complications in hospitalized patients with solid tumors. This study was performed across 50 Michigan hospitals and included 3235 patients with solid tumor cancers and who had a PICC. Overall, 15.2% of patients experienced a complication, including central line-associated bloodstream infections, deep vein thrombosis, pulmonary embolism, or catheter occlusion. Complication rates varied across hospitals. PICCs are associated with substantial complications in hospitalized patients with solid tumors.
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Cateterismo Venoso Central , Cateteres Venosos Centrais , Neoplasias , Embolia Pulmonar , Sepse , Trombose Venosa , Adulto , Antibacterianos/uso terapêutico , Cateterismo Venoso Central/efeitos adversos , Cateteres Venosos Centrais/efeitos adversos , Humanos , Neoplasias/complicações , Neoplasias/epidemiologia , Neoplasias/terapia , Embolia Pulmonar/complicações , Estudos Retrospectivos , Fatores de Risco , Trombose Venosa/epidemiologia , Trombose Venosa/etiologiaRESUMO
Venous thromboembolism (VTE) is an important complication of coronavirus disease 2019 (COVID-19). To date, few studies have described vascular access device use and VTE risk in this cohort. To examine the use of vascular access devices and incidence of VTE in patients hospitalized with COVID-19. We performed a retrospective, multi-center cohort study of patients hospitalized with COVID-19 who received a midline catheter, peripherally inserted central catheter (PICCs), tunneled or non-tunneled central venous catheter (CVC), hemodialysis (HD) catheter or a port during hospitalization. Mixed-effects multivariable logit models adjusting for VTE risk factors in the Caprini risk score were fit to understand the incremental risk of VTE in patients with vascular access devices vs. those that did not receive devices. Management of VTE was determined by examining anticoagulant use pre- vs. post-thrombosis. Results were expressed using odds ratios (ORs) and associated 95% confidence intervals (CI). A total of 1228 hospitalized COVID-19 patients in 40 hospitals, of which 261 (21.3%) received at least one vascular access device of interest, were included. The prevalence of acute, non-tunneled CVCs was 42.2%, acute HD catheters 18.4%, midline catheters 15.6%, PICCs 15.6%, tunneled CVCs 6.8%, and implanted ports 1.4%. The prevalence of VTE was 6.0% in the study cohort, and 10.0% among patients with vascular access devices. After adjusting for known VTE risk factors, patients that had a vascular access device placed were observed to have a four-fold greater odds of VTE than those that did not (OR 4.17, 95% CI 2.33-7.46). Patients who received multiple different catheters experienced more VTE events compared with patients that received only one type (21.5% vs. 6.1%, p < .001). Among the 26 patients with VTE, only 8 (30.8%) survived to discharge and among these, only 5 were discharged on therapeutic doses of anticoagulation. Hospitalized patients with COVID-19 that receive vascular access devices experienced higher rates of VTE than those that do not. Future studies to evaluate the nexus between COVID-19, vascular device use, and thrombosis appear are warranted.
Assuntos
COVID-19 , Cateterismo Venoso Central , Trombose , Dispositivos de Acesso Vascular , Tromboembolia Venosa , COVID-19/complicações , Cateterismo Venoso Central/efeitos adversos , Hospitais , Humanos , Michigan/epidemiologia , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2 , Trombose/epidemiologia , Trombose/etiologia , Dispositivos de Acesso Vascular/efeitos adversos , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologiaRESUMO
The type III secretion system (T3SS) of plant-pathogenic Pseudomonas syringae is essential for virulence. Genes encoding the T3SS are not constitutively expressed and must be induced upon infection. Plant-derived metabolites, including sugars such as fructose and sucrose, are inducers of T3SS-encoding genes, yet the molecular mechanisms underlying perception of these host signals by P. syringae are unknown. Here, we report that sugar-induced expression of type III secretion A (setA), predicted to encode a DeoR-type transcription factor, is required for maximal sugar-induced expression of T3SS-associated genes in P. syringae DC3000. From a Tn5 transposon mutagenesis screen, we identified two independent mutants with insertions in setA. When both setA::Tn5 mutants were cultured in minimal medium containing fructose, genes encoding the T3SS master regulator HrpL and effector AvrRpm1 were expressed at lower levels relative to that of a wild-type strain. Decreased hrpL and avrRpm1 expression also occurred in a setA::Tn5 mutant in response to glucose, sucrose, galactose, and mannitol, demonstrating that setA is genetically required for T3SS induction by many different sugars. Expression of upstream regulators hrpR/S and rpoN was not altered in setA::Tn5, indicating that SetA positively regulates hrpL expression independently of increased transcription of these genes. In addition to decreased response to defined sugar signals, a setA::Tn5 mutant had decreased T3SS deployment during infection and was compromised in its ability to grow in planta and cause disease. These data suggest that SetA is necessary for P. syringae to effectively respond to T3SS-inducing sugar signals encountered during infection.
Assuntos
Proteínas de Bactérias/fisiologia , Pseudomonas syringae/genética , Açúcares/química , Fatores de Transcrição/fisiologia , Sistemas de Secreção Tipo III/genética , Arabidopsis/microbiologia , Elementos de DNA Transponíveis , Proteínas de Ligação a DNA , Regulação Bacteriana da Expressão Gênica , Mutagênese , Doenças das Plantas/microbiologiaAssuntos
COVID-19/terapia , Hospitalização , Avaliação de Resultados em Cuidados de Saúde , Análise de Sobrevida , Idoso , COVID-19/epidemiologia , COVID-19/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , SARS-CoV-2Assuntos
COVID-19 , Seguimentos , Hospitalização , Humanos , Michigan , Atenção Primária à Saúde , SARS-CoV-2RESUMO
The tumour immune microenvironment is shaped by the crosstalk between cancer cells, immune cells, fibroblasts, endothelial cells and other stromal components. Although the immune tumour microenvironment (TME) serves as a source of therapeutic targets, it is also considered a friend or foe to tumour-directed therapies. This is readily illustrated by the importance of T cells in triple-negative breast cancer (TNBC), culminating in the advent of immune checkpoint therapy in combination with cytotoxic chemotherapy as standard of care for both early and advanced-stage TNBC, as well as recent promising signs of efficacy in a subset of hormone receptor-positive disease. In this Review, we discuss the various components of the immune TME in breast cancer and therapies that target or impact the immune TME, as well as the complexity of host physiology.
Assuntos
Microambiente Tumoral , Humanos , Microambiente Tumoral/imunologia , Feminino , Neoplasias da Mama/imunologia , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Neoplasias de Mama Triplo Negativas/imunologia , Neoplasias de Mama Triplo Negativas/tratamento farmacológico , Animais , Inibidores de Checkpoint Imunológico/uso terapêutico , Inibidores de Checkpoint Imunológico/farmacologia , Imunoterapia/métodosRESUMO
Many plant pathogenic bacteria suppress host defenses by secreting small molecule toxins or immune-suppressing proteins into host cells, processes that likely require close physical contact between pathogen and host. Yet, in most cases, little is known about whether phytopathogenic bacteria physically attach to host surfaces during infection. Here we report that Pseudomonas syringae pv. tomato strain DC3000, a Gram-negative bacterial pathogen of tomato and Arabidopsis, attaches to polystyrene and glass surfaces in response to chemical signals exuded from Arabidopsis seedlings and tomato leaves. We characterized the molecular nature of these attachment-inducing signals and discovered that multiple hydrophilic metabolites found in plant exudates, including citric acid, glutamic acid, and aspartic acid, are potent inducers of surface attachment. These same compounds were previously identified as inducers of P. syringae genes encoding a type III secretion system (T3SS), indicating that both attachment and T3SS deployment are induced by the same plant signals. To test if surface attachment and T3SS are regulated by the same signaling pathways, we assessed the attachment phenotypes of several previously characterized DC3000 mutants, and found that the T3SS master regulator HrpL was partially required for maximal levels of surface attachment, whereas the response regulator GacA, a negative regulator of T3SS, negatively regulated DC3000 surface attachment. Together, our data indicate that T3SS deployment and surface attachment by P. syringae may be co-regulated by the same host signals during infection, possibly to ensure close contact necessary to facilitate delivery of T3SS effectors into host cells.
Assuntos
Arabidopsis , Arabidopsis/genética , Pseudomonas syringae/genética , Proteínas de Bactérias/genéticaRESUMO
Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.
Assuntos
Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Cateterismo Periférico , Trombose , Adulto , Humanos , Feminino , Estudos de Coortes , Cateterismo Venoso Central/efeitos adversos , Estudos Retrospectivos , Catéteres , Trombose/etiologia , Cateterismo Periférico/efeitos adversos , Complicações Pós-Operatórias/etiologia , Infecções Relacionadas a Cateter/epidemiologia , Fatores de RiscoRESUMO
Importance: Peripherally inserted central catheters (PICCs) and midlines are frequently used for short-term venous access; whether one is safer than the other in this setting has not been adequately reported. Objective: To compare outcomes between patients who had a PICC vs midline placed for the indication of difficult vascular access or antibiotic therapy for 30 or fewer days. Design, Setting, and Participants: This cohort study analyzed data from a multihospital registry including patients admitted to a participating site from December 2017 through January 2020 who had a PICC or midline placement for the indications of difficult venous access or intravenous antibiotic therapy prescribed for 30 or fewer days. Data were analyzed from October 2020 to March 2021. Exposures: PICC and midline placement. Main Outcomes and Measures: Major complications, including a composite of symptomatic catheter-associated deep vein thrombosis (DVT), catheter-related bloodstream infection, and catheter occlusion. Logistic regression and Cox proportional hazards regression models (taking into account catheter dwell) were used to estimate risk for major complications, adjusting for patient and device characteristics and the clustered nature of the data. Sensitivity analyses limiting analyses to 10 days of device dwell were performed. Results: Data on 10â¯863 patients, 5758 with PICCs and 5105 with midlines (median [IQR] age of device recipients, 64.8 [53.4-75.4] years; 5741 [52.8%] were female), were included. After adjusting for patient characteristics, comorbidities, catheter lumens, and dwell time in logit models, patients who received PICCs had a greater risk of developing a major complication compared with those who received midlines (odds ratio, 1.99; 95% CI, 1.61-2.47). Reduction in complications stemmed from lower rates of occlusion (2.1% vs 7.0%; P < .001) and bloodstream infection (0.4% vs 1.6%; P < .001) in midlines vs PICCs; no significant difference in the risk of DVT between PICCs and midlines was observed. In time-to-event models, similar outcomes for bloodstream infection and catheter occlusion were noted; however, the risk of DVT events was lower in patients who received PICCs vs midlines (hazard ratio, 0.53; 95% CI, 0.38-0.74). Results were robust to sensitivity analyses. Conclusions and Relevance: In this cohort study among patients with placement of midline catheters vs PICCs for short-term indications, midlines were associated with a lower risk of bloodstream infection and occlusion compared with PICCs. Whether DVT risk is similar or greater with midlines compared with PICCs for short-term use is unclear. Randomized clinical trials comparing these devices for this indication are needed.
Assuntos
Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Idoso , Infecções Relacionadas a Cateter/prevenção & controle , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) provides evidence-based criteria for peripherally inserted central catheter (PICC) use. Whether implementing MAGIC improves PICC appropriateness and reduces complications is unknown. METHODS: A quasiexperimental study design to implement MAGIC in 52 Michigan hospitals was used. Data were collected from medical records by trained abstractors. Hospital performance on three appropriateness criteria was measured: short-term PICC use (≤5 days), use of multilumen PICCs and PICC placement in patients with chronic kidney disease. PICC appropriateness and device complications preintervention (January 2013 to December 2016) versus postintervention (January 2017 to January 2020) were compared. Change-point analysis was used to evaluate the effect of the intervention on device appropriateness. Logistic regression and Poisson models were fit to assess the association between appropriateness and complications (composite of catheter occlusion, venous thromboembolism (VTE) and central line-associated bloodstream infection (CLABSI)). RESULTS: Among 38 592 PICCs, median catheter dwell ranged from 8 to 56 days. During the preintervention period, the mean frequency of appropriate PICC use was 31.9% and the mean frequency of complications was 14.7%. Following the intervention, PICC appropriateness increased to 49.0% (absolute difference 17.1%, p<0.001) while complications decreased to 10.7% (absolute difference 4.0%, p=0.001). Compared with patients with inappropriate PICC placement, appropriate PICC use was associated with a significantly lower odds of complications (OR 0.29, 95% CI 0.25 to 0.34), including decreases in occlusion (OR 0.25, 95% CI 0.21 to 0.29), CLABSI (OR 0.61, 95% CI 0.46 to 0.81) and VTE (OR 0.40, 95% CI 0.33 to 0.47, all p<0.01). Patients with appropriate PICC placement had lower rate of complications than those with inappropriate PICC use (incidence rate ratio 0.987, 95% CI 0.98 to 0.99, p<0.001). CONCLUSIONS: Implementation of MAGIC in Michigan hospitals was associated with improved PICC appropriateness and fewer complications. These findings have important quality, safety and policy implications for hospitals, patients and payors.
Assuntos
Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Cateterismo Periférico , Cateteres Venosos Centrais , Tromboembolia Venosa , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Catéteres , Hospitais , Humanos , Michigan , Estudos Retrospectivos , Fatores de RiscoRESUMO
Opioid and benzodiazepine prescribing after COVID-19 hospitalization is not well understood. We aimed to characterize opioid and benzodiazepine prescribing among naïve patients hospitalized for COVID and to identify the risk factors associated with a new prescription at discharge. In this retrospective study of patients across 39 Michigan hospitals from March to November 2020, we identified 857 opioid- and benzodiazepine-naïve patients admitted with COVID-19 not requiring mechanical ventilation. Of these, 22% received opioids, 13% received benzodiazepines, and 6% received both during the hospitalization. At discharge, 8% received an opioid prescription, and 3% received a benzodiazepine prescription. After multivariable adjustment, receipt of an opioid or benzodiazepine prescription at discharge was associated with the length of inpatient opioid or benzodiazepine exposure. These findings suggest that hospitalization represents a risk of opioid or benzodiazepine initiation among naïve patients, and judicious prescribing should be considered to prevent opioid-related harms.
Assuntos
Analgésicos Opioides , Tratamento Farmacológico da COVID-19 , Analgésicos Opioides/uso terapêutico , Benzodiazepinas/uso terapêutico , Hospitalização , Humanos , Estudos RetrospectivosRESUMO
OBJECTIVE: To examine the effectiveness of antimicrobial and antithrombogenic materials incorporated into peripherally inserted central catheters (PICCs) to prevent bloodstream infection, thrombosis, and catheter occlusion. METHODS: Prospective cohort study involving 52 hospitals participating in the Michigan Hospital Medicine Safety Consortium. Sample included adult hospitalized medical patients who received a PICC between January 2013 and October 2019. Coated and impregnated catheters were identified by name, brand, and device marketing or regulatory materials. Multivariable Cox proportional hazards models with robust sandwich standard error estimates accounting for the clustered nature of data were used to identify factors associated with PICC complications in coated versus noncoated devices across general care, intensive care unit (ICU), and oncology patients. Results were expressed as hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). RESULTS: Of 42,562 patients with a PICC, 39,806 (93.5%) were plain polyurethane, 2,263 (5.3%) incorporated antimicrobial materials, and 921 (2.2%) incorporated antithrombogenic materials. Most were inserted in general ward settings (n = 28,111, 66.0%), with 12, 078 (28.4%) and 1,407 (3.3%) placed in ICU and oncological settings, respectively. Within the entire cohort, 540 (1.3%) developed thrombosis, 745 (1.8%) developed bloodstream infection, and 4,090 (9.6%) developed catheter occlusion. Adjusting for known risk factors, antimicrobial PICCs were not associated with infection reduction (HR, 1.16; 95% CI, 0.82-1.64), and antithrombogenic PICCs were not associated with reduction in thrombosis and occlusion (HR, 1.15; 95% CI, 0.92-1.44). Results were consistent across populations and care settings. CONCLUSIONS: Antimicrobial and antithrombogenic PICCs were not associated with a reduction in major catheter complications. Guidance aimed at informing use of these devices, balancing benefits against cost, appear necessary.
Assuntos
Anti-Infecciosos , Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Cateterismo Periférico , Cateteres Venosos Centrais , Doenças Transmissíveis , Neoplasias , Sepse , Trombose , Adulto , Antibacterianos , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/etiologia , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Catéteres , Cateteres Venosos Centrais/efeitos adversos , Humanos , Estudos Prospectivos , Fatores de Risco , Sepse/etiologia , Trombose/etiologia , Trombose/prevenção & controleRESUMO
BACKGROUND: We sought to determine the incidence of community-onset and hospital-acquired coinfection in patients hospitalized with coronavirus disease 2019 (COVID-19) and to evaluate associated predictors and outcomes. METHODS: In this multicenter retrospective cohort study of patients hospitalized for COVID-19 from March 2020 to August 2020 across 38 Michigan hospitals, we assessed prevalence, predictors, and outcomes of community-onset and hospital-acquired coinfections. In-hospital and 60-day mortality, readmission, discharge to long-term care facility (LTCF), and mechanical ventilation duration were assessed for patients with versus without coinfection. RESULTS: Of 2,205 patients with COVID-19, 141 (6.4%) had a coinfection: 3.0% community onset and 3.4% hospital acquired. Of patients without coinfection, 64.9% received antibiotics. Community-onset coinfection predictors included admission from an LTCF (OR, 3.98; 95% CI, 2.34-6.76; P < .001) and admission to intensive care (OR, 4.34; 95% CI, 2.87-6.55; P < .001). Hospital-acquired coinfection predictors included fever (OR, 2.46; 95% CI, 1.15-5.27; P = .02) and advanced respiratory support (OR, 40.72; 95% CI, 13.49-122.93; P < .001). Patients with (vs without) community-onset coinfection had longer mechanical ventilation (OR, 3.31; 95% CI, 1.67-6.56; P = .001) and higher in-hospital mortality (OR, 1.90; 95% CI, 1.06-3.40; P = .03) and 60-day mortality (OR, 1.86; 95% CI, 1.05-3.29; P = .03). Patients with (vs without) hospital-acquired coinfection had higher discharge to LTCF (OR, 8.48; 95% CI, 3.30-21.76; P < .001), in-hospital mortality (OR, 4.17; 95% CI, 2.37-7.33; P ≤ .001), and 60-day mortality (OR, 3.66; 95% CI, 2.11-6.33; P ≤ .001). CONCLUSION: Despite community-onset and hospital-acquired coinfection being uncommon, most patients hospitalized with COVID-19 received antibiotics. Admission from LTCF and to ICU were associated with increased risk of community-onset coinfection. Future studies should prospectively validate predictors of COVID-19 coinfection to facilitate the reduction of antibiotic use.
Assuntos
COVID-19 , Coinfecção , Antibacterianos/uso terapêutico , COVID-19/epidemiologia , Estudos de Coortes , Coinfecção/tratamento farmacológico , Coinfecção/epidemiologia , Mortalidade Hospitalar , Hospitalização , Hospitais , Humanos , Estudos Retrospectivos , Fatores de RiscoRESUMO
Pseudomonas syringae are Gram-negative, plant pathogenic bacteria that use a type III secretion system (T3SS) to disarm host immune responses and promote bacterial growth within plant tissues. Despite the critical role for type III secretion in promoting virulence, T3SS-encoding genes are not constitutively expressed by P. syringae and must instead be induced during infection. While it has been known for many years that culturing P. syringae in synthetic minimal media can induce the T3SS, relatively little is known about host signals that regulate the deployment of the T3SS during infection. The recent identification of specific plant-derived amino acids and organic acids that induce T3SS-inducing genes in P. syringae has provided new insights into host sensing mechanisms. This review summarizes current knowledge of the regulatory machinery governing T3SS deployment in P. syringae, including master regulators HrpRS and HrpL encoded within the T3SS pathogenicity island, and the environmental factors that modulate the abundance and/or activity of these key regulators. We highlight putative receptors and regulatory networks involved in linking the perception of host signals to the regulation of the core HrpRS-HrpL pathway. Positive and negative regulation of T3SS deployment is also discussed within the context of P. syringae infection, where contributions from distinct host signals and regulatory networks likely enable the fine-tuning of T3SS deployment within host tissues. Last, we propose future research directions necessary to construct a comprehensive model that (a) links the perception of host metabolite signals to T3SS deployment and (b) places these host-pathogen signaling events in the overall context of P. syringae infection.
RESUMO
BACKGROUND: Healthcare associated infections are associated with indwelling devices. Yet, data regarding prevalence of indwelling devices in noncritically ill hospitalized patients remains scant. METHODS: Adult, noncritically ill patients on general care, telemetry, and surgical floors at our quaternary care hospital were surveyed on 2 separate days. Data regarding presence of indwelling vascular, urinary, and gastrointestinal devices, as well as nurse to patient ratio on each unit were collected. RESULTS: There were 1,229 devices observed among the 857 patients surveyed across 2 days. Of the surveyed patients, 780 (91.0%) had at least 1 indwelling device. Among all devices, intravenous catheters were the most common (90.1%), followed by gastrointestinal devices (12.8%) and urinary catheters (10.2%). The most prevalent device was peripheral intravenous catheters. The median nurse to patient ratio was 3 patients to 1 nurse; no difference in nurse to patient ratio based on the number of devices present was observed. CONCLUSIONS: Indwelling device use appears highly prevalent in general care settings and variation among devices is common. Healthcare associated infections prevention strategies targeting these devices are necessary.
Assuntos
Infecção Hospitalar , Infecções Urinárias , Adulto , Cateteres de Demora/efeitos adversos , Humanos , Prevalência , Centros de Atenção Terciária , Cateterismo Urinário , Cateteres UrináriosRESUMO
PURPOSE: Vascular access patterns in the intensive care unit (ICU) have shifted from non-tunneled central venous catheters (CVCs) towards peripherally inserted central catheters (PICCs). We evaluated perceptions of critical care practitioners regarding these devices and variation in evidence-based practice. MATERIALS: A 35-question survey on ICU vascular access was deployed in 13 Michigan hospitals. Descriptive statistics summarized responses. Differences in utilization, perceptions and evidence-based practices between PICCs and CVCs, by participant and site-level characteristics, were assessed. RESULTS: 314 of 621 eligible providers responded to the survey (response rate 51%). 15% of providers reported not routinely using ultrasound when placing CVCs. Respondents whom were trainees, from larger hospitals, and from closed ICUs were more likely to use ultrasound (p < 0.001). Additionally, 21% of respondents stated they did not specify number of CVC lumens, while 46% did not specify number of PICC lumens (p < 0.001). The likelihood of specifying PICC lumens increased when vascular access protocols were in place (p = 0.001). 2/3 of respondents (n = 173, 66%) stated more research on ICU vascular access was needed. CONCLUSION: Variation in guideline-based vascular access practices exists in the ICU. Defined local protocols may improve guideline adherence. Studies evaluating vascular access decisions and patient safety in the ICU appear necessary.
Assuntos
Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Cateterismo Periférico , Cateteres Venosos Centrais , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Cuidados Críticos , Estudos Transversais , Humanos , Unidades de Terapia IntensivaRESUMO
ABSTRACT: During the spring 2020 COVID-19 surge, hospitals in Southeast Michigan were overwhelmed, and hospital beds were limited. However, it is unknown whether threshold for hospital admission varied across hospitals or over time.Using a statewide registry, we performed a retrospective cohort study. We identified adult patients hospitalized with COVID-19 in Southeast Michigan (3/1/2020-6/1/2020). We classified disease severity on admission using the World Health Organization (WHO) ordinal scale. Our primary measure of interest was the proportion of patients admitted on room air. We also determined the proportion without acute organ dysfunction on admission or any point during hospitalization. We quantified variation across hospitals and over time by half-month epochs.Among 1315 hospitalizations across 22 hospitals, 57.3% (754/1,315) were admitted on room air, and 26.1% (343/1,315) remained on room air for the duration of hospitalization. Across hospitals, the proportion of COVID-19 hospitalizations admitted on room air varied from 32.3% to 80.0%. Across half-month epochs, the proportion ranged from 49.4% to 69.4% and nadired in early April 2020. Among patients admitted on room air, 75.1% (566/754) had no acute organ dysfunction on admission, and 35.3% (266/754) never developed acute organ dysfunction at any point during hospitalization; there was marked variation in both proportions across hospitals. In-hospital mortality was 13.7% for patients admitted on room air vs 26.3% for patients requiring nasal cannula oxygen.Among patients hospitalized with COVID-19 during the spring 2020 surge in Southeast Michigan, more than half were on room air and a third had no acute organ dysfunction upon admission, but experienced high rates of disease progression and in-hospital mortality.
Assuntos
COVID-19/complicações , Hospitalização/estatística & dados numéricos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Fatores de TempoRESUMO
OBJECTIVE: To describe patient characteristics, symptoms, patterns of care and outcomes for patients hospitalised with COVID-19 in Michigan. DESIGN: Multicentre retrospective cohort study. SETTING: 32 acute care hospitals in the state of Michigan. PARTICIPANTS: Patients discharged (16 March-11 May 2020) with suspected or confirmed COVID-19 were identified. Trained abstractors collected demographic information on all patients and detailed clinical data on a subset of COVID-19-positive patients. PRIMARY OUTCOME MEASUREMENTS: Patient characteristics, treatment and outcomes including cardiopulmonary resuscitation, mortality and venous thromboembolism within and across hospitals. RESULTS: Demographic-only data from 1593 COVID-19-positive and 1259 persons under investigation discharges were collected. Among 1024 cases with detailed data, the median age was 63 years; median body mass index was 30.6; and 51.4% were black. Cough, fever and shortness of breath were the top symptoms. 37.2% reported a known COVID-19 contact; 7.0% were healthcare workers; and 16.1% presented from congregated living facilities.During hospitalisation, 232 (22.7%) patients were treated in an intensive care unit (ICU); 558 (54.9%) in a 'cohorted' unit; 161 (15.7%) received mechanical ventilation; and 90 (8.8%) received high-flow nasal cannula. ICU patients more often received hydroxychloroquine (66% vs 46%), corticosteroids (34% vs 18%) and antibiotic therapy (92% vs 71%) than general ward patients (p<0.05 for all). Overall, 219 (21.4%) patients died, with in-hospital mortality ranging from 7.9% to 45.7% across hospitals. 73% received at least one COVID-19-specific treatment, ranging from 32% to 96% across sites.Across 14 hospitals, the proportion of patients admitted directly to an ICU ranged from 0% to 43.8%; mechanical ventilation on admission from 0% to 12.8%; mortality from 7.9% to 45.7%. Use of at least one COVID-19-specific therapy varied from 32% to 96.3% across sites. CONCLUSIONS: During the early days of the Michigan outbreak of COVID-19, patient characteristics, treatment and outcomes varied widely within and across hospitals.