The burden and costs of sepsis and reimbursement of its treatment in a developing country: An observational study on focal infections in Indonesia.

OBJECTIVES: This study aimed to determine the burden of sepsis with focal infections in the resource-limited context of Indonesia and to propose national prices for sepsis reimbursement. METHODS: A retrospective observational study was conducted from 2013-2016 on cost of surviving and non-surviving sepsis patients from a payer perspective using inpatient billing records in four hospitals. The national burden of sepsis was calculated and proposed national prices for reimbursement were developed. RESULTS: Of the 14,076 sepsis patients, 5,876 (41.7%) survived and 8,200 (58.3%) died. The mean hospital costs incurred per surviving and deceased sepsis patient were US$1,011 (SE ± 23.4) and US$1,406 (SE ± 27.8), respectively. The national burden of sepsis in 100,000 patients was estimated to be US$130 million. Sepsis patients with multifocal infections and a single focal lower-respiratory tract infection (LRTI) were estimated as being the two with the highest economic burden (US$48 million and US$33 million, respectively, within 100,000 sepsis patients). Sepsis with cardiovascular infection was estimated to warrant the highest proposed national price for reimbursement (US$4,256). CONCLUSIONS: Multifocal infections and LRTIs are the major focal infections with the highest burden of sepsis. This study showed varying cost estimates for sepsis, necessitating a new reimbursement system with adjustment of the national prices taking the particular foci into account.

Intensive care resources required to care for critically ill children with focal intracranial infections.

The authors reviewed cases in which children with a focal infection inside the head (ex: a brain abscess) were cared for in their pediatric ICU to describe the frequency of complications and quantify the ICU resources needed (ex: breathing tube, blood pressure medications, and/or an intracranial pressure monitor). This information helps clarify illness severity and has identified complications that we should further investigate to improve care for these children.

[Focal infections in otorhinolaryngology].

This publication is focused on the mechanisms underlying the clinical course of acute focal infections concomitant with ENT pathology, factors responsible for their chronization and the development of complications. Also discussed are the methods for the early adequate conservative and surgical treatment of these conditions. Special emphasis is placed on the principles of management of chronic tonsillitis.

Extracranial head and neck infections.

This article outlines infections in the submandibular, lateral pharyngeal, retropharyngeal, danger, and prevertebral spaces, in conjunction with infections of the sinuses and mediastinum. By understanding the anatomy and pathophysiology, the reader will gain insight into the rationale for various therapeutic options.

[An update on focal infection of oral origin]. / Point actuel sur l'infection focale d'origine buccodentaire.

Focal infection of oral origin means that an oral infectious focus may have widespread effects. This concept remains controversial since it is difficult to prove the oral origin of germs responsible for an extra-oral infection. Experiments on animal models and clinical studies suggested several physiopathological mechanisms: bacteremia, toxinic and immunological mechanisms. Various operations induce the passage of bacterial flora (transcytosis) and its toxins into the bloodstream: oral care, chewing, or tooth brushing. Bacteremia is worsened by poor oral hygiene or an infection. The germs are usually destroyed by the host's reticuloendothelial system in a few minutes, but the presence of a valvular disease or a weak immune system favors focal infection. Besides infectious endocarditis, this may concern cardiovascular diseases, lung infections, prematurity and hypotrophy, diabetes, prosthetic infections, cerebral abscesses, etc. This update is based on literature review, selected according to its high level of scientific proof, as well as on a selected choice of consensus conferences. The current recommendation is to limit antibiotic prophylaxis to the high bacteremia risk procedures and to patients highly at risk of developing a focal infection.

Tonsillar focal infectious disease involving IgA nephropathy, pustulosis, and ossification.

We report a rare case of IgA nephropathy (IgAN), that was considered as showing tonsillar focal infection, involving pulmoplantar pustulosis (PPP), and sternocostoclavicular hyperosteosis (SCCH). A 53-year-old man with a 3-year history of PPP had hematuria and proteinuria, and he sometimes had anterior chest pain. He was also diagnosed with IgAN and SCCH. We performed tonsillectomy as a treatment. The tonsillectomy was done with the patient under general anesthesia, and this treatment was followed by steroid therapy. Interestingly, all the symptoms of IgAN, PPP, and SCCH were alleviated 6 months after the tonsillectomy. Thus, tonsillectomy and steroid therapy may be effective and could be considered as treatment for these diseases.

Determining optimum management of descending necrotizing mediastinitis with CT; experience with 32 cases.

To determine the value of helical computed tomography (CT) in the diagnosis, management and outcome of patients suspected of having descending necrotizing mediastinitis (DNM). Thirty-two patients with suspected DNM were submitted to contrast-enhanced single detector-row helical CT, four detector-row CT and 16 detector-row CT of the neck and chest. In 10/32 patients (group 1) no abnormality was observed in the neck or in the chest spaces on CT scan. These patients were all treated non-operatively. In 12/32 patients (group 2) CT showed the presence in the neck spaces of fluid collections, fasciitis, cellulitis, myositis, jugular vein thrombosis and lymphadenopathy; in all these patients the chest was unaffected. A cervical drainage was performed in ten patients. In the remaining ten patients (group 3), the neck infection involved the mediastinal spaces in all the cases and the pleural and pericardial spaces; CT findings included mediastinal cellulitis and fluid collections, pleural and pericardial effusions, venous thrombosis and lymphadenopathy. In these patients, a cervico-mediastinal drainage was performed and antibiotics were administered. The CT provides a highly accurate depiction of the presence and the spread of DNM. The CT findings and the extension of disease are important factors in order to predict for patient management and outcome.

[Some aspects of focal infections of the head and neck region]. / Einige Gesichtspunkte zum Fokusgeschehen im Hals-Nasen-Ohren-Bereich.

The so-called focal infections are today considered to be poly-etiologic manifestations, in which there is a summation of various aggressions. The concept of focal infection is still not exactly defined. Bacterial products, toxic or antigenic substances originating from different foci are but one of the elements susceptible of unleashing the disease. This explains why there are so many foci and so few results after their elimination. The diagnosis of chronic tonsillitis or occult sinusitis especially concerning a focal disease is sometimes difficult. The ENT-specialist is responsible for both the detection of a focus in the head and neck region and its operative treatment. The interrelationship between a focal infection and its actual secondary disease must be diagnosed by the primarily inquired doctor. The diagnosis and the treatment of focal infections of the head and neck region are an interdisciplinary problem.

Salvage of the septic ankle with concomitant tibial osteomyelitis.

Five patients with concomitant distal tibia osteomyelitis and ankle sepsis with an open, draining wound were treated. All of the patients were men with an average age of 54.8 years. All of the bone infections were polymicrobial and had open draining wounds. A standardized protocol of radical soft tissue and bone debridement, soft tissue transfer, intravenous antibiotics, and delayed ankle fusion was employed. All five fusions were successful on first attempt, with an average time to fusion of 3.5 months. All patients were free of infection at an average follow-up of 27 months. We believe our aggressive treatment protocol can salvage these extremities and preclude amputation in properly selected cases.

Suppurative thrombophlebitis in children: a ten-year experience.

OBJECTIVE: To determine the clinical and diagnostic features, complications, management and prevention of superficial suppurative thrombophlebitis (ST) in children < 18 years of age. STUDY DESIGN: A retrospective review of medical records was performed for patients in two urban hospitals from January 1, 1985, through June 30, 1995, with a discharge diagnosis of phlebitis. RESULTS: We identified 21 patients, including 12 neonates, with ST. The majority had underlying medical conditions or preceding invasive procedures and administration of broad spectrum antibiotics or total parenteral nutrition as possible predisposing factors. More than two-thirds had localizing signs (swelling, erythema, induration or a palpable cord); one-third had purulent drainage from the vein. Septicemia was present in one-third of patients. Fever and tenderness were present in older children. Nearly one-half had involvement of an upper extremity. Cultures of vein (63%), blood (67%) or abscess (86%) grew pathogens in most. Gram-positive organisms were predominant; Staphylococcus aureus was isolated from 44%, Gram-negative enterics from 16.7% and Candida species from another 16.7% of patients. Eleven children had vein excision, whereas 10 had only incision and drainage. Complications, including death in one patient, occurred in 33% but could not be correlated with age or method of surgical intervention. CONCLUSIONS: ST is a rare but serious nosocomial infection in infants and children that results in substantial morbidity. It should be suspected in any hospitalized child who is or was receiving intravenous fluids and who has fever, localizing signs or persistent bacteremia. Prompt vein excision, with adjunctive antimicrobial therapy, is the recommended treatment.

[The correction of immunity in adolescents and children with focal staphylococcal diseases]. / Korektsiia imunitetu u pidlitkiv i ditei z vohnyshchevymy stafilokokovymy zakhvoriuvanniamy.

The aim of the work done was to improve treatment options for focal Staphylococcus-induced diseases in adolescents and children with the aid of adsorbed staphylococcal anatoxin (ASA) concurrently with low-intensive EHF therapy. Overall fifty patients aged 3 to 17 years with Staphylococcus infection in tonsils, nose, ears were kept under medical surveillance. ASA and EHF therapies were instituted according to the developed schemes of such therapies. Positive dynamics was shown of clinical picture and parameters characterizing humoral and cell-mediated immunity. There were no unfavourable side-effects. The proposed mode of treatment can, we believe, be widely used in a clinical setting.

Children with chronic conditions in a pediatric emergency department.

The objective of this study was to describe the use of a pediatric emergency department (PED) by children with chronic conditions. The study design was retrospective and descriptive in an urban tertiary care pediatric hospital setting. We reviewed 8561 visits to a PED over a three-month time period. Two thousand twenty-four (24%) of the visits were by children with one or more chronic conditions. There were no interventions. The mean age of the patients was 4.9 years, and 61% were male. Thirty-one percent of the patients sought care between 8 AM and 5 PM Monday through Friday. Five subspecialty areas accounted for 86% of the chronic conditions seen: asthma (43%), neurology (15%), hematology/oncology (14%), neurosurgery (10%), and cardiology (4%). Twenty-eight percent of the chronically ill patients were admitted as compared to 11% of the nonchronically ill patients (P < 0.001). One percent of the chronically ill patients were admitted to the intensive care unit as compared to 0.03% of the nonchronically ill patients (P < 0.0001). It was concluded that children with chronic conditions account for one-quarter of all PED visits. Sixty-nine percent of those visits were made during evening/ nighttime hours or on the weekend. A relatively large percentage of these children were admitted. The pediatric emergency physicians provide an important service to both the children with chronic conditions and the subspecialists who care for them. PEDs may need to refine emergency department systems to serve this group of patients as efficiently and effectively as possible.

Focal infection revisited.

This paper reviews the theory of focal infection that was widely held to explain the aetiology of inflammatory joint disease in the first three decades of this century. The theoretical basis for these beliefs and the practical consequences for physician and patient alike are examined, as are the results of such radical treatments as were applied.

[The efficacy of leukinferon in suppurative-septic diseases]. / Effektivnost' leikinferona pri gnoino-septicheskikh zabolevaniiakh.

In the complex of treatment of purulent-septic diseases leukinferon at a dose of 300 IU/kg was used according to the following scheme: 3 injections with the 48 h interval between injections. The effect of leukinferon mainly on the function of neutrophil granulocytes and subpopulation of T-lymphocytes was established. Together with clinico-laboratory data indicative of the effectiveness of treatment, normalization of interferon status and decrease in the level of a circulating factor of tumour necrosis in seriously ill patients was observed.

[Focal infections caused by non-typhi Salmonella: a review of our case series and comparison with other series]. / Infecciones focales por Salmonella no typhi: revisión de nuestra casuística y comparación con otras series.

Nine cases of local infection due to non typhi Salmonella enterica, some of them of unusual localization, in 8 patients (mean age 64.9 +/- 12.4 years) attended in Zamora's Virgen de la Concha Hospital over a period of five years, are described. Focal salmonellosis represented 1.5% of non-typhi salmonellosis cases in that period (9 out of 606 detected cases). 6 of the 8 patients (75%) showed a predisposing disease. In two patients the previous existence of gastroenteritis due to Salmonella was assessed and only in one of them concomitant bacteremia was detected. Soft-tissue infections were the more frequent clinical feature: plantar abscess, two abdominal wall abscesses--one of them after cholecystectomy--post-pericardiotomy thoracic wall abscess and perianal abscess. Three soft-tissue infections were due to group B serotypes. 4 out of five soft-tissue infections evolved favorably with surgical treatment. The rest of the series is formed by two cases with acute cholecystitis in patients with previous cholelithiasis (one of whom relapsed originating an abdominal wall abscess), a recurrent pleural empyema and a purulent pericarditis. The pericarditis was produced by S. enteritidis. Patient showed signs of cardiac tamponade, his condition improving after pericardial drainage and parenteral and intrapericardial administration of ciprofloxacin. Epidemiologic and clinic characteristic of our series are compared with other series of focal salmonellosis.

[The diagnosis and treatment of rhinogenous intracranial complications]. / Diagnostika i lechenie rinogennykh vnutricherepnykh oslozhnenii.

The article describes the cases of acute affections of accessory sinuses of nose complicated by toxic infectious oedema of cerebrum with hypertension syndrome. Intracranial complications were originated by decompensation of the local inflammatory process, and need urgent surgical management on accessory sinuses of nose and further conservative treatment. The author gives the differentiated diagnostics of rhinogenous intracranial complications and recommendations for surgical and complex medicinal treatment of such patients.

[The urogenital inflammatory focus and its treatment in Reiter's disease]. / Urogenital'nyi vospalitel'nyi ochag i ego lechenie pri bolezni Reitera.

The complement fixation test, microprecipitation, leukocyte migration inhibition, leukocyte agglomeration phenomenon, direct and indirect immunofluorescence were used to demonstrate that chronic prostatovesiculitis associated with Reiter's disease may be of immune-induced nature. This requires a differentiated approach to the choice of the treatment policy. The methods of the treatment for the urogenital inflammatory focus in men suffering from Reiter's disease are provided. It is indicated that complete cure of Reiter's disease can be attained only after elimination of inflammation in the urogenital organs.