Effectiveness of Bio-K+ for the prevention of Clostridioides difficile infection: Stepped-wedge cluster-randomized controlled trial.

OBJECTIVE: To evaluate the impact of administering probiotics to prevent Clostridioides difficile infection (CDI) among patients receiving therapeutic antibiotics. DESIGN: Stepped-wedge cluster-randomized trial between September 1, 2016, and August 31, 2019. SETTING: This study was conducted in 4 acute-care hospitals across an integrated health region. PATIENTS: Hospitalized patients, aged ≥55 years. METHODS: Patients were given 2 probiotic capsules daily (Bio-K+, Laval, Quebec, Canada), containing 50 billion colony-forming units of Lactobacillus acidophilus CL1285, L. casei LBC80R, and L. rhamnosus CLR2. We measured hospital-acquired CDI (HA-CDI) and the number of positive C. difficile tests per 10,000 patient days as well as adherence to administration of Bio-K+ within 48 and 72 hours of antibiotic administration. Mixed-effects generalized linear models, adjusted for influenza admissions and facility characteristics, were used to evaluate the impact of the intervention on outcomes. RESULTS: Overall adherence of Bio-K+ administration ranged from 76.9% to 84.6% when stratified by facility and periods. Rates of adherence to administration within 48 and 72 hours of antibiotic treatment were 60.2% -71.4% and 66.7%-75.8%, respectively. In the adjusted analysis, there was no change in HA-CDI (incidence rate ratio [IRR], 0.92; 95% confidence interval [CI], 0.68-1.23) or C. difficile positivity rate (IRR, 1.05; 95% CI, 0.89-1.24). Discharged patients may not have received a complete course of Bio-K+. Our hospitals had a low baseline incidence of HA-CDI. Patients who did not receive Bio-K+ may have differential risks of acquiring CDI, introducing selection bias. CONCLUSIONS: Hospitals considering probiotics as a primary prevention strategy should consider the baseline incidence of HA-CDI in their population and timing of probiotics relative to the start of antimicrobial administration.

The impact of the COVID-19 pandemic on hospital-acquired infections at a comprehensive cancer center.

BACKGROUND: Robust infection prevention and control (IPC) measures were deployed across health care institutions at the start of the COVID-19 pandemic, resulting in increased use of personal protective equipment, enhanced contact precautions, and an emphasis on hand hygiene. Here, we evaluate the effect of enhanced IPC practices on the occurrence of various hospital-associated infections (HAIs) in a comprehensive cancer center. METHODS: From September 2016 through March 2022, we calculated the incidence rates (IRs) of HAIs for C. difficile infection, multidrug-resistant organisms, respiratory viral infections (RVIs), and device-related infections. We analyzed the incidence rate ratios for all HAIs during the periods before the pandemic, during the pandemic, at the time of the surges, and in COVID-19-designated wards. RESULTS: When comparing the prepandemic to the pandemic period, the IR across all MRDOs was similar. We observed a decrease in the IR of central line-associated bloodstream infections and a stable IR of catheter-associated urinary tract infections. A significant decrease was observed in the IR of C. difficile infection. The total IR of nosocomial RVIs decreased, as did for each respiratory virus. A similar IR of nosocomial RVIs between COVID-19 community surge versus nonsurge periods was observed except for SARS-CoV-2, RSV, and influenza. multidrug resistant organisms were 5 times more likely to occur on the COVID-19 wards compared with the non-COVID-19 wards. CONCLUSIONS: Implementing strict IPC measures during the COVID-19 pandemic in a cancer hospital led to a significant decrease in many HAIs and a reduction in nosocomial RVIs.

Identification of an Outbreak Cluster of Extensively Antibiotic-Resistant GC1 Acinetobacter baumannii Isolates in U.S. Military Treatment Facilities.

An outbreak involving an extensively antibiotic-resistant Acinetobacter baumannii strain in three military treatment facilities was identified. Fifty-nine isolates recovered from 30 patients over a 4-year period were found among a large collection of isolates using core genome multilocus sequence typing (MLST). They differed by only 0 to 18 single nucleotide polymorphisms (SNPs) and carried the same resistance determinants except that the aphA6 gene was missing in 25 isolates. They represent a novel sublineage of GC1 lineage 1 that likely originated in Afghanistan. IMPORTANCE A. baumannii is recognized as one of the most important nosocomial pathogens, and carbapenem-resistant strains pose a particularly difficult treatment challenge. Outbreaks linked to this pathogen are reported worldwide, particularly during periods of societal upheaval, such as natural disasters and conflicts. Understanding how this organism enters and establishes itself within the hospital environment is key to interrupting transmission, but few genomic studies have examined these transmissions over a prolonged period. Though historical, this report provides an in-depth analysis of nosocomial transmission of this organism across continents and within and between different hospitals.

Nosocomial COVID-19 at a comprehensive cancer center during the first year of the pandemic: Lessons learned.

BACKGROUND: The spread of coronavirus disease 2019 (COVID-19) in health care settings endangers patients with cancer. As knowledge of the transmission of COVID-19 emerged, strategies for preventing nosocomial COVID-19 were updated. We describe our early experience with nosocomial respiratory viral infections (RVIs) at a cancer center in the first year of the pandemic (March 2020-March 2021). METHODS: Nosocomial RVIs were identified through our infection control prospective surveillance program, which conducted epidemiologic investigations of all microbiologically documented RVIs. Data was presented as frequencies and percentages or medians and ranges. RESULTS: A total of 35 of 3944 (0.9%) documented RVIs were determined to have been nosocomial acquired. Majority of RVIs were due to SARS CoV-2 (13/35; 37%) or by rhinovirus/enterovirus (12/35; 34%). A cluster investigation of the first 3 patients with nosocomial COVID-19 determined that transmission most likely occurred from employees to patients. Five patients (38%) required mechanical ventilation and 4 (31%) died during the same hospital encounter. CONCLUSIONS: Our investigation of the cluster led to enhancement of our infection control measures. The implications of COVID-19 vaccination on infection control policies is still unclear and further studies are needed to delineate its impact on the transmission of COVID-19 in a hospital setting.

Neonatal outcomes from a quasi-experimental clinical trial of Family Integrated Care versus Family-Centered Care for preterm infants in U.S. NICUs.

BACKGROUND: Family Integrated Care (FICare) benefits preterm infants compared with Family-Centered Care (FCC), but research is lacking in United States (US) Neonatal Intensive Care Units (NICUs). The outcomes for infants of implementing FICare in the US are unknown given differences in parental leave benefits and health care delivery between the US and other countries where FICare is used. We compared preterm weight and discharge outcomes between FCC and mobile-enhanced FICare (mFICare) in the US. METHODS: In this quasi-experimental study, we enrolled preterm infant (≤ 33 weeks)/parent dyads from 3 NICUs into sequential cohorts: FCC or mFICare. Our primary outcome was 21-day change in weight z-scores. Our secondary outcomes were nosocomial infection, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and human milk feeding (HMF) at discharge. We used intention-to-treat analyses to examine the effect of the FCC and mFICare models overall and per protocol analyses to examine the effects of the mFICare intervention components. FINDINGS: 253 infant/parent dyads participated (141 FCC; 112 mFICare). There were no parent-related adverse events in either group. In intention-to-treat analyses, we found no group differences in weight, ROP, BPD or HMF. The FCC cohort had 2.6-times (95% CI: 1.0, 6.7) higher odds of nosocomial infection than the mFICare cohort. In per-protocol analyses, we found that infants whose parents did not receive parent mentoring or participate in rounds lost more weight relative to age-based norms (group-difference=-0.128, CI: -0.227, -0.030; group-difference=-0.084, CI: -0.154, -0.015, respectively). Infants whose parents did not participate in rounds or group education had 2.9-times (CI: 1.0, 9.1) and 3.8-times (CI: 1.2, 14.3) higher odds of nosocomial infection, respectively. CONCLUSION: We found indications that mFICare may have direct benefits on infant outcomes such as weight gain and nosocomial infection. Future studies using implementation science designs are needed to optimize intervention delivery and determine acute and long-term infant and family outcomes. CLINICAL TRIAL REGISTRATION: NCT03418870 01/02/2018.

Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset.

BACKGROUND: Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS: Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. RESULTS: The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (ß=16032.5, p=0.008). CONCLUSIONS: Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.

Clinical Feature, Therapy, Antimicrobial Resistance Gene Distribution, and Outcome of Nosocomial Meningitis Induced by Multidrug-Resistant Enterobacteriaceae-A Longitudinal Cohort Study From Two Neurosurgical Centers in Northern China.

Objectives: This is a comparative cohort study aiming to evaluate the mortality risk factors for patients with nosocomial meningitis (NM) induced by multidrug-resistant Enterobacteriaceae (MDRE) in China. The clinical features and therapies of patients and the resistance mechanisms of MDRE pathogens were also assessed. Methods: MDRE-NM patients from two neurosurgical centers in China from 2014 to 2019 were included in this study. Clinical features were extracted from the medical record databases of the two centers. The molecular mechanisms underlying the microbiological resistance mechanisms of each MDRE pathogen were determined, Kaplan-Meier survival analysis was conducted, and multivariable analyses were performed using a Cox proportional hazard model. Results: Ninety MDRE-NM patients were included in this study. Klebsiella pneumoniae accounted for the highest proportion of causative pathogens (46/90, 51.1%), and 40 causative pathogens (44.4%) were meropenem-resistant. blaKPC (27/40, 67.5%) was the predominant carbapenem resistance gene. Multivariate Cox analysis showed that external ventricular drainage (EVD) [hazard ratio (HR) = 2.524, 95% confidence interval (CI) = 1.101-5.787, p = 0.029] and a Glasgow Coma Scale (GCS) score ≤;8 (HR = 4.033, 95% CI = 1.526-10.645, p = 0.005) were mortality risk factors for patients with MDRE-NM. A total of 90.0%, 94.4%, and 97.8% of MDRE-NM patients received antibiotic prophylaxis (AP), antibiotic empirical therapy (AET), and antibiotic definitive therapy (ADT), respectively. Conclusions: NM caused by MDRE is an important sign of the failure of neurosurgery. MDRE possesses multiple drug resistance genotypes, and EVD and a GCS score ≤;8 are independent mortality risk factors for patients with MDRE-NM, which deserve the attention of microbiologists and neurosurgical clinicians.

Correlation between antibiotic consumption and the occurrence of multidrug-resistant organisms in a Malaysian tertiary hospital: a 3-year observational study.

Inappropriate use of antibiotics has been shown to contribute to the occurrence of multidrug-resistant organisms (MROs). A surveillance study was performed in the largest tertiary care hospital in Kuala Lumpur, Malaysia, from 2018 to 2020 to observe the trends of broad-spectrum antibiotics (beta-lactam/beta-lactamases inhibitors (BL/BLI), extended-spectrum cephalosporins (ESC), and fluoroquinolones (FQ)) and antibiotics against MRO (carbapenems, polymyxins, and glycopeptides) usage and the correlation between antibiotic consumption and MROs. The correlation between 3-year trends of antibiotic consumption (defined daily dose (DDD)/100 admissions) with MRO infection cases (per 100 admissions) was determined using a Jonckheere-Terpstra test and a Pearson's Correlation coefficient. The antimicrobial resistance trend demonstrated a positive correlation between ESC and FQ towards the development of methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL)-producing Klebsiella spp, ESBL-producing Escherichia coli (E. coli), and MRO Acinetobacter baumannii (A. baumannii). Increasing carbapenem consumption was positively correlated with the occurrence of ESBL-producing Klebsiella spp and E. coli. Polymyxin use was positively correlated with ESBL-producing Klebsiella spp, MRO A. baumannii, and carbapenem-resistant Enterobacteriaceae. The findings reinforced concerns regarding the association between MRO development, especially with a surge in ESC and FQ consumption. Stricter use of antimicrobials is thus crucial to minimise the risk of emerging resistant organisms.

Assessment of the incidence and etiology of nosocomial diarrhea in a medical ward in Iraq.

This study aimed to detect the incidence, etiology, risk factors, and severity of nosocomial diarrhea among adult inpatients in a medical ward in Iraq. The study was conducted among patients admitted to the medical ward from June 1, 2019, to January 31, 2020, in AL-Sader medical city. The surveillance for nosocomial diarrhea was performed by monitoring every patient in the ward 3 times/week. 1050 patients were admitted to the medical ward in AL-Sader medical city. Of these, 52 patients (mean age 58±12.91 years, range 32 to 80) developed new-onset diarrhea during hospitalization. There was a significant relationship between the severity of diarrhea and age, residence, antibiotic use, including number and duration of antibiotics, immunosuppressive agents (steroids/chemotherapy), duration of hospital stay, level of consciousness, and enema use. Nosocomial diarrhea is a significant clinical problem that complicates about 5% of all admission in the medical ward. Various microorganisms account for nosocomial diarrhea, including E. histolytica, G. lamblia, and Candida. Several risk factors associated with the severe form of nosocomial diarrhea include old age, antibiotic use, immunosuppressive use, and length of hospital stay.

The Epidemiology and Pathogenesis and Treatment of Pseudomonas aeruginosa Infections: An Update.

Pseudomonas aeruginosa is a Gram-negative bacterial pathogen that is a common cause of nosocomial infections, particularly pneumonia, infection in immunocompromised hosts, and in those with structural lung disease such as cystic fibrosis. Epidemiological studies have identified increasing trends of antimicrobial resistance, including multi-drug resistant (MDR) isolates in recent years. P. aeruginosa has several virulence mechanisms that increase its ability to cause severe infections, such as secreted toxins, quorum sensing and biofilm formation. Management of P. aeruginosa infections focuses on prevention when possible, obtaining cultures, and prompt initiation of antimicrobial therapy, occasionally with combination therapy depending on the clinical scenario to ensure activity against P. aeruginosa. Newer anti-pseudomonal antibiotics are available and are increasingly being used in the management of MDR P. aeruginosa.

Impact of a nutrition support therapy on hospital-acquired infections: A value analysis.

BACKGROUND: Hospital-acquired conditions (HACs) have a direct impact on value, as they decrease quality and increase costs. Numerous interventions have been tried, including nutrition support therapy, with unknown effect on value. Therefore, a value analysis of nutrition support therapy on HACs was performed. METHODS: An extensive literature search was performed. Using the Medicare Parts A and B Claims 5% Sample data set, analytic claims modeling was conducted. RESULTS: The search identified 1099 studies, with eight meeting the inclusion criteria. All studies were performed on adult critically ill patients and focused on HA infections (HAIs) as the HAC. One study underwent Medicare claims modeling and revealed nutrition therapy has the potential of saving at least $104 million annually in Medicare patients with HAIs. CONCLUSION: Nutrition support therapy has the potential to reduce costs of Medicare spending in respect to HAIs.

Epidemiology, species distribution, and outcome of nosocomial Candida spp. bloodstream infection in Shanghai: an 11-year retrospective analysis in a tertiary care hospital.

BACKGROUND: The incidence of Candida bloodstream infections (BSIs), has increased over time. In this study, we aimed to describe the current epidemiology of Candida BSI in a large tertiary care hospital in Shanghai and to determine the risk factors of 28-day mortality and the impact of antifungal therapy on clinical outcomes. METHODS: All consecutive adult inpatients with Candida BSI at Ruijin Hospital between January 1, 2008, and December 31, 2018, were enrolled. Underlying diseases, clinical severity, species distribution, antifungal therapy, and their impact on the outcomes were analyzed. RESULTS: Among the 370 inpatients with 393 consecutive episodes of Candida BSI, the incidence of nosocomial Candida BSI was 0.39 episodes/1000 hospitalized patients. Of the 393 cases, 299 (76.1%) were treated with antifungal therapy (247 and 52 were treated with early appropriate and targeted antifungal therapy, respectively). The overall 28-day mortality rate was 28.5%, which was significantly lower in those who received early appropriate (25.5%) or targeted (23.1%) antifungal therapy than in those who did not (39.4%; P = 0.012 and P = 0.046, respectively). In multivariate Cox regression analysis, age, chronic renal failure, mechanical ventilation, and severe neutropenia were found to be independent risk factors of the 28-day mortality rate. Patients who received antifungal therapy had a lower mortality risk than did those who did not. CONCLUSIONS: The incidence of Candida BSI has increased steadily in the past 11 years at our tertiary care hospital in Shanghai. Antifungal therapy influenced short-term survival, but no significant difference in mortality was observed between patients who received early appropriate and targeted antifungal therapy.

Transformation of microbiology data into a standardised data representation using OpenEHR.

The spread of multidrug resistant organisms (MDRO) is a global healthcare challenge. Nosocomial outbreaks caused by MDRO are an important contributor to this threat. Computer-based applications facilitating outbreak detection can be essential to address this issue. To allow application reusability across institutions, the various heterogeneous microbiology data representations needs to be transformed into standardised, unambiguous data models. In this work, we present a multi-centric standardisation approach by using openEHR as modelling standard. Data models have been consented in a multicentre and international approach. Participating sites integrated microbiology reports from primary source systems into an openEHR-based data platform. For evaluation, we implemented a prototypical application, compared the transformed data with original reports and conducted automated data quality checks. We were able to develop standardised and interoperable microbiology data models. The publicly available data models can be used across institutions to transform real-life microbiology reports into standardised representations. The implementation of a proof-of-principle and quality control application demonstrated that the new formats as well as the integration processes are feasible. Holistic transformation of microbiological data into standardised openEHR based formats is feasible in a real-life multicentre setting and lays the foundation for developing cross-institutional, automated outbreak detection systems.

The pathogenic characteristics and influencing factors of health care-associated infection in elderly care center under the mode of integration of medical care and elderly care service: A cross-sectional study.

ABSTRACT: The aim of this study was to analyze the distribution of pathogenic bacteria in hospitalized patients in elderly care centers under the mode of integration of medical care and elderly care service, and explore the influencing factors to reduce the health care-associated infection rate of hospitalized patients.A total of 2597 inpatients admitted to elderly care centers from April 2018 to December 2019 were included in the study. The etiology characteristics of health care-associated infections (HCAI) was statistically analyzed, univariate analysis, and multivariate logistic regression analysis method were used to analyze the influencing factors of HCAI.A total of 98 of 2597 inpatients in the elderly care centers had HCAI, and the infection rate was 3.77%. The infection sites were mainly in the lower respiratory tract and urinary tract, accounting for 53.92% and 18.63%, respectively. A total of 53 pathogenic bacteria were isolated, 43 of which (81.13%) were Gram-negative, mainly Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae, which respectively accounted for 24.53, 16.98, and 13.21%. 9 (16.98%) strains were Gram-positive, mainly Staphylococcus aureus and Enterococcus faecium, respectively accounting for 7.55 and 5.66%. Only 1 patient (1.89%) had a fungal infection. Multivariate logistic regression analysis indicated that total hospitalization days, antibiotic agents used, days of central line catheter, use of urinary catheter and diabetes were independent risk factors of nosocomial infection in elderly care centers (P < .05).Many factors can lead to nosocomial infections in elderly care centers. Medical staff should take effective intervention measures according to the influencing factors to reduce the risk of infection in elderly care facilities.

Early Outcomes of a National Cancer Center's Strategy Against COVID-19 Executed Through a Disease Outbreak Response Taskforce.

PURPOSE: We present the strategy of a comprehensive cancer center organized to make operations pandemic proof and achieve continuity of cancer care during the COVID-19 pandemic. METHODS: Disease Outbreak Response (DORS) measures implemented at our center and its satellite clinics included strict infection prevention, manpower preservation, prudent resource allocation, and adaptation of standard-of-care treatments. Critical day-to-day clinical operations, number of persons screened before entry, staff temperature monitoring, and personal protection equipment stockpile were reviewed as a dashboard at daily DORS taskforce huddles. Polymerase chain reaction swab tests performed for patients and staff who met defined criteria for testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were tracked. Descriptive statistics of outpatient attendances and treatment caseloads from February 3 to May 23, 2020, were compared with the corresponding period in 2019. RESULTS: We performed COVID-19 swabs for 80 patients and 93 staff, detecting three cancer patients with community-acquired COVID-19 infections with no nosocomial transmission. Patients who required chemotherapy, radiotherapy, or surgery and patients who are on maintenance treatment continued to receive timely treatment without disruption. The number of intravenous chemotherapy treatments was maintained at 97.8% compared with 2019, whereas that of weekly radiotherapy treatments remained stable since December 2019. All cancer-related surgeries proceeded without delay, with a 0.3% increase in workload. Surveillance follow-ups were conducted via teleconsultation, accounting for a 30.7% decrease in total face-to-face clinic consultations. CONCLUSION: Through the coordinated efforts of a DORS taskforce, it is possible to avoid nosocomial SARS-CoV-2 transmissions among patients and staff without compromising on care delivery at a national cancer center.

Bloodstream infections caused by ST2 Acinetobacter baumannii: risk factors, antibiotic regimens, and virulence over 6 years period in China.

BACKGROUND: Bloodstream infection (BSI) caused by multidrug-resistant Acinetobacter baumannii (MDR-AB) has been increasingly observed among hospitalized patients. The following study analyzed the epidemiology and microbiological characteristics of MDR-AB, as well as the clinical features, antimicrobial treatments, and outcomes in patients over a six years period in China. METHODS: This retrospective study was conducted in a large tertiary hospital in China between January 2013 and December 2018. The clinical and microbiological data of all consecutive hospitalized patients with MDR-AB induced bloodstream infection were included and analyzed. RESULTS: A total of 108 BSI episodes were analyzed. All MDR isolates belonged to ST2, a sequence type that has spread all over the world. Overall, ST2 strains showed strong biofilm formation ability, high serum resistance, and high pathogenicity. As for the clinical characteristics of the patient, 30-day mortality was 69.4% (75/108). The three main risk factors included mechanical ventilation, intensive care unit (ICU) stay, and thrombocytopenia; three protective factors included a change of antimicrobial regimen within 48 h after positive blood culture, use of the antibacterial agent combination, and more inpatient days. The most effective antibacterial regimen was the combination of cefoperazone/sulbactam and tigecycline. CONCLUSIONS: BSI caused by ST2 A.baumannii represents a difficult challenge for physicians, considering the high mortality associated with this infection. The combination of cefoperazone/sulbactam and tigecycline may be an effective treatment option.

Appropriateness of diagnosis and antibiotic use in sepsis patients admitted to a tertiary hospital in Indonesia.

OBJECTIVE: To evaluate the diagnostic and antibiotic treatment strategies for patients suspected of sepsis, in a tertiary hospital in Indonesia. This can identify areas for improvement in care provided, and inform diagnostic and antimicrobial stewardship activities within the hospital. METHODS: Retrospective review of medical records with regards to the diagnosis and management of adult patients with sepsis admitted to a tertiary hospital in Indonesia. We assessed the diagnostic process, and whether or not the antibiotic treatment provided was appropriate for the diagnosis. Appropriateness of antibiotic treatment was classified as being definite appropriate, probable appropriate, inappropriate, or unknown. RESULTS: The study included 535 adult patients, of whom 295 (55%) were diagnosed with a community-acquired sepsis, and 240 (45%) with a hospital-acquired sepsis. A specimen for culture and antimicrobial susceptibility testing was collected from three out of four patients (392/535). All but 10 patients had information on antibiotic treatment at the time of sepsis diagnosis. Of those, nearly 50% (257/525) of the patients received antibiotic treatment with unknown appropriateness because no cultures were taken (n = 141) or all cultures were negative (n = 116). Just 3.4% and 9.1% of the patients received definite or probable appropriate antibiotic treatment, respectively. CONCLUSIONS: There is a clear need in encouraging attending physicians to obtain the much-required blood cultures, or cultures from the suspected source of infection before empirical antibiotic treatment is started. This will improve the use of appropriate antibiotic treatment strategies, and contribute to antimicrobial stewardship.

[Effectiveness and safety of two lipid emulsions for parenteral nutrition in postsurgical critically ill patients: Clinoleic® versus SMOFlipid®]. / Eficacia y seguridad de dos emulsiones lipídicas de nutrición parenteral en pacientes críticos posquirúrgicos: Clinoleic® frente a SMOFlipid®.

INTRODUCTION: Introduction: a lipid emulsion (LE) may result in different immunomodulatory effects depending on its fatty acid composition. LEs enriched with fish oil and those based on olive oil (OOBE) have shown advantages over those derived from soybean oil, although very few studies have compared these with each other, and none was performed in critically ill surgical patients. Objectives: to demonstrate non-inferiority for the therapeutic efficacy of SMOFlipid® (enriched with fish oil) versus Clinoleic® (OOBE) in relation to the occurrence of nosocomial infection and other evolutionary parameters. To demonstrate non-inferiority in the safety profile of SMOFlipid® versus Clinoleic® in terms of mortality and adverse events. Material and method: a phase-III, non-inferiority clinical trial performed in critically ill postsurgical patients. The subjects were randomized to receive SMOFlipid® or Clinoleic®. For comparison of qualitative variables case frequencies and percentages were obtained using the Chi-squared test or Fisher's exact test. Means were compared between groups using Student's t-test. A p-value lower than 0.05 was considered statistically significant. The Farrington-Manning, Miettinen-Nurminen, and Gart-Nam tests were applied in the main non-inferiority analysis of the primary endpoint. Results: during de inclusion period 73 patients were selected, 37 of whom received Clinoleic® and 36 SMOFlipid®. Regarding the variable "decrease in nosocomial infections", SMOFlipid® proved to be non-inferior to Clinoleic®. Regarding the main variable "mortality", SMOFlipid® proved to be non-inferior to Clinoleic®. There were no statistically significant differences in the occurrence of adverse effects either. Conclusions: in our study, SMOFlipid® proved to be non-inferior to Clinoleic® in terms of efficacy and safety.

INTRODUCCIÓN: Introducción: las emulsiones lipídicas (EL) pueden asociar distintos efectos inmunomoduladores dependiendo de su composición de ácidos grasos. Las EL enriquecidas con aceite de pescado y las basadas en aceite de oliva (EBAO) han mostrado ventajas frente a las derivados del aceite de soja, aunque son muy escasos los estudios que las comparan entre sí y no existe ninguno en pacientes críticos quirúrgicos. Objetivos: Demostrar la no inferioridad de la eficacia terapéutica de SMOFlipid® (enriquecida con aceite de pescado) frente a Clinoleic® (EBAO) en relación con la aparición de infecciones nosocomiales y otros parámetros evolutivos. Demostrar la no inferioridad de la seguridad de SMOFlipid® frente a Clinoleic® expresada como aparición de mortalidad y acontecimientos adversos. Material y método: ensayo clínico de fase III, de no inferioridad, realizado en pacientes críticos posquirúrgicos. Los sujetos se aleatorizaron para recibir SMOFlipid® o Clinoleic®. Para comparar variables cualitativas se obtuvieron la frecuencia y el porcentaje de casos, realizando la prueba del chi cuadrado o el test de Fisher. Las medias entre dos grupos se compararon empleando el test de la "t" de Student. Se consideró estadísticamente significativo un valor de p menor de 0,05. Para el análisis principal de no inferioridad de la variable principal se aplicaron los test de Farrington-Manning, Miettinen-Nurminen y Gart-Nam. Resultados: se incluyeron 73 pacientes, de los cuales 37 recibieron Clinoleic® y 36 SMOFlipid®. En la variable "disminución de infecciones nosocomiales", SMOFlipid® demostró no ser inferior a Clinoleic®. En la variable principal "mortalidad", SMOFlipid® demostró no ser inferior a Clinoleic®. Tampoco existieron diferencias estadísticamente significativas en cuanto a la aparición de efectos adversos. Conclusiones: en nuestro estudio, SMOFlipid® demostró no ser inferior a Clinoleic® en términos de eficacia y seguridad.

Hospital-acquired Clostridioides difficile infection among patients at an urban safety-net hospital in Philadelphia: Demographics, neighborhood deprivation, and the transferability of national statistics.

OBJECTIVE: To investigate associations between healthcare-associated Clostridioides difficile infection and patient demographics at an urban safety-net hospital and compare findings with national surveillance statistics. METHODS: Study participants were selected using a case-control design using medical records collected between August 2014 and May 2018 at Hahnemann University Hospital in Philadelphia. Controls were frequency matched to cases by age and length of stay. Final sample included 170 cases and 324 controls. Neighborhood-level factors were measured using American Community Survey data. Multilevel models were used to examine infection by census tract, deprivation index, race/ethnicity, insurance type, referral location, antibiotic use, and proton-pump inhibitor use. RESULTS: Patients on Medicare compared to private insurance had 2.04 times (95% CI, 1.31-3.20) the odds of infection after adjusting for all covariables. Prior antibiotic use (2.70; 95% CI, 1.64-4.46) was also associated with infection, but race or ethnicity and referral location were not. A smaller proportion of hospital cases occurred among white patients (25% vs 44%) and patients over the age of 65 (39% vs 56%) than expected based on national surveillance statistics. CONCLUSIONS: Medicare and antibiotics were associated with Clostridioides difficile infection, but evidence did not indicate association with race or ethnicity. This finding diverges from national data in that infection is higher among white people compared to nonwhite people. Furthermore, a greater proportion of hospital cases were aged <65 years than expected based on national data. National surveillance statistics on CDI may not be transportable to safety-net hospitals, which often disproportionately serve low-income, nonwhite patients.

Association between Antibiotic Consumption and Incidence of Clostridioides difficile Infection in a Hospital.

Previous exposure to antimicrobials is a major risk factor for Clostridioides difficile infection (CDI). Antibiotic prescription and C. difficile toxin assay records of patients admitted to a tertiary hospital in Korea from 2009 to 2013 were collected to investigate the association between antibiotic consumption and CDI incidence. A Spearman's correlation analysis between CDI incidence (positive result of toxin assay/10,000 admissions) and antibiotic consumption (defined daily dose/1,000 patient-days) was performed on a monthly basis. Using the matched month approach, we found a significant correlation between CDI rate and moxifloxacin consumption (Spearman's r = 0.351, P < 0.001). Furthermore, using the one-month delay approach, we found that the consumption of clindamycin (Spearman's r = 0.272, P = 0.037) and moxifloxacin (Spearman's r = 0.297, P = 0.022) was significantly correlated with CDI incidence. Extended-spectrum cephalosporins did not have any effect on CDI incidence.