RESUMO
BACKGROUND: Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets. OBJECTIVES: To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England. METHODS: The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process. RESULTS: Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration. CONCLUSIONS: The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.
Assuntos
Anti-Infecciosos , Infecções Comunitárias Adquiridas , Humanos , Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Prevalência , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/prevenção & controle , Anti-Infecciosos/uso terapêutico , Prescrições , Inglaterra/epidemiologia , Prescrições de MedicamentosRESUMO
Objective: To explore the distribution characteristics of pathogens in adult patients with community-acquired pneumonia (CAP) and to provide basis for the diagnosis, treatment, prevention of CAP. Methods: 1 446 inpatients with CAP were prospectively enrolled in a third-class hospital in Beijing in recent 5 years (from January 2015 to December 2019). Respiratory tract samples were collected for smear, culture, nucleic acid, antigen and antibody detection to identify the pathogen of CAP. Mann-Whitney U test was used for continuous variables and χ2 test or Fisher's exact test was used for categorical data for statistical analysis. Results: Among the 1 446 patients, 822 (56.85%) patients were infected with a single pathogen, 231 (15.98%) patients were infected with multiple pathogens, and 393 (27.18%) patients were not clear about the pathogen. Influenza virus is the first pathogen of CAP (20.95%, 303/1 446), mainly H1N1 (8.51%, 123/1 446), followed by mycoplasma pneumoniae (7.19%, 104/1 446), Mycobacterium tuberculosis (5.33%, 77/1 446) and Streptococcus pneumoniae (5.05%, 73/1 446). The outbreak of H1N1 occurred from December 2018 to February 2019, and the epidemic of mycoplasma pneumoniae pneumonia was monitored from August to November 2019. Patients under 65 years old had high detection rates of Mycoplasma pneumoniae (14.41% vs. 2.41%, χ²=74.712,P<0.001), Streptococcus pneumoniae (8.16% vs. 2.99%, χ²=18.156, P<0.001), rhinovirus (6.08% vs. 3.56%, χ²=5.025, P<0.025), Chlamydia pneumoniae (5.90% vs. 1.15%, χ²=26.542, P<0.001) and adenovirus (3.13% vs. 0.92%, χ²=9.547, P=0.002). The severe disease rate of CAP was 14.66% (212/1 446), and the average mortality rate was 3.66% (53/1 446). The severe illness rate and mortality rate of bacterial-viral co-infection were 28.97% (31/107) and 19.63% (21/107), respectively. Conclusions: Influenza virus is the primary pathogen of adult CAP. Outbreaks of Mycoplasma pneumoniae and H1N1 were detected in 2018 and 2019, respectively. The remission rate and mortality rate of virus-bacteria co-infection were significantly higher than those of single pathogen infection. Accurate etiological basis not only plays a role in clinical diagnosis and treatment, but also provides important data support for prevention and early warning.
Assuntos
Chlamydophila pneumoniae , Infecções Comunitárias Adquiridas , Vírus da Influenza A Subtipo H1N1 , Pneumonia por Mycoplasma , Adulto , Idoso , Infecções Comunitárias Adquiridas/prevenção & controle , Hospitais , Humanos , Pneumonia por Mycoplasma/epidemiologia , Pneumonia por Mycoplasma/prevenção & controleRESUMO
With the notable exceptions of the United States and Canada in particular, the global burden of disease in adults due to invasive infection with the dangerous respiratory, bacterial pathogen, Streptococcus pneumoniae (pneumococcus) remains. This situation prevails despite the major successes of inclusion of polysaccharide conjugate vaccines (PCVs) in many national childhood immunization programs and associated herd protection in adults, as well as the availability of effective antimicrobial agents. Accurate assessment of the geographic variations in the prevalence of invasive pneumococcal disease (IPD) has, however, been somewhat impeded by the limitations imposed on the acquisition of reliable epidemiological data due to reliance on often insensitive, laboratory-based, pathogen identification procedures. This, in turn, may result in underestimation of the true burden of IPD and represents a primary focus of this review. Other priority topics include the role of PCVs in the changing epidemiology of IPD in adults worldwide, smoking as a risk factor not only in respect of increasing susceptibility for development of IPD, but also in promoting pneumococcal antibiotic resistance. The theme of pneumococcal antibiotic resistance has been expanded to include mechanisms of resistance to commonly used classes of antibiotics, specifically ß-lactams, macrolides and fluoroquinolones, and, perhaps somewhat contentiously, the impact of resistance on treatment outcome. Finally, but no less importantly, the role of persistent antigenemia as a driver of a chronic, subclinical, systemic proinflammatory/procoagulant phenotype that may underpin the long-term sequelae and premature mortality of those adults who have recovered from an episode of IPD, is considered.
Assuntos
Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/prevenção & controle , Infecções Pneumocócicas/tratamento farmacológico , Infecções Pneumocócicas/prevenção & controle , Adulto , Antibacterianos/uso terapêutico , Criança , Infecções Comunitárias Adquiridas/imunologia , Resistência Microbiana a Medicamentos , Humanos , Infecções Pneumocócicas/imunologia , Vacinas Pneumocócicas , Fatores de Risco , Sorogrupo , Streptococcus pneumoniae , Vacinas Conjugadas , Vaping/efeitos adversosRESUMO
BACKGROUND: Extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) are increasing in globally. The aim of this study was to compare community-acquired infections (CAIs) and hospital-acquired infections (HAIs) and determine the rate of third-generation cephalosporin resistance and ESBL-PE at a tertiary referral hospital in Rwanda. METHODS: This was a cross-sectional study of Rwandan acute care surgery patients with infection. Samples were processed for culture and susceptibility patterns using Kirby-Bauer disk diffusion method. Third-generation cephalosporin resistance and ESBL-PE were compared in patients with CAI versus HAI. RESULTS: Over 14 months, 220 samples were collected from 191 patients: 116 (62%) patients had CAI, 59 (32%) had HAI, and 12 (6%) had both CAI and HAI. Most (n = 178, 94%) patients were started on antibiotics with third-generation cephalosporins (ceftriaxone n = 109, 57%; cefotaxime n = 52, 27%) and metronidazole (n = 155, 81%) commonly given. Commonly isolated organisms included Escherichia coli (n = 62, 42%), Staphylococcus aureus (n = 27, 18%), and Klebsiella spp. (n = 22, 15%). Overall, 67 of 113 isolates tested had resistance to third-generation cephalosporins, with higher resistance seen in HAI compared with CAI (74% vs 46%, p value = 0.002). Overall, 47 of 89 (53%) isolates were ESBL-PE with higher rates in HAI compared with CAI (73% vs 38%, p value = 0.001). CONCLUSIONS: There is broad and prolonged use of third-generation cephalosporins despite high resistance rates. ESBL-PE are high in Rwandan surgical patients with higher rates in HAI compared with CAIs. Infection prevention practices and antibiotic stewardship are critical to reduce infection rates with resistant organisms in a low-resource setting.
Assuntos
Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecção Hospitalar/tratamento farmacológico , Infecções por Enterobacteriaceae/tratamento farmacológico , Adulto , Infecções Comunitárias Adquiridas/prevenção & controle , Infecção Hospitalar/prevenção & controle , Estudos Transversais , Farmacorresistência Bacteriana , Infecções por Enterobacteriaceae/prevenção & controle , Escherichia coli/isolamento & purificação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Staphylococcus aureus/isolamento & purificação , Centros de Atenção TerciáriaRESUMO
The new SARS-CoV-2 pandemic is an example of an international public health emergency, which is associated with considerable social and economic challenges. At the healthcare level there is the risk that nosocomial outbreaks can be local amplifiers. Adequate infection control practices are of critical importance, which include proper use of personal protective equipment. This equipment must be appropriate to the pathogen transmission route that, in the case of SARS-CoV-2, occurs through droplet and contact routes. The infected individual, when talking, coughing or sneezing, spreads droplets containing the virus, directly contaminating other individuals within one to two meters of distance, as well as the surrounding environment. Airborne transmission may occur when aerosol-generating procedures are performed. Concerning respiratory protection, there is currently weak evidence that the use of respirators provides better protection than surgical masks for SARS-CoV-2 or other viruses (with the exception of aerosol-generating procedures, in which case the use of a respirator is recommended). Eye protection should be guaranteed whenever there is a risk of splashes, droplets or aerosols. The use of different, or higher than necessary, level of personal protective equipment, for the transmission route of the agent, is a form of misuse and can affect its supply for situations when it is clearly indicated. The adequate provision of protective equipment, as well as training of healthcare professionals in its correct use, is highly recommended to ensure safety of care.
A nova pandemia por SARS-CoV-2 é um exemplo de uma emergência de saúde pública de âmbito internacional, associada a consideráveis desafios sociais e económicos. A nível das unidades de saúde há o risco que surtos nosocomiais sejam amplificadores locais. Perante tal, práticas de controlo de infeção são de importância crítica no funcionamento destes serviços, de que faz parte a utilização adequada de equipamento de proteção individual. Este deve ser adequado à via de transmissão do agente que, no caso do SARS-CoV-2, é através de gotícula e contacto. O indivíduo infetado, ao falar, tossir ou espirrar, dissemina gotículas que contêm o vírus, contaminando diretamente outros indivíduos, que estão num raio de um a dois metros, assim como o ambiente. A transmissão por via aérea também poderá ocorrer, no caso de procedimentos geradores de aerossóis. A nível da proteção respiratória existe, atualmente, fraca evidência que a utilização de respiradores permita maior proteção que máscara cirúrgica para o SARS-CoV-2 ou outros vírus(com exceção dos procedimentos geradores de aerossóis, em que a utilização de um respirador é recomendada). A proteção ocular deverá ser garantida sempre que houver risco de salpicos, gotículas ou aerossóis. A utilização incorreta de equipamento de proteção individual, para a via de transmissão do agente ou superior ao necessário, é uma forma de uso indevido e pode afetar o seu suprimento para as situações em que é realmente indicado. A disponibilização deste equipamento de proteção, e formação dos profissionais de saúde na sua correta utilização, é fortemente recomendado para garantir a prestação de cuidados seguros.
Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Dispositivos de Proteção dos Olhos , Pessoal de Saúde , Controle de Infecções , Pandemias/prevenção & controle , Equipamento de Proteção Individual , Pneumonia Viral/prevenção & controle , Microbiologia do Ar , Broncoscopia/efeitos adversos , COVID-19 , Infecções Comunitárias Adquiridas/prevenção & controle , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/transmissão , Face , Humanos , Higiene , Controle de Infecções/instrumentação , Controle de Infecções/métodos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Intubação Intratraqueal/efeitos adversos , Máscaras/classificação , Máscaras/provisão & distribuição , Equipamento de Proteção Individual/provisão & distribuição , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , SARS-CoV-2 , Equipamentos Cirúrgicos/efeitos adversosRESUMO
The COVID-19 pandemic is having a devastating effect on the nursing homes for dependent older people. The difficulty of management of this crisis is aggravated by the frailty of the people served and by the specific characteristics of the care area, mainly the fact of not being integrated into the health system. The objective of this work is to describe the pharmaceutical care developed by a hospital pharmacy service established in a nursing home and, from a more global perspective, analyze the strengths and weaknesses found from the various experiences of hospital pharmacy in all spanish autonomous communities to deal with this pandemic. Specialized pharmaceutical care has provided rigor in the validation and treatments review processes from a comprehensive perspective, maximizing safety and collaborating in the establishment of the therapeutic intensity degree most appropriate to the individual situation, has ensured the availability of all necessary medications, has collaborated in the acquisition and management of personal protective equipment, has been able to adapt the dispensation processes to the internal nursing homes sectorization and has facilitated the coordination between the nursing home and the health system. It is clear that the crisis casued by COVID- 19 has put relevance of the need to integrate the social-health level into the health system. And also, the contribution of specialized pharmaceutical care in improving healthcare coverage and coordination with health services has highlighted the urgency of developing the current legislation, prioritizing the establishment of pharmacy services able to provid specialized and specific care for this area, so that it meets healthcare needs and is integrated into the health system.
La pandemia COVID-19 está teniendo un efecto devastador en las residencias de personas mayores dependientes. La dificultad de la gestión de la crisis se ve agravada por la fragilidad de las personas atendidas y por las propias características del ámbito asistencial, principalmente el hecho de no estar integrado en el sistema de salud. El objetivo del presente trabajo es describir la atención farmacéutica especializada desarrollada por un servicio de farmacia hospitalario establecido en un centro sociosanitario y, desde una perspectiva más global, analizar las fortalezas y debilidades encontradas desde las diversas experiencias de la farmacia hospitalaria en el conjunto de comunidades autónomas para hacer frente a esta pandemia. La atención farmacéutica especializada ha aportado rigor en los procesos de validación y revisión de los tratamientos desde una perspectiva integral, maximizando la seguridad y colaborando en el establecimiento del grado de intensidad terapéutica más adecuado a la situación individual de la persona afectada, ha asegurado la disponibilidad de todos los medicamentos necesarios, ha colaborado en la adquisición y gestión de los equipos de protección individual, ha sido capaz de adaptar los procesos de dispensación a la sectorización interna de las residencias y ha facilitado la coordinación entre la residencia y el sistema de salud. Resulta evidente que la crisis provocada por la COVID-19 ha puesto de relevancia la necesidad de integrar el ámbito sociosanitario en el sistema de salud. Y asimismo, la contribución de la atención farmacéutica especializada en la mejora de la cobertura asistencial y de la coordinación con los servicios sanitarios ha puesto de manifiesto la urgencia de desarrollar la legislación vigente, priorizando el establecimiento de servicios de farmacia capaces de proporcionar una atención especializada y específica para este ámbito asistencial, de forma que cubra las necesidades asistenciales y quede integrada en la estructura sanitaria.
Assuntos
Assistência Ambulatorial/organização & administração , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Casas de Saúde/organização & administração , Pandemias , Serviço de Farmácia Hospitalar/organização & administração , Pneumonia Viral/tratamento farmacológico , Idoso , COVID-19 , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Infecções Comunitárias Adquiridas/transmissão , Comorbidade , Infecções por Coronavirus/enfermagem , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Surtos de Doenças , Interações Medicamentosas , Feminino , Idoso Fragilizado , Humanos , Controle de Infecções/organização & administração , Masculino , Sistemas de Medicação no Hospital/organização & administração , Pandemias/prevenção & controle , Equipamento de Proteção Individual , Admissão e Escalonamento de Pessoal , Pneumonia Viral/enfermagem , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Polimedicação , SARS-CoV-2 , Espanha/epidemiologia , Tratamento Farmacológico da COVID-19RESUMO
Resumen: Objetivo: Evaluar la efectividad del uso de cubrebocas quirúrgico en ámbitos comunitarios para reducir la probabilidad de contagio por SARS-CoV-2 u otra infección respiratoria aguda viral, en comparación con no usar cubrebocas. Material y métodos: Se utilizó la metodología de revisiones rápidas de Cochrane. La estrategia de búsqueda abarcó una base de datos académica y pre-prints hasta el 1 de abril de 2020. Los títulos y resúmenes fueron revisados por un investigador. La revisión de textos completos fue dividida entre tres investigadores. Los resultados fueron sintetizados de forma narrativa. Resultados: Se identificaron 713 manuscritos, de los cuales 21 cumplieron los criterios de inclusión. De seis revisiones sistemáticas, cuatro no encontraron reducciones en la probabilidad de contagio y seis estudios experimentales en hogares no encontraron diferencias en la probabilidad de contagio asociado con el uso de cubrebocas. Únicamente un estudio de modelaje estimó una reducción de 20% en la incidencia de enfermedad respiratoria, asumiendo que 10 a 50% de la población hace uso correcto de cubrebocas quirúrgicos. Conclusiones: La evidencia científica no es concluyente para recomendar o desalentar el uso de cubrebocas a nivel poblacional. Considerando los potenciales efectos negativos, las recomendaciones gubernamentales deberían esperar a los resultados de los experimentos naturales en países que han recomendado la utilización poblacional de cubrebocas.
Abstract: Objective: To assess the effectiveness of using surgical masks in community settings to reduce the probability of infection by SARS-CoV-2 or other acute viral respiratory infection, compared to not using surgical masks. Materials and methods: We followed the Cochrane rapid review methodology. The search strategy encompasses one academic database and pre-prints until April 1, 2020. Titles and abstracts were reviewed by one investigator. The full text review was divided among three researchers. The results were synthesized in a narrative way. Result: 713 manuscripts were identified, of which 21 met the inclusion criteria. Of six systematic reviews, four found no reduction in the probability of transmission. Experimental home studies found no differences in the probability of contagion associated with the use of mouth masks. Only one modeling study estimated a 20% reduction in the incidence of acute respiratory disease, assuming that 10 to 50% of the population use the surgical masks correctly. Conclusions: The scientific evidence is inconclusive to recommend or discourage the use of surgical masks at the population level. Considering the potential negative effects, official recommendations should await for the results of natural experiments currently occurring in countries that have recommended the use of face masks at the population level.
Assuntos
Humanos , Infecções Respiratórias/prevenção & controle , Pandemias , Betacoronavirus , Máscaras/estatística & dados numéricos , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Pneumonia Viral/epidemiologia , Infecções Respiratórias/transmissão , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/epidemiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Infecções Comunitárias Adquiridas/transmissão , Pandemias/prevenção & controle , SARS-CoV-2 , COVID-19RESUMO
BACKGROUND: Athletic training rooms have a high prevalence of bacteria, including multidrug-resistant organisms, increasing the risk for both local and systematic infections in athletes. There are limited data outlining formal protocols or standardized programs to reduce bacterial and viral burden in training rooms as a means of decreasing infection rate at the collegiate and high school levels. HYPOTHESIS: Adaptation of a hygiene protocol would lead to a reduction in bacterial and viral pathogen counts in athletic training rooms. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: Two high school and 2 collegiate athletic training rooms were studied over the course of the 2017-2018 academic year. A 3-phase protocol, including introduction of disinfectant products followed by student-athlete and athletic trainer education, was implemented at the 4 schools. Multiple surfaces in the athletic training rooms were swabbed at 4 time points throughout the investigation. Bacterial and viral burden from swabs were analyzed for overall bacterial aerobic plate count (APC), bacterial adenosine triphosphate activity, influenza viral load, and multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE). RESULTS: Overall bacterial load, as measured by APC, was reduced by 94.7% (95% CI, 72.6-99.0; P = 0.003) over the course of the investigation after protocol implementation. MRSA and VRE were found on 24% of surfaces prior to intervention and were reduced to 0% by the end of the study. Influenza was initially detected on 25% of surfaces, with no detection after intervention. No cases of athletic training room-acquired infections were reported during the study period. CONCLUSION: A uniform infection control protocol was effective in reducing bacterial and viral burden, including multidrug-resistant organisms, when implemented in the athletic training rooms of 2 high schools and 2 colleges. CLINICAL RELEVANCE: A standardized infection control protocol can be utilized in athletic training rooms to reduce bacterial and viral burden.
Assuntos
Infecções Comunitárias Adquiridas/prevenção & controle , Reservatórios de Doenças/microbiologia , Controle de Infecções/métodos , Instituições Acadêmicas , Infecções Comunitárias Adquiridas/transmissão , Desinfetantes/administração & dosagem , Infecções por Bactérias Gram-Positivas/prevenção & controle , Infecções por Bactérias Gram-Positivas/transmissão , Desinfecção das Mãos , Educação em Saúde , Humanos , Influenza Humana/prevenção & controle , Influenza Humana/transmissão , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Orthomyxoviridae/isolamento & purificação , Comportamento de Redução do Risco , Infecções Estafilocócicas/prevenção & controle , Infecções Estafilocócicas/transmissão , Enterococos Resistentes à Vancomicina/isolamento & purificaçãoRESUMO
BACKGROUND: Community acquired blood stream infections (CA-CLABSI) are a major source of morbidity and mortality for pediatric patients. Many organizations discharge pediatric patients to home health agencies to care for central lines. To reduce the incidence of CA-CLABSIs requires a concentrated effort between hospitals and home health agencies. It is important for home health agencies to be accountable for the care and maintenance they provide to patients with central lines. Local Problem: At a large children's hospital, CA-CLABSI metrics and collaboration with home health agencies to reduce CACLABSI events lacked organizational standardization. METHODS: An organizational committee was formed to establish standards of care for CA-CLABSI follow-up and reduction. RESULTS: As a result of the committee's work, several best practices resulted including the creation of a CA-CLABSI resource booklet; a screening tool to identify contributing risks associated with a CA-CLABSI, and increased awareness of CA-CLABSIs. Since implementation of these best practices, the organization has seen a 30% reduction in the number of CA-CLABSIs. Standardization of CA-CLABSI efforts and proactive surveillance of central line care may lead to decreases in the number of CA-CLABSI events. Collaboration between service lines may identify siloed best practices that can be implemented organizationally that may have a large impact.
Assuntos
Infecções Relacionadas a Cateter/prevenção & controle , Infecções Comunitárias Adquiridas/prevenção & controle , Continuidade da Assistência ao Paciente/normas , Serviços de Assistência Domiciliar/normas , Programas de Rastreamento/normas , Guias de Prática Clínica como Assunto , Bacteriemia/epidemiologia , Bacteriemia/prevenção & controle , Infecções Relacionadas a Cateter/epidemiologia , Cateteres Venosos Centrais/efeitos adversos , Criança , Pré-Escolar , Infecções Comunitárias Adquiridas/epidemiologia , Feminino , Humanos , Comunicação Interdisciplinar , Masculino , Melhoria de Qualidade , Medição de Risco , Análise de Sobrevida , Estados UnidosRESUMO
Introduction: Community-acquired pneumonia (CAP) has the highest rate of mortality of all infectious diseases, especially among the elderly. Severe CAP (sCAP) is defined as a CAP in which intensive care management is required and is associated with an unfavorable clinical course. Areas covered: This review aims to identify prevention strategies for reducing the incidence of CAP and optimized management of sCAP. We highlight the main prevention approaches for CAP, focusing on the latest vaccination plans and on the influence of health-risk behaviors. Lastly, we report the latest recommendations about the optimal approach for sCAP when CAP has already been diagnosed, including prompt admission to ICU, early empirical antibiotic therapy, and optimization of antibiotic use. Expert opinion: Despite improvements in the diagnosis and treatment of sCAP, more efforts are needed to combat preventable causes, including the implementation and improvement of vaccine coverage, anti-tobacco campaigns and correct oral hygiene. Moreover, future research should aim to assess the benefits of early antimicrobial therapy in primary care. Pharmacokinetic studies in the target population may help clinicians to adjust dosage regimens in critically ill patients with CAP and thus reduce rates of treatment failure.
Assuntos
Infecções Comunitárias Adquiridas/prevenção & controle , Pneumonia/prevenção & controle , Alcoolismo/complicações , Antibacterianos/uso terapêutico , Humanos , Vacinas contra Influenza , Unidades de Terapia Intensiva , Saúde Bucal , Vacinas Pneumocócicas , Guias de Prática Clínica como Assunto , Fatores de Risco , Fumar/efeitos adversosRESUMO
BACKGROUND: Management of partially-treated, community-acquired bacterial meningitis (PCBM) is commonly compromised by lack of microbiological diagnosis. We aimed to analyze the impact of FilmArray Meningitis-Encephalitis (FA-ME) PCR on the management of PCBM. METHODS: Comparison of treatment variables of PCBM cases between two periods, before (6.5 years, control group) and after (2 years, study group) the application of FA-ME PCR assay. RESULTS: The total duration of antimicrobial treatment in the study group (n = 8) was significantly shorter than the control group (n = 23) (9.5 ± 3.7 days vs. 15.2 ± 5 days, p = 0.007). The percentage of narrow-spectrum regimens was significantly higher in the study group (78 ± 11% vs. 40 ± 9%, p = 0.03). There was a significant difference in implementation of antimicrobial chemoprophylaxis for close contacts (4/8 (50%) vs. 1/23 (4%), p = 0.01). CONCLUSIONS: The use of FA-ME PCR provides significant benefits in the management of PCBM by shortening duration of antibiotic treatment, increasing the use of narrow-spectrum regimens, and allowing proper administration of antimicrobial chemoprophylaxis. TRIAL REGISTRATION: The study was approved and retrospectively registered by the Tel-Aviv Sourasky Medical Center ( 0378-17-TLV , 10/17/2017) and Rabin Medical Center ( 0270-18-RMC , 11/11/2018) Ethics committees and conforms to recognized standards.
Assuntos
Encefalite/diagnóstico , Meningites Bacterianas/diagnóstico , Meningites Bacterianas/tratamento farmacológico , Reação em Cadeia da Polimerase/métodos , Adulto , Antibacterianos/uso terapêutico , Quimioprevenção , Estudos de Coortes , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/prevenção & controle , Encefalite/genética , Feminino , Humanos , Israel , Masculino , Meningites Bacterianas/epidemiologia , Meningites Bacterianas/prevenção & controle , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
Streptococcus pneumoniae (S. pneumoniae) and viruses are considered as primary risks of community-acquired pneumonia (CAP), and the effects of co-infection bacterial and virus in the prognosis of patients with severe CAP (SCAP) are poorly described. Therefore, this study is conducted to investigate the regulation of Beclin1-PI3K/AKT axis in reinfection of S. pneumoniae after influenza A virus in mice model of bronchoalveolar lavage fluid (BALF). Samples of sputum and BALF were collected from patients with SCAP for etiological detection. The expression of each gene was determined by RT-qPCR and western blot analysis. Influenza A/PR/8/34 and S. pneumoniae were used to establish the mice model of reinfection pneumonia. The virus quantity, expression levels of inflammatory factors, bacterial load, and myeloperoxidase (MPO) activity were tested. HE staining was applied to observe histopathology of lung tissue. The expression of Beclin1 was downregulated and the PI3K/AKT pathway was activated in viral pneumonia. In vivo experiment, the reinfection of S. pneumoniae following influenza A virus infection increased the number of S. pneumoniae population, the activity of MPO, and the expression of TNF-α, IL-6, and IFN-γ in BALF of mice. In contrast, inhibition of the PI3K/AKT pathway or overexpression of Beclin1 reduced the number of S. pneumoniae population, the activity of MPO, and the expression of TNF-α, IL-6, and IFN-γ in BALF of mice reinfected with S. pneumoniae after influenza A virus infection. Collectively, our study demonstrates that inhibition of the PI3K/AKT signaling pathway or overexpressed Beclin1 alleviates reinfection of S. pneumoniae after influenza A virus infection in SCAP.
Assuntos
Proteína Beclina-1/metabolismo , Infecções Comunitárias Adquiridas , Influenza Humana/complicações , Inibidores de Fosfoinositídeo-3 Quinase/farmacologia , Infecções Pneumocócicas/prevenção & controle , Pneumonia , Proteínas Proto-Oncogênicas c-akt/antagonistas & inibidores , Transdução de Sinais/efeitos dos fármacos , Animais , Infecções Comunitárias Adquiridas/microbiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Infecções Comunitárias Adquiridas/virologia , Modelos Animais de Doenças , Humanos , Vírus da Influenza A , Influenza Humana/virologia , Camundongos , Fosfatidilinositol 3-Quinases/metabolismo , Inibidores de Fosfoinositídeo-3 Quinase/uso terapêutico , Infecções Pneumocócicas/patologia , Infecções Pneumocócicas/virologia , Pneumonia/microbiologia , Pneumonia/prevenção & controle , Pneumonia/virologia , Proteínas Proto-Oncogênicas c-akt/metabolismo , Recidiva , Prevenção Secundária , Streptococcus pneumoniaeRESUMO
Introduction: Bacterial pneumonia remains an important cause of morbidity and mortality in people living with HIV (PLWH) in the antiretroviral therapy (ART) era. In addition to being immunocompromised, as reflected by low CD4 cell counts and elevated HIV viral loads, PLWH often have other behaviors associated with an increased risk of pneumonia including smoking and injected drug use. As PLWH are aging, comorbid conditions such as chronic obstructive pulmonary disease (COPD), cancers, and cardiovascular, renal and liver diseases are emerging as additional risk factors for pneumonia. Pathogens are often similar to those in HIV-uninfected individuals; however, PLWH are at risk for unusual and/or multi-drug resistant organisms causing bacterial pneumonia based, in part, on their CD4 cell counts and other exposures. Areas covered: In this review, we focus on the recognition and management of bacterial community-acquired pneumonia (CAP) in PLWH. Along with antimicrobial treatment, we discuss prevention strategies such as vaccination and smoking cessation. Expert opinion: Early initiation of ART after HIV infection can decrease the risk of pneumonia. Improved efforts at vaccination, smoking cessation, and reduction of other substance use are urgently needed in PLWH to decrease the risk for bacterial pneumonia. As PLWH are aging, comorbidities are additional risk factors for bacterial CAP.
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Infecções por HIV/complicações , Pneumonia Bacteriana/tratamento farmacológico , Fumar , Infecções Comunitárias Adquiridas/complicações , Infecções Comunitárias Adquiridas/tratamento farmacológico , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Comorbidade , Humanos , Pneumonia Bacteriana/complicações , Pneumonia Bacteriana/epidemiologia , Pneumonia Bacteriana/prevenção & controle , Doença Pulmonar Obstrutiva Crônica , Fatores de Risco , Abandono do Hábito de Fumar , VacinaçãoRESUMO
BACKGROUND: The Lebanese Society of Infectious Diseases and Clinical Microbiology (LSIDCM) is involved in antimicrobial stewardship. In an attempt at guiding clinicians across Lebanon in regards to the proper use of antimicrobial agents, members of this society are in the process of preparing national guidelines for common infectious diseases, among which are the guidelines for empiric and targeted antimicrobial therapy of complicated intra-abdominal infections (cIAI). The aims of these guidelines are optimizing patient care based on evidence-based literature and local antimicrobial susceptibility data, together with limiting the inappropriate use of antimicrobials thus decreasing the emergence of antimicrobial resistance (AMR) and curtailing on other adverse outcomes. METHODS: Recommendations in these guidelines are adapted from other international guidelines but modeled based on locally derived susceptibility data and on the availability of pharmaceutical and other resources. RESULTS: These guidelines propose antimicrobial therapy of cIAI in adults based on risk factors, site of acquisition of infection, and clinical severity of illness. We recommend using antibiotic therapy targeting third-generation cephalosporin (3GC)-resistant gram negative organisms, with carbapenem sparing as much as possible, for community-acquired infections when the following risk factors exist: prior (within 90 days) exposure to antibiotics, immunocompromised state, recent history of hospitalization or of surgery and invasive procedure all within the preceding 90 days. We also recommend antimicrobial de-escalation strategy after culture results. Prompt and adequate antimicrobial therapy for cIAI reduces morbidity and mortality; however, the duration of therapy should be limited to no more than 4 days when adequate source control is achieved and the patient is clinically stable. The management of acute pancreatitis is conservative, with a role for antibiotic therapy only in specific situations and after microbiological diagnosis. The use of broad-spectrum antimicrobial agents including systemic antifungals and newly approved antibiotics is preferably restricted to infectious diseases specialists. CONCLUSION: These guidelines represent a major step towards initiating a Lebanese national antimicrobial stewardship program. The LSIDCM emphasizes on development of a national AMR surveillance network, in addition to a national antibiogram for cIAI stratified based on the setting (community, hospital, unit-based) that should be frequently updated.
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Anti-Infecciosos/uso terapêutico , Resistência Microbiana a Medicamentos , Infecções Intra-Abdominais/tratamento farmacológico , Adulto , Infecções Comunitárias Adquiridas/prevenção & controle , Humanos , Hospedeiro Imunocomprometido , Infecções Intra-Abdominais/microbiologia , Líbano , Testes de Sensibilidade Microbiana , Pancreatite/tratamento farmacológico , Pancreatite/microbiologia , Fatores de TempoRESUMO
PURPOSE: Patients with primary immunodeficiency diseases (PID) are perceived to be at high risk for acquiring as well as developing complications from infections. There is little data describing the infection type and frequency these patients may acquire in the community or during hospital admissions. Data is critically needed in order to inform best practices on how to protect these vulnerable patients. METHODS: This is a retrospective study which included PID patients who were discharged from Children's National Health System (CNHS) from January 1, 2011, through August 31, 2017, and were assigned a discharge diagnosis code indicating PID. Hospitalizations that occurred in the study period were reviewed to extract information on the type of infections upon admission and during hospitalization. The rate of hospital acquired infections (HAIs) was calculated by the number of HAIs divided by the total number of days between date of admission and date of discharge or receiving the first bone marrow transplant, whichever the one came first. The rates were then compared to the HAI rate among oncology patients receiving treatment at CNHS during the same study period. RESULTS: During this study period, 33 PID patients were admitted 80 times for a total of 1855 patient days. Of these 80 admissions, 31 were due to an infection. Ten of the 31 admissions with severe combined immunodeficiency disease (SCID) were infection related, 4/4 in ectodermal dysplasia with immunodeficiency due to gain of function mutation (IkappaBalpha) patients, 8/10 in Wiskott-Aldrich patients, 1/2 in STAT3 mutation patients, 1/1 in Hyper IGM patient, 1/5 in severe chronic active EBV (SCAEBV) patients, 1/1 NK defect, 2/21 in primary hemophagocytic lymphohistiocytosis patients, 3/4 chronic granulomatous disease, and 0/1 congenital neutropenia. HAI occurred in 11 out of 80 admissions (13.75%). Patients with SCID had the highest HAI rate of 13.09 per 1000 patient days, followed by SCAEBV (11.10), IkappaBalpha (6.58), and Wiskott-Aldrich (4.91). Comparing to oncology patients in which the HAI rate was 0.92 per 1000 patient days. SCID patients had 11.7 (95% confidence interval 3.7-29; p < 0.001) and T cell defects excluding SCID had 4.8 (95% CI 1.0-14.8; p = 0.03) times greater risk of acquiring an infection during a hospitalization. CONCLUSIONS: Patients with severe T cell defects such as SCID are at greater risk for infections in the community and in hospital settings. Additional infection prevention measures are likely needed when caring for these patients in a clinic or as an inpatient. Further studies are urgently needed to determine the most appropriate measures for these patients.
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Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/etiologia , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/etiologia , Síndromes de Imunodeficiência/complicações , Síndromes de Imunodeficiência/epidemiologia , Biomarcadores , Infecções Comunitárias Adquiridas/prevenção & controle , Infecção Hospitalar/prevenção & controle , Suscetibilidade a Doenças , Hospitalização , Humanos , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
INTRODUCTION: Despite active antiretroviral therapy (ART), community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients and incurs high health costs. Areas covered: This article reviews the most recent publications on bacterial CAP in the HIV-infected population, focusing on epidemiology, prognostic factors, microbial etiology, therapy, and prevention. The data discussed here were mainly obtained from a non-systematic review using Medline, and references from relevant articles. Expert commentary: HIV-infected patients are more susceptible to bacterial CAP. Although ART improves their immune response and has reduced CAP incidence, these patients continue to present increased risk of pneumonia in part because they show altered immunity and because immune activation persists. The risk of CAP in HIV-infected patients and the probability of polymicrobial or atypical infections are inversely associated with the CD4 cell count. Mortality in HIV-infected patients with CAP ranges from 6% to 15% but in well-controlled HIV-infected patients on ART the mortality is low and similar to that seen in HIV-negative individuals. Vaccination and smoking cessation are the two most important preventive strategies for bacterial CAP in well-controlled HIV-infected patients on ART.
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Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Infecções Comunitárias Adquiridas/epidemiologia , Pneumonia Bacteriana/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/etiologia , Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Adulto , Animais , Fármacos Anti-HIV/administração & dosagem , Contagem de Linfócito CD4 , Infecções Comunitárias Adquiridas/etiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , Humanos , Incidência , Pneumonia Bacteriana/etiologia , Pneumonia Bacteriana/prevenção & controle , Fatores de Risco , Abandono do Hábito de Fumar/métodos , Vacinação/métodosRESUMO
BACKGROUND: Individuals with certain chronic medical conditions are at higher risk of developing pneumonia and pneumococcal disease than those without. Using data from the Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA), this post hoc analysis assessed the efficacy of the 13-valent pneumococcal conjugate vaccine (PCV13) in adults aged ≥65â¯years with at-risk conditions. METHODS: The Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA) was a double-blind, parallel-group, randomized, placebo-controlled study in the Netherlands in which adults aged ≥65â¯years received either PCV13 or placebo. Outcomes of interest were identified using prespecified clinical criteria, radiographic confirmation, routine microbiologic testing, and a serotype-specific urinary antigen detection assay. In this post hoc analysis, participants were classified by at-risk status based on self-reporting of any of the following chronic medical conditions: heart disease, lung disease, asthma, diabetes, liver disease, and smoking. The objective of this analysis was to assess PCV13 vaccine efficacy (VE) against a first episode of vaccine-serotype community-acquired pneumonia (VT-CAP) in at-risk participants. RESULTS: Of the 84,496 adults enrolled in the study, 41,385 (49.2%) were considered at risk owing to chronic medical conditions. Of the 139 VT-CAP cases, 115 (82.7%) occurred in these participants. VE of PCV13 against a first episode of VT-CAP among participants with at-risk conditions was 40.3% (95.2% CI: 11.4%, 60.2%). Average duration of follow-up since vaccination was 3.95â¯years for at-risk participants; protection did not wane over the study period. CONCLUSIONS: This post hoc analysis of the Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA) showed significant and persistent efficacy of PCV13 against VT-CAP in at-risk older adults. ClinicalTrials.gov identifier: NCT00744263.
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Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Infecções Pneumocócicas/epidemiologia , Infecções Pneumocócicas/prevenção & controle , Vacinas Pneumocócicas/imunologia , Streptococcus pneumoniae/imunologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Comorbidade , Feminino , Seguimentos , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Vigilância em Saúde Pública , Medição de RiscoRESUMO
Pediatric patients with intestinal failure often require central venous catheters for extended periods of time for parenteral nutrition, blood sampling, and medication administration, increasing morbidity, mortality, and costs. In 2007, we reported a central line-associated bloodstream infection rate of 7.0 per 1,000 catheter line-days in our pediatric patients with intestinal failure. On the basis of this high rate of catheter-associated infections, we developed and implemented a central line care curriculum for patients/family caregivers and home health nurses. We aim to show with the implementation of patient/family caregiver and home health nurse standardized education, the central line-associated bloodstream infection rate can be significantly reduced and that this is sustainable. A retrospective review of 80 pediatric outpatients with intestinal failure and long-term central venous access was performed between January 1, 2009, and December 31, 2014. During this time period, the nursing department at Children's Medical Center of Dallas implemented a systematic central line care education program for patients and/or caregivers. The number of community-acquired central line-associated bloodstream infections during this time period was collected and compared with our previously reported data from 2005 to 2007 prior to the implementation of education program. With the implementation of standardized care guidelines and a central venous catheter care curriculum, the community-acquired rate decreased from 4.8 to 2.9 per 1,000 catheter-days in 80 patients with intestinal failure between January 1, 2009, and December 31, 2014 (p < .001). This was also a significant decrease compared with the initial central line-associated bloodstream infection rate of 7.0 per 1,000 central line days in 2007 (p < .001) prior to the development of the central venous catheter care curriculum. We have shown that the incidence of community-acquired central line-associated bloodstream infections in children with intestinal failure can be reduced through formal education of central venous catheter care to family members.
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Cuidadores/educação , Infecções Relacionadas a Cateter/prevenção & controle , Cateteres Venosos Centrais/efeitos adversos , Currículo , Adulto , Infecções Relacionadas a Cateter/epidemiologia , Criança , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Humanos , Incidência , Enteropatias , Nutrição Parenteral , Estudos RetrospectivosRESUMO
This case study is part of a series centered on the Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) health care-associated infection (HAI) surveillance definitions. This specific case study focuses on the definitions and protocols used to make HAI infection determinations, such as the infection window period and secondary bloodstream infection attribution period. The case reflects the real-life and complex patient scenarios that infection preventionists (IPs) face when identifying and reporting HAIs to NHSN. The intent of the case study series is to foster standardized application of the NHSN HAI surveillance definitions among IPs and encourage accurate determination of HAI events. An online survey link is provided where participants may confidentially answer questions related to the case study and receive immediate feedback in the form of correct answers and explanations and rationales. Details of the case study, answers, and explanations have been reviewed and approved by NHSN staff. We hope that participants take advantage of this educational offering and thereby gain a greater understanding of NHSN HAI surveillance definitions.