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PURPOSE: To identify associations with unplanned repeat irrigation and debridement (I&D) after arthrotomy for native septic arthritis. METHODS: A retrospective review identified patients with native septic arthritis treated with open arthrotomies. The primary outcome was unplanned repeat I&D within 90 days. Associations evaluated for included comorbidities, ability to bear weight, fever, immunosuppressed status, purulence, C-reactive protein, erythrocyte sedimentation rate, white blood cell count (synovial fluid and serum levels), and synovial fluid polymorphonuclear cell percentage (PMN%). RESULTS: There were 59 arthrotomies in 53 patients involving the knee (n = 32), shoulder (n = 10), elbow (n = 8), ankle (n = 6), and hip (n = 3). The median patient age was 52, and a 71.2% were male. An unplanned repeat I&D was required in 40.7% (n = 24). The median time to the second I&D was 4 days (interquartile range 3 to 9). On univariate analysis, unplanned repeat I&Ds were associated with fever (p = 0.03), purulence (p = 0.01), bacteria growth on cultures (p = 0.02), and the use of deep drains (p = 0.05). On multivariate analysis, the only variables that remained associated with unplanned repeat I&Ds were fever (odds ratio (OR) 5.5, 95% confidence interval (CI) 1.3, 23.6, p = 0.02) and purulence (OR 5.3, CI 1.1, 24.4, p = 0.03). CONCLUSIONS: An unplanned repeat I&D was required in 40.7% of patients and was associated with fever and purulence. These findings highlight the difficulty of controlling these infections and support the need for future research into better methods of management. LEVEL OF EVIDENCE: Diagnostic, Level III.
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Artrite Infecciosa , Desbridamento , Irrigação Terapêutica , Humanos , Artrite Infecciosa/terapia , Artrite Infecciosa/cirurgia , Masculino , Desbridamento/métodos , Irrigação Terapêutica/métodos , Feminino , Estudos Retrospectivos , Pessoa de Meia-Idade , Adulto , Reoperação/estatística & dados numéricos , Líquido Sinovial/microbiologia , Idoso , Febre/etiologia , Proteína C-Reativa/análise , Contagem de LeucócitosRESUMO
INTRODUCTION: Despite the successful implementation of Haemophilus influenzae vaccination, invasive serotypes still lead to a fatal infection. We recently cared for a patient with a ventriculoperitoneal shunt (VPS) and H. influenzae meningitis and septicemia complicated by vasospasm. Vasospasm caused by Haemophilus central nervous system infection has not been previously reported. CASE PRESENTATION: A 34-month-old patient with a recent VPS presented with H. influenzae meningitis and sepsis. Despite the explant of hardware, followed by maximum medical management, the patient developed stroke due to severe vasospasm, which led to diffused anoxic brain injury. CONCLUSIONS: We aim to alert for the possible critical condition caused by H. influenzae. It is essential to treat the underlying illness, despite the presence of a VPS. Surgical implant tends to be overlooked by other subspecialists. Being vaccinated to H. influenzae does not protect from different subtypes like non-typeable H. influenzae. The cause of vasospasm remains unclear.
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Meningite por Haemophilus , Sepse , Vasoespasmo Intracraniano , Criança , Pré-Escolar , Haemophilus influenzae , Humanos , Lactente , Vasoespasmo Intracraniano/etiologia , Derivação Ventriculoperitoneal/efeitos adversosRESUMO
PURPOSE: To evaluate the effect of a bundled intervention on the number of skin-to-skin ("kangaroo care") events occurring in a level IV NICU. DESIGN: A quality improvement effort centering around the introduction of an intervention bundle intended to safely increase the rate of skin-to-skin holding. Rates of unplanned extubations were recorded as a balancing measure to estimate safety. SAMPLE: All infants admitted to the NICU from December 2017 through September 2019 were included. The "preintervention" period was the 6 months prior to the initiation of the intervention bundle (December 2017-May 2018). RESULTS: The absolute number of skin-to-skin holds increased from the preintervention phase (range 7-28 holds/month, median 11 holds/month) to the postintervention phase (range 16-100 holds/month, median 55 holds/month). The total unplanned extubations showed no significant change between the preintervention and postintervention periods.
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Unidades de Terapia Intensiva Neonatal , Melhoria de Qualidade , Humanos , Recém-Nascido , PeleRESUMO
INTRODUCTION: Distinguishing between septic arthritis and crystal arthropathy flares can be challenging. The purpose of this study was to determine how the presence of synovial crystals affects the diagnostic criteria of septic arthritis. METHODS: A retrospective review identified patients undergoing joint aspirations to rule out native septic arthritis. Differences between septic arthritis presenting with and without synovial crystals were analyzed. A receiver-operating characteristic curve was plotted for laboratory markers to determine the area under the curve, or diagnostic accuracy, for septic arthritis and to evaluate thresholds that maximized sensitivity and specificity. RESULTS: There were 302 joint aspirations in 267 patients. Septic arthritis was diagnosed in 17.9% (54/302). Patients with synovial crystals were less likely to have septic arthritis (4.2% [5/119] vs. 26.8% [49/183], P < 0.0001). Septic arthritis in patients with no synovial crystals was associated with fever and a higher synovial white blood cell (WBC) count, synovial polymorphonuclear cell percentage (PMN%), serum WBC, and C-reactive protein (CRP) ( P < 0.05). Septic arthritis in patients with synovial crystals was only associated with inability to bear weight and a higher synovial WBC and CRP ( P < 0.05). Synovial PMN% was considered nondiagnostic of septic arthritis (area under the curve 0.56) in patients with crystals while synovial WBC and CRP had acceptable (0.76) and excellent (0.83) diagnostic utility, respectively. The WBC and CRP value thresholds that maximized sensitivity and specificity for septic arthritis were greater in patients with crystals (21,600 vs. 17,954 cells/µL and 125 vs. 69 mg/L, respectively). DISCUSSION: The presence of synovial crystals reduced the likelihood of septic arthritis and altered the laboratory diagnostic criteria. PMN% was nondiagnostic in the setting of synovial crystals.
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Artrite Infecciosa , Proteína C-Reativa , Artropatias por Cristais , Humanos , Artrite Infecciosa/diagnóstico , Estudos Retrospectivos , Masculino , Feminino , Idoso , Artropatias por Cristais/diagnóstico , Pessoa de Meia-Idade , Proteína C-Reativa/análise , Diagnóstico Diferencial , Sensibilidade e Especificidade , Líquido Sinovial/química , Líquido Sinovial/citologia , Contagem de Leucócitos , Curva ROC , Idoso de 80 Anos ou mais , AdultoRESUMO
We report a series of five pediatric patients admitted with acute respiratory failure due to delta-variant SARS-CoV-2, found to have a methicillin-sensitive Staphylococcus aureus (MSSA) co-infection. All five patients required escalation of their respiratory support within 24 hours of discovering the MSSA infections. Four out of the five patients received immune-modulating therapies. Four patients required extracorporeal membrane oxygenation support. One patient died, and the other four survived until hospital discharge. Clinicians should consider secondary bacterial infections in patients with COVID-19 treated with immune modulators. MSSA co-infection can lead to increased morbidity and mortality in patients with COVID-19.
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Introduction: Previous small-scale, single-center investigations of Streptococcus pneumoniae associated hemolytic uremic syndrome (SpHUS) have shown increased disease severity among SpHUS relative to non-SpHUS patients. Our study compares the impact of S. pneumoniae on patient outcomes between SpHUS cases and non-SpHUS controls using the national, multicenter retrospective Pediatric Health Information Systems (PHIS) Database. Methods: Children <18 years of age with a diagnosis of HUS were included. Univariate analyses and multivariable linear and logistic regressions were utilized to assess the impact of S. pneumoniae on mortality, length of stay (LOS), intensive care unit admission (ICU), and mechanical ventilation use. Models were adjusted for demographic and clinical characteristics, including cardiac, neurologic, pulmonary, gastrointestinal, immunologic and renal clinical complications. Results: Of 3,952 index HUS hospitalizations, 231 (5.8%) were due to SpHUS. SpHUS patients had worse outcomes, including longer hospital stays, increased rate of ICU admission, and increased use of mechanical ventilation (p < 0.001 for all). There was a strong positive relationship between clinical complications and adverse outcomes. After adjusting for covariates, SpHUS was associated with an increase in hospital LOS by 3.47 days (p = 0.009) and overall ICU-LOS by 4.21 days (p < 0.001). SpHUS was also associated with increased likelihood of mechanical ventilation (OR: 3.08; p < 0.001), with no increase in ICU admission (p = 0.070) and in-hospital mortality (p = 0.3874). Discussion: Our study highlights that SpHUS patients are at increased risk of multiple adverse outcomes likely due to the summative impact of pneumococcal infection and HUS as well as more frequent clinical complications.
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BACKGROUND: A significant increase in the rate of vancomycin-resistant Enterococcus faecium (VREfm) bacteremia at our health service, despite improved infection control, prompted us to investigate the cause. METHODS: E. faecium bacteremia (including VREfm) over a 12-year period (1998-2009) was investigated using multilocus sequence typing, antibiotic and antiseptic susceptibility profiles, optical mapping, and whole genome sequencing of historical and recent isolates. RESULTS: For 10 years, the rate of bacteremia due to vanB VREfm remained stable and sequence type (ST) 17 was predominant. In 2005, ST203 vancomycin-susceptible E. faecium first appeared at our institution, and from March 2007, coinciding with the appearance of a vanB VREfm ST203, the rate of VRE bacteremia has increased exponentially. Although we found no difference in antiseptic susceptibility or presence of genes encoding putative virulence determinants (esp(Efm), hyl(Efm), and fms genes), comparative genomics revealed almost 500 kb of unique sequence when an ST17 and an ST203 VREfm isolate were compared, suggesting that other genomic factors are responsible for the apparent success of E. faecium. CONCLUSIONS: The application of multilocus sequence typing has uncovered the emergence of an epidemic clone of E. faecium ST203 that appears to have acquired the vanB locus and has caused a sustained outbreak of VRE bacteremia.
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Bacteriemia/microbiologia , Proteínas de Bactérias/genética , Surtos de Doenças , Enterococcus faecium/genética , Infecções por Bactérias Gram-Positivas/epidemiologia , Infecções por Bactérias Gram-Positivas/microbiologia , Resistência a Vancomicina/genética , Antibacterianos/farmacologia , Austrália/epidemiologia , Bacteriemia/tratamento farmacológico , Bacteriemia/epidemiologia , Técnicas de Tipagem Bacteriana , Doenças Transmissíveis Emergentes/microbiologia , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Eletroforese em Gel de Campo Pulsado , Enterococcus faecium/classificação , Enterococcus faecium/efeitos dos fármacos , Genômica , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Humanos , Incidência , Meropeném , Testes de Sensibilidade Microbiana , Filogenia , Tienamicinas/uso terapêutico , Vancomicina/uso terapêuticoRESUMO
OBJECTIVE: Hand hygiene adherence has been associated with reductions in nosocomial infection. We assessed the effect of improvements in electronically measured hand hygiene adherence on the incidence of hospital-acquired infections. METHODS: This quasi-experimental study was conducted in a 555-bed urban safety-net level I trauma center. The preintervention period was January 2015 through June 2016. Baseline electronic hand hygiene data collection took place from April through June 2016. The intervention period was July 2016 through December 2017. An electronic hand hygiene system was installed in 4 locations in our hospital. Performance improvement strategies were implemented that included education, troubleshooting, data dissemination, and feedback. Adherence rates were tracked over time. Rates of hospital-acquired infections were evaluated in the intervention units and in control units selected for comparison. The intervention period was subdivided into the initial and subsequent 9-month periods and were compared to the baseline period. RESULTS: Electronically measured hand hygiene rates improved significantly from baseline to intervention, from 47% 77% adherence. Rates >70% continued to be measured 18 months after the intervention. Interrupted time series analysis indicated a significant effect of hand hygiene on healthcare facility-onset Clostridioides difficile infection rates during the first 9 months of the intervention. This trend continued during the final 9 months of the intervention but was nonsignificant. No effects were observed for other hospital-acquired infection rates. CONCLUSIONS: Implementation of electronic hand hygiene monitoring and performance improvement interventions resulted in reductions in hospital-onset Clostridioides difficile infection rates.
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Infecção Hospitalar , Higiene das Mãos , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/prevenção & controle , Fidelidade a Diretrizes , Desinfecção das Mãos , Hospitais , Humanos , Controle de InfecçõesRESUMO
Background: The U.S. Centers for Disease Control and Prevention recommend bathing prior to surgery, surgical skin antisepsis, peri-operative antibiotic administration, normothermia throughout the procedure, serum glucose concentration <200 mg/dL throughout the procedure, and hyperoxygenation in the immediate post-operative period to prevent surgical site infection (SSI). We developed interventions to standardize skin antisepsis and peri-operative antibiotic administration at our institution. Methods: This is a cross-sectional evaluation of surgical skin antisepsis and antibiotic administration before and after a series of interventions designed to standardize the processes. Results: One hundred twenty-four surgical skin antisepsis opportunities were observed; significant improvement was seen in hand hygiene prior to performing skin antisepsis (compliance changing from 1% to 48%; p < 0.001), sleeves being worn during skin antisepsis (1% versus 67%; p < 0.001), use of the correct cleansing time (47% versus 85%; p < 0.001), allowance for adequate drying time (67% versus 87%; p = 0.02), and use of a cleansing motion from the incision to the periphery (78% versus 95%; p = 0.004). Pre-operative antibiotic order placement, correct antibiotic selection, and optimal antibiotic dose were evaluated in 466 surgical procedures. Significant improvement was seen in both peri-operative order placement (59% versus 70%; p = 0.02) and correct antibiotic selection (52% versus 95%; p < 0.001). Conclusion: An intervention to standardize skin antisepsis and to encourage early ordering of peri-operative antibiotics was successful.
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Antibioticoprofilaxia/métodos , Antissepsia/métodos , Cuidados Pré-Operatórios/métodos , Pele/microbiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/normas , Antissepsia/normas , Estudos Controlados Antes e Depois , Estudos Transversais , Feminino , Higiene das Mãos/métodos , Higiene das Mãos/normas , Humanos , Masculino , Pessoa de Meia-Idade , Equipamento de Proteção Individual , Cuidados Pré-Operatórios/normasRESUMO
Twenty-seven patients receiving prolonged inpatient antibiotic therapy for a serious bacterial infection received a single dose of dalbavancin 7-10 days before the planned end date to facilitate earlier hospital discharge. Eighty-one percent met criteria for clinical success, 7% experienced a potential adverse event, and 182 hospital days were averted.
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We surveyed emergency department and urgent care clinicians to assess patterns of use and perceived usefulness of a local antibiotic stewardship application to deliver institution-specific prescribing guidance. Among 114 eligible respondents, the application was widely utilized, and it was perceived to be a useful clinical resource that improved prescribing.
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Assistência Ambulatorial/organização & administração , Antibacterianos/uso terapêutico , Gestão de Antimicrobianos/normas , Serviço Hospitalar de Emergência/organização & administração , Padrões de Prática Médica/normas , Gestão de Antimicrobianos/organização & administração , Prescrições de Medicamentos , Humanos , Prescrição Inadequada/prevenção & controle , Padrões de Prática Médica/organização & administração , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Staphylococcus aureus bacteremia (SAB) is the second-most common cause of community-onset (CO) bacteremia. The incidence of methicillin-resistant S. aureus (MRSA) has recently decreased across much of the United States, and we seek to describe risk factors for CO-MRSA bacteremia, which will aid emergency providers in their choice of empiric antibiotics. METHODS: This is a retrospective cohort study of all patients with SAB at a 500-bed safety net hospital. The proportion of S. aureus isolates that were MRSA ranged from 32-35% during the study period. Variables of interest included age, comorbid medical conditions, microbiology results, antibiotic administration, duration of bacteremia, duration of hospital admission, suspected source of SAB, and Elixhauser comorbidity score. The primary outcome was to determine risk factors for CO-MRSA bacteremia as compared to methicillin-susceptible S. aureus (MSSA) bacteremia in patients admitted to the hospital through the emergency department. RESULTS: We identified 135 consecutive patients with CO-SAB. In comparison to those with MSSA bacteremia, patients with MRSA bacteremia were younger (odds ratio [OR] 0.5, 95% confidence interval [CI], 0.4-0.7) with higher Elixhauser comorbidity scores (OR 1.4, 95% CI, 1.1-1.7). Additionally, these patients were more likely to have a history of MRSA infection or colonization (OR 8.9, 95% CI, 2.7-29.7) and intravenous drug use (OR 2.4, 95% CI, 1.0-5.7). CONCLUSION: SAB continues to be prevalent in our urban community with CO-MRSA accounting for almost one-third of SAB cases. Previous MRSA colonization was the strongest risk factor for current MRSA infection in this cohort of patients with CO-SAB.
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Antibacterianos , Bacteriemia , Infecções Comunitárias Adquiridas , Staphylococcus aureus Resistente à Meticilina , Adulto , Idoso , Antibacterianos/classificação , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Bacteriemia/epidemiologia , Bacteriemia/microbiologia , Estudos de Coortes , Colorado/epidemiologia , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/microbiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Masculino , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
We implemented a cleaning process for mobile patient equipment (MPE) and determined its success using adenosine trisphosphate (ATP) monitoring and data feedback. Following education for staff and ATP data feedback, the data suggest that the MPE cleaning program we implemented was successful.
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Trifosfato de Adenosina/análise , Desinfecção/normas , Contaminação de Equipamentos/prevenção & controle , Zeladoria Hospitalar/normas , Avaliação de Programas e Projetos de Saúde , Estudos Transversais , Desinfecção/métodos , Hospitais de Ensino , Zeladoria Hospitalar/métodos , Modelos Lineares , Medições LuminescentesRESUMO
BACKGROUND: Depictions of eye images and messages encouraging compliance with social norms have successfully motivated behavioral change in a variety of experimental and applied settings. We studied the effect of these 2 visual cues on hand hygiene adherence in a cohort of hospital-based healthcare providers participating in an electronic monitoring and feedback program. METHODS: Prospective, quasi-experimental study utilizing an interrupted time-series design. Intervention placards depicting an image of eyes, a social norms message, or a control placard were placed near soap and alcohol-based hand-rub dispensers on 2 hospital units. Placards were alternated every 10 days. Hand hygiene opportunities and adherence rates were assessed electronically via the CenTrak Hand Hygiene Compliance Solution. RESULTS: A total of 166 nurses and certified nursing assistants (74 on a medical-surgical unit and 92 on a progressive care unit) were monitored electronically over the 4-month study period. In total, 184,172 electronic observations were collected (110,903 on a medical-surgical unit and 73,269 on a progressive care unit). The median daily number of electronic observations was 1,471 (interquartile range, 1,337-1,584). The preintervention baseline hand hygiene adherence rate was 70%. No statistically significant increase in hand hygiene adherence was observed as a result of either intervention. CONCLUSION: Displaying eye images or a social norms message in the hospital environment did not result in measurable improvements in HH adherence in a cohort of healthcare providers participating in an electronic monitoring and feedback program.
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Fidelidade a Diretrizes/estatística & dados numéricos , Desinfecção das Mãos/métodos , Recursos Humanos em Hospital , Normas Sociais , Anti-Infecciosos Locais/administração & dosagem , Infecção Hospitalar/prevenção & controle , Etanol/administração & dosagem , Unidades Hospitalares , Humanos , Análise de Séries Temporais Interrompida , Estudos Prospectivos , Sabões/administração & dosagemRESUMO
Smartphones are increasingly used to access clinical decision support, and many medical applications provide antimicrobial prescribing guidance. However, these applications do not account for local antibiotic resistance patterns and formularies. We implemented an institution-specific antimicrobial stewardship smartphone application and studied patterns of use over a 1-year period.
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Gestão de Antimicrobianos/métodos , Aplicativos Móveis/estatística & dados numéricos , Smartphone/estatística & dados numéricos , Antibacterianos , Colorado , Estudos Transversais , Sistemas de Apoio a Decisões Clínicas/estatística & dados numéricos , Hospitais de Ensino , Humanos , Modelos Lineares , Aplicativos Móveis/provisão & distribuiçãoRESUMO
BACKGROUND: The CDC's National Healthcare Safety Network's (NHSN) current risk adjustment model for surgical site infections (SSI) following open reduction internal fixation (ORIF) of long bone fractures is a suboptimal predictor of risk. We hypothesized that by including variables known to be associated with SSI following ORIF, we would develop a model that would increase the accuracy and predictability of SSI risk. METHODS: Patients who underwent ORIF of a long bone between January 1, 2012 and December 31, 2014 were included in the study (n=1543). Patient risk factors, injury risk factors and perioperative risk factors were considered in the development of this model. We developed a risk prediction model for SSI following ORIF and then applied this to a new dataset of ORIF to determine the expected number of infections. This was compared to the expected number of infections calculated using the NHSN risk adjusted model. RESULTS: The final multivariate model included age (odds ratio: 1.02, p-value<0.001, 95% confidence interval: 1.00-1.04), lower leg fracture (2.63, 0.004, 1.40-4.93), open fracture (1.87, 0.07, 0.93-3.76), American Society of Anesthesiologists (ASA) (2.09, 0.02, 1.07-4.08) and history of methicillin-resistant Staphylococcus aureus (MRSA), which was the most important predictor of infection (7.20, <0.001, 2.61-19.85). The c-index was 0.74 compared to 0.65 for the NHSN model, indicating that our model more accurate in estimating infection risk. When the developed model was used to predict the number of expected infections on a new dataset from 2015, 36.3 SSI were expected compared to 5.7 calculated by the NHSN model. CONCLUSIONS: The model that was developed uses five easily identifiable risk factors that result in a more accurate prediction of infection at our facility than the currently used model. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.