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1.
J Antimicrob Chemother ; 61(6): 1376-83, 2008 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-18344548

RESUMEN

BACKGROUND: A considerable number of gram-negative bacteraemias occur outside intensive care units (ICUs). Inadequate antibiotic therapy in ICUs has been associated with adverse outcomes; however, there are no prospective studies in non-ICU patients. METHODS: A 6 month (1 August 2006-31 January 2007), prospective cohort study of non-ICU patients with gram-negative bacteraemia in a tertiary-care hospital was performed. Inadequate empirical antibiotic therapy was defined as no antibiotic or starting a non-susceptible antibiotic within 24 h after the initial positive blood culture. RESULTS: Two hundred and fifty non-ICU patients had gram-negative bacteraemia. The mean age was 56.4 (+/-16.1) years. The predominant bacteria in monomicrobial infections were Escherichia coli (24%), Klebsiella pneumoniae (18%) and Pseudomonas aeruginosa (8%). Sixty-one (24%) patients had polymicrobial bacteraemia. Seventy patients (28%) required ICU transfer and 35 (14%) died. Seventy-nine (31.6%) received inadequate empirical antibiotic therapy. These patients were more likely to have a hospital-acquired infection [odds ratio (OR) = 1.99, 95% confidence interval (CI) = 1.11-3.56, P = 0.02] and less likely to have E. coli monomicrobial bacteraemia [OR 0.40 (95% CI 0.19-0.86), P = 0.02]. There were no differences in occurrence of sepsis [72 (91.1%) patients with inadequate versus 159 (93.0%) with adequate therapy; P = 0.6], ICU transfer [20 (25.3%) versus 50 (29.2%); P = 0.5], post-bacteraemia length of stay (median = 6.8 versus 6.1 days; P = 0.09) or death [11 (13.9%) versus 24 (14.0%); P = 1.0]. CONCLUSIONS: Nearly one-third of the non-ICU patients with gram-negative bacteraemia received inadequate empirical antibiotic therapy. There was no difference in adverse outcomes between patients receiving inadequate or adequate therapy in this study.


Asunto(s)
Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Bacteriemia/microbiología , Infección Hospitalaria/tratamiento farmacológico , Bacterias Gramnegativas/efectos de los fármacos , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Adulto , Anciano , Antibacterianos/farmacología , Bacteriemia/complicaciones , Bacteriemia/mortalidad , Estudios de Cohortes , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Escherichia coli/efectos de los fármacos , Escherichia coli/aislamiento & purificación , Femenino , Bacterias Gramnegativas/aislamiento & purificación , Infecciones por Bacterias Gramnegativas/microbiología , Infecciones por Bacterias Gramnegativas/mortalidad , Hospitales , Humanos , Pacientes Internos , Klebsiella pneumoniae/efectos de los fármacos , Klebsiella pneumoniae/aislamiento & purificación , Tiempo de Internación , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Prospectivos , Pseudomonas aeruginosa/efectos de los fármacos , Pseudomonas aeruginosa/aislamiento & purificación , Sepsis/microbiología , Resultado del Tratamiento
2.
J Am Med Inform Assoc ; 12(4): 383-9, 2005.
Artículo en Inglés | MEDLINE | ID: mdl-15802481

RESUMEN

A commercial rule base (Cerner Multum) was used to identify medication orders exceeding recommended dosage limits at five hospitals within BJC HealthCare, an integrated health care system. During initial testing, clinical pharmacists determined that there was an excessive number of nuisance and clinically insignificant alerts, with an overall alert rate of 9.2%. A method for customizing the commercial rule base was implemented to increase rule specificity for problematic rules. The system was subsequently deployed at two facilities and achieved alert rates of less than 1%. Pharmacists screened these alerts and contacted ordering physicians in 21% of cases. Physicians made therapeutic changes in response to 38% of alerts presented to them. By applying simple techniques to customize rules, commercial rule bases can be used to rapidly deploy a safety net to screen drug orders for excessive dosages, while preserving the rule architecture for later implementations of more finely tuned clinical decision support.


Asunto(s)
Sistemas de Información en Farmacia Clínica , Quimioterapia Asistida por Computador , Sistemas Especialistas , Errores de Medicación/prevención & control , Sistemas de Medicación en Hospital , Preparaciones Farmacéuticas/administración & dosificación , Sistemas de Apoyo a Decisiones Clínicas , Humanos
3.
Antimicrob Agents Chemother ; 49(4): 1306-11, 2005 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-15793102

RESUMEN

Pseudomonas aeruginosa bloodstream infection is a serious infection with significant patient mortality and health-care costs. Nevertheless, the relationship between initial appropriate antimicrobial treatment and clinical outcomes is not well established. This study was a retrospective cohort analysis employing automated patient medical records and the pharmacy database at Barnes-Jewish Hospital. Three hundred five patients with P. aeruginosa bloodstream infection were identified over a 6-year period (January 1997 through December 2002). Sixty-four (21.0%) patients died during hospitalization. Hospital mortality was statistically greater for patients receiving inappropriate initial antimicrobial treatment (n = 75) compared to appropriate initial treatment (n = 230) (30.7% versus 17.8%; P = 0.018). Multiple logistic regression analysis identified inappropriate initial antimicrobial treatment (adjusted odds ratio [AOR], 2.04; 95% confidence interval [CI], 1.42 to 2.92; P = 0.048), respiratory failure (AOR, 5.18; 95% CI, 3.30 to 8.13; P < 0.001), and circulatory shock (AOR, 4.00; 95% CI, 2.71 to 5.91; P < 0.001) as independent determinants of hospital mortality. Appropriate initial antimicrobial treatment was administered statistically more often among patients receiving empirical combination antimicrobial treatment for gram-negative bacteria compared to empirical monotherapy (79.4% versus 65.5%; P = 0.011). Inappropriate initial empirical antimicrobial treatment is associated with greater hospital mortality among patients with P. aeruginosa bloodstream infection. Inappropriate antimicrobial treatment of P. aeruginosa bloodstream infections may be minimized by increased use of combination antimicrobial treatment until susceptibility results become known.


Asunto(s)
Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Bacteriemia/mortalidad , Pseudomonas aeruginosa/efectos de los fármacos , Adulto , Anciano , Bacteriemia/microbiología , Estudios de Cohortes , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Análisis Multivariante , Infecciones por Pseudomonas/tratamiento farmacológico , Infecciones por Pseudomonas/microbiología , Infecciones por Pseudomonas/mortalidad , Estudios Retrospectivos
4.
N Engl J Med ; 352(5): 468-75, 2005 Feb 03.
Artículo en Inglés | MEDLINE | ID: mdl-15689585

RESUMEN

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging cause of infections outside of health care settings. We investigated an outbreak of abscesses due to MRSA among members of a professional football team and examined the transmission and microbiologic characteristics of the outbreak strain. METHODS: We conducted a retrospective cohort study and nasal-swab survey of 84 St. Louis Rams football players and staff members. S. aureus recovered from wound, nasal, and environmental cultures was analyzed by means of pulsed-field gel electrophoresis (PFGE) and typing for resistance and toxin genes. MRSA from the team was compared with other community isolates and hospital isolates. RESULTS: During the 2003 football season, eight MRSA infections occurred among 5 of the 58 Rams players (9 percent); all of the infections developed at turf-abrasion sites. MRSA infection was significantly associated with the lineman or linebacker position and a higher body-mass index. No MRSA was found in nasal or environmental samples; however, methicillin-susceptible S. aureus was recovered from whirlpools and taping gel and from 35 of the 84 nasal swabs from players and staff members (42 percent). MRSA from a competing football team and from other community clusters and sporadic cases had PFGE patterns that were indistinguishable from those of the Rams' MRSA; all carried the gene for Panton-Valentine leukocidin and the gene complex for staphylococcal-cassette-chromosome mec type IVa resistance (clone USA300-0114). CONCLUSIONS: We describe a highly conserved, community-associated MRSA clone that caused abscesses among professional football players and that was indistinguishable from isolates from various other regions of the United States.


Asunto(s)
Absceso/microbiología , Resistencia a la Meticilina , Infecciones Cutáneas Estafilocócicas/microbiología , Staphylococcus aureus/genética , Absceso/epidemiología , Adulto , Células Clonales , Estudios de Cohortes , Infecciones Comunitarias Adquiridas/epidemiología , Infecciones Comunitarias Adquiridas/microbiología , Brotes de Enfermedades , Electroforesis en Gel de Campo Pulsado , Fútbol Americano , Geles , Humanos , Hidroterapia , Masculino , Pruebas de Sensibilidad Microbiana , Nariz/microbiología , Estudios Retrospectivos , Factores de Riesgo , Piel/lesiones , Piel/microbiología , Infecciones Estafilocócicas/epidemiología , Infecciones Estafilocócicas/microbiología , Infecciones Cutáneas Estafilocócicas/epidemiología , Infecciones Cutáneas Estafilocócicas/transmisión , Staphylococcus aureus/clasificación , Staphylococcus aureus/aislamiento & purificación , Estados Unidos/epidemiología
5.
Crit Care Med ; 32(12): 2450-6, 2004 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-15599150

RESUMEN

OBJECTIVE: To determine the impact of the rotation of antimicrobial agents on the rates of infection, intestinal colonization, and acquisition with antimicrobial-resistant Gram-negative bacteria. DESIGN: Pre- and postintervention design. SETTING: A 19-bed, medical intensive care unit. PATIENTS: Individuals admitted to the study unit for >48 hrs. INTERVENTIONS: After a 5-month baseline observation period, four classes of antimicrobial agents with Gram-negative activity were cycled at 3- to 4-month intervals for 24 months. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the acquisition rate of antimicrobial resistance among Enterobacteriaceae and Pseudomonas aeruginosa obtained from rectal swab cultures performed on admission, weekly during the patients' stay, and at discharge. Rates and microbiology of nosocomial bloodstream infections and ventilator-associated pneumonia were also compared between baseline and cycling periods. The cycling program resulted in a significant change in prescribing practices; the predominant agent used changed with each cycle. Among study patients who were not already colonized with a resistant organism, the rate of acquisition of enteric colonization with bacteria resistant to any of the target drugs remained stable during the cycling period for P. aeruginosa (relative rate, 0.96; 95% confidence Interval, 0.47-2.16) and Enterobacteriaceae (relative rate, 1.57; 95% confidence interval, 0.80-3.43). Hospital-wide, P. aeruginosa from routine clinical cultures resistant to the target drugs increased during the cycling period. The proportion of Gram-negative bacteria isolated from cases of nosocomial bloodstream infection (29% baseline vs. 26% cycling; p = .11) and ventilator-associated pneumonia (80% vs. 41%; p = .06) did not significantly differ. CONCLUSIONS: In this study, antimicrobial cycling did not result in a significant change in enteric acquisition of resistant Gram-negative bacteria among intensive care unit patients.


Asunto(s)
Antibacterianos/uso terapéutico , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/microbiología , Bacterias Gramnegativas/efectos de los fármacos , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Unidades de Cuidados Intensivos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Intervalos de Confianza , Enfermedad Crítica , Infección Hospitalaria/mortalidad , Infección Hospitalaria/prevención & control , Farmacorresistencia Bacteriana , Femenino , Bacterias Gramnegativas/aislamiento & purificación , Infecciones por Bacterias Gramnegativas/mortalidad , Infecciones por Bacterias Gramnegativas/prevención & control , Hospitales de Enseñanza , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Probabilidad , Pronóstico , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento
6.
Chest ; 125(6): 2224-31, 2004 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-15189945

RESUMEN

STUDY OBJECTIVES: To determine whether an educational initiative could decrease rates of ventilator-associated pneumonia in a regional health-care system. SETTING: Two teaching hospitals (one adult, one pediatric) and two community hospitals in an integrated health system. DESIGN: Preintervention and postintervention observational study. PATIENTS: Patients admitted to the four participating hospitals between January 1, 1999, and June 30, 2002, who acquired ventilator-associated pneumonia. INTERVENTION: An educational program for respiratory care practitioners and ICU nurses emphasizing correct practices for the prevention of ventilator-associated pneumonia. The program included a self-study module on risk factors for, and strategies to prevent, ventilator-associated pneumonia and education-based in-services. Fact sheets and posters reinforcing the information were posted throughout the ICU and respiratory care departments. MEASUREMENTS AND RESULTS: Completion rates for the module were calculated by job title at each hospital. Rates of ventilator-associated pneumonia per 1,000 ventilator days were calculated for all hospitals combined and for each hospital separately. Overall 635 of 792 ICU nurses (80.1%) and 215 of 239 respiratory therapists (89.9%) completed the study module. There were 874 episodes of ventilator-associated pneumonia at the four hospitals during the 3.5-year study period out of 129,527 ventilator days. Ventilator-associated pneumonia rates for all four hospitals combined dropped by 46%, from 8.75/1,000 ventilator days in the year prior to the intervention to 4.74/1,000 ventilator days in the 18 months following the intervention (p < 0.001). Statistically significant decreased rates were observed at the pediatric hospital and at two of the three adult hospitals. No change in rates was seen at the community hospital with the lowest rate of study module completion among respiratory therapists (56%). CONCLUSIONS: Educational interventions can be associated with decreased rates of ventilator-associated pneumonia in the ICU setting. The involvement of respiratory therapy staff in addition to ICU nurses is important for the success of educational programs aimed at the prevention of ventilator-associated pneumonia.


Asunto(s)
Control de Infecciones/métodos , Capacitación en Servicio , Neumonía Bacteriana/epidemiología , Neumonía Bacteriana/etiología , Respiración Artificial/efectos adversos , Adulto , Anciano , Niño , Preescolar , Estudios de Cohortes , Infección Hospitalaria/etiología , Infección Hospitalaria/prevención & control , Prestación Integrada de Atención de Salud , Femenino , Educación en Salud , Hospitales de Enseñanza , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Neumonía Bacteriana/prevención & control , Prevención Primaria/métodos , Respiración Artificial/métodos , Estudios Retrospectivos , Sensibilidad y Especificidad
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