SARS-CoV-2-Induced ARDS Associates with MDSC Expansion, Lymphocyte Dysfunction, and Arginine Shortage.

PURPOSE: The SARS-CoV-2 infection can lead to a severe acute respiratory distress syndrome (ARDS) with prolonged mechanical ventilation and high mortality rate. Interestingly, COVID-19-associated ARDS share biological and clinical features with sepsis-associated immunosuppression since lymphopenia and acquired infections associated with late mortality are frequently encountered. Mechanisms responsible for COVID-19-associated lymphopenia need to be explored since they could be responsible for delayed virus clearance and increased mortality rate among intensive care unit (ICU) patients. METHODS: A series of 26 clinically annotated COVID-19 patients were analyzed by thorough phenotypic and functional investigations at days 0, 4, and 7 after ICU admission. RESULTS: We revealed that, in the absence of any difference in demographic parameters nor medical history between the two groups, ARDS patients presented with an increased number of myeloid-derived suppressor cells (MDSC) and a decreased number of CD8pos effector memory cell compared to patients hospitalized for COVID-19 moderate pneumonia. Interestingly, COVID-19-related MDSC expansion was directly correlated to lymphopenia and enhanced arginase activity. Lastly, T cell proliferative capacity in vitro was significantly reduced among COVID-19 patients and could be restored through arginine supplementation. CONCLUSIONS: The present study reports a critical role for MDSC in COVID-19-associated ARDS. Our findings open the possibility of arginine supplementation as an adjuvant therapy for these ICU patients, aiming to reduce immunosuppression and help virus clearance, thereby decreasing the duration of mechanical ventilation, nosocomial infection acquisition, and mortality.

Effect of Supplemental Parenteral Nutrition Versus Enteral Nutrition Alone on Clinical Outcomes in Critically Ill Adult Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Enteral nutrition (EN) is considered the first feeding route for critically ill patients. However, adverse effects such as gastrointestinal complications limit its optimal provision, leading to inadequate energy and protein intake. We compared the clinical outcomes of supplemental parenteral nutrition added to EN (SPN + EN) and EN alone in critically ill adults. Electronic databases restricted to full-text randomized controlled trials available in the English language and published from January 1990 to January 2019 were searched. The risk of bias was evaluated using the Jadad scale, and the meta-analysis was conducted using the MedCalc software. A total of five studies were eligible for inclusion in the systematic review and meta-analysis. Compared to EN alone, SPN + EN decreased the risk of nosocomial infections (relative risk (RR) = 0.733, p = 0.032) and intensive care unit (ICU) mortality (RR = 0.569, p = 0.030). No significant differences were observed between SPN + EN and EN in the length of hospital stay, hospital mortality, length of ICU stay, and duration of mechanical ventilation. In conclusion, when enteral feeding fails to fulfill the energy requirements in critically ill adult patients, SPN may be beneficial as it helps in decreasing nosocomial infections and ICU mortality, in addition to increasing energy and protein intakes with no negative effects on other clinical outcomes.

Lower body mass indices and near-target early energy nutrition therapy may increase intensive care unit-associated infections: A retrospective study in Guangzhou, China.

BACKGROUND AND OBJECTIVES: The optimal energy intake for early nutrition therapy in critically ill patients is unknown, especially in Chinese patients with a lower BMI. This study investigated the relationship between energy intake and clinical outcomes in this patient population. METHODS AND STUDY DESIGN: A retrospective study was carried out at a tertiary hospital. Critically ill patients were recruited and divided into 3 tertiles according to the ratio of actual/target energy intake during the first week of hospitalization in the intensive care unit (ICU) (tertile I, <33.4%; tertile II, 33.4%-66.7%; and tertile III, >66.7%). 60-day mortality and other clinical outcomes were compared. To adjust for potentially confounding factors, multivariate and sensitivity analyses were performed exclusively in patients who stayed in the ICU for ≥7 days. RESULTS: A total of 325 patients with a mean BMI of 22.5±4.7 kg/m2 were recruited. 60-day mortality was similar between the 3 tertiles. In the unadjusted analysis, tertile III had a longer length of stay in the ICU and at the hospital, longer duration of mechanical ventilation, and higher rate of ICU-associated infections, but only the latter showed a significant difference between the 3 tertiles in the multivariate and sensitivity analyses. Logistic regression analysis showed that energy groups was an independent risk factor for ICU-associated infections. CONCLUSIONS: Energy intake in early nutrition therapy influences risk of ICU-associated infections in Chinese critically ill patients with lower BMI. Furthermore, patients with near-target energy intake have more frequent ICU-associated infections.

Risk Factors of Clostridium Difficile Infection After Spinal Surgery: National Health Insurance Database.

The purpose of this study was to evaluate risk factors of Clostridium Difficile infection (CDI) after spinal surgery using the Health Insurance Review and Assessment Service (HIRA) data. The incidence of postoperative CDI was investigated using HIRA data from 2012 to 2016. Cases involving CDI that occurred within a 30-day postoperative period were identified. Risk factors, including age, sex, comorbidities, postoperative infection, spinal surgery procedure, type of antibiotic, and duration of antibiotic use, were evaluated. Duration of hospital stay, medical cost, and mortality were also evaluated. In total, 71,322 patients were included. Presumed cases of CDI were identified in 57 patients, with CDI rate of 0.54 per 10,000 patient days. Advanced age, staged operation, postoperative infection, and the use of multiple antibiotics were significant risk factors. First-generation cephalosporins were shown to be associated with a lower incidence of CDI. CDI was also associated with longer hospital stays and increased medical cost, and it was an independent risk factor for increased mortality. Extra attention should be paid to patients at high risk for the development of postoperative CDI, and unnecessary use of multiple antibiotics should be avoided. Level of Evidence: Level III, retrospective cohort study.

Volvulus with intestinal malrotation hiding a near-total intestinal aganglionosis: Case report.

Total colonic aganglionosis occurring together with malrotation is a rare occurrence and may pose diagnostic and management dilemmas for the pediatric surgeon. We report the case of a new born, who was operated at the age of three days for malrotation with volvulus, treated by Ladd procedure. Postoperatively, we noticed persistent abdominal distension and emission of a small amount of meconium every 4 to 5 days. The barium enema showed a non-functional microcolon. Surgical exploration on the 24th day found an ileo-ileal transition zone located 60 cm distal to the ligament of Treitz. Extemporaneous biopsies from the colon and mid-ileum confirmed the absence of ganglion cells. We performed an ileostomy at 50 cm from duodeno-jejunal flexure. Unfortunately, the patient succumbed to nosocomial infection at 33 days of age.This case was a challenging scenario for us where a diagnosis of complicated malrotation had obscured the Hirschsprung's disease.

Risk Factors for Carbapenem-Resistant Pseudomonas aeruginosa, Zhejiang Province, China.

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a public health concern worldwide, but comprehensive analysis of risk factors for CRPA remains limited in China. We conducted a retrospective observational study of carbapenem resistance in 71,880 P. aeruginosa isolates collected in Zhejiang Province during 2015-2017. We analyzed risk factors for CRPA, including the type of clinical specimen; the year, season, and region in which it was collected; patient information, including age, whether they were an outpatient or inpatient, and whether inpatients were in the intensive care unit or general ward; and the level of hospital submitting isolates. We found CRPA was more prevalent among isolates from patients >60 years of age and in inpatients, especially in intensive care units. In addition, specimen types and seasons in which they were collected were associated with higher rates of CRPA. Our findings can help hospitals reduce the spread of P. aeruginosa and optimize antimicrobial drug use.

A cluster of nosocomial Lassa fever cases in a tertiary health facility in Nigeria: Description and lessons learned, 2018.

BACKGROUND: Lassa fever is an acute viral haemorrhagic disease endemic in Nigeria. The 2018 Lassa fever outbreak in Nigeria was unprecedented, with 8% of all cases occurring among healthcare workers (HCWs). A disproportionately high number of these infections occurred in HCWs working in a tertiary health facility in Nigeria. This paper describes the cluster of Lassa fever infections among HCWs in a treatment centre and the lessons learnt. METHODS: We analysed clinical, epidemiological and laboratory data from surveillance and laboratory records kept during the 2018 outbreak. Interviews were conducted with surviving HCWs using a questionnaire developed specifically for the investigation of Lassa fever infections in HCWs. Descriptive analysis of the data was performed in Microsoft excel. RESULTS: The index case was a 15-year-old male who presented at the health facility with fever and uncontrolled nasopharyngeal bleeding, following a recent uvulectomy by a traditional healer. Overall, 16 HCWs were affected (15 confirmed and 1 probable) with five deaths (CFR-31.6%). Of the 15 confirmed cases, five (33.3%) were asymptomatic. Nine HCWs were direct contacts of the index case; the remaining six HCWs had no direct contact with the index case. HCW interviews identified a low index of suspicion for Lassa fever leading to inadequate infection prevention and control (IPC) practices as possible contributing factors to nosocomial transmission. CONCLUSION: Maintaining a high index of suspicion for Lassa fever in all patients, especially in endemic areas, is essential in adhering to adequate IPC practices in health facilities in order to prevent nosocomial transmission of Lassa fever among HCWs. There is a need to continually train and sensitise HCWs on strict adherence to IPC measures while providing care, irrespective of a patient's provisional diagnosis.

Nosocomial spondylodiscitis after intradiscal electrothermal therapy: Case series.

Intradiscal electrothermal therapy (IDET) is a method applied for treatment of pain caused by the disc and involves reaching spinal disc through a catheter under fluoroscopy and solidifying disc interior by heating. We retrospectively evaluated ten patients treated and followed up with diagnosis of nosocomial spondylodiscitis after IDET. Ten patients, to whom IDET was applied for low back pain treatment in a tertiary healthcare organization, came with complaints of fever and low back pain during postoperative process. Appropriate antibiotics treatment was commenced after the reproduction of Pseudomonas aeruoginosa in abscess culture.Even though spondylodiscitis developing after IDET is a rare complication, it is also a clinical condition that needs to be thought in the patients whose complaints increase and clinically do not recover after the procedure. Adherence to rules of the asepsis will reduce the frequency of infection as in all nosocomial infections.

Effect of early supplemental parenteral nutrition in the paediatric ICU: a preplanned observational study of post-randomisation treatments in the PEPaNIC trial.

BACKGROUND: Large randomised controlled trials have shown that early supplemental parenteral nutrition in patients admitted to adult and paediatric intensive care units (PICUs) is harmful. Overdosing of energy with too little protein was suggested as a potential reason for this. This study analysed which macronutrient was associated with harm caused by early supplemental parenteral nutrition in the Paediatric Early versus Late Parenteral Nutrition In Critical Illness (PEPaNIC) randomised trial. METHODS: Patients in the initial randomised controlled trial were randomly assigned to receive suppplemental parenteral nutrition (PN) within 24 h of PICU admission (early PN) or to receive such PN after 1 week (late PN) when enteral nutrition was insufficient. In this post-randomisation, observational study, doses of glucose, lipids, and aminoacids administered during the first 7 days of PICU stay were expressed as % of reference doses from published clinical guidelines for age and weight. Independent associations between average macronutrient doses up to each of the first 7 days and likelihood of acquiring an infection in the PICU, of earlier live weaning from mechanical ventilation, and of earlier live PICU discharge were investigated using multivariable Cox proportional hazard analyses. The three macronutrients were included in the analysis simultaneously and baseline risk factors were adjusted for. FINDINGS: From June 18, 2012, to July 27, 2015, 7519 children aged between newborn and 17 years were assessed for eligibility. 6079 patients were excluded, and 1440 children were randomly assigned to receive either early PN (n=723) or late PN (n=717). With increasing doses of aminoacids, the likelihood of acquiring a new infection was higher (adjusted hazard ratios [HRs] per 10% increase between 1·043-1·134 for days 1-5, p≤0·029), while the likelihood of earlier live weaning from mechanical ventilation was lower (HRs 0·950-0·975 days 3-7, p≤0·045), and the likelihood of earlier live PICU discharge was lower (HRs 0·943-0·972 days 1-7, p≤0·030). By contrast, more glucose during the first 3 days of PICU stay was independently associated with fewer infections (HRs 0·870-0·913, p≤0·036), whereas more lipids was independently associated with earlier PICU discharge (HRs 1·027-1·050, p≤0·043 days 4-7). Risk of harm with aminoacids was also shown for low doses. INTERPRETATION: These associations suggest that early administration of aminoacids, but not glucose or lipids, could explain harm caused by early supplemental parenteral nutrition in critically ill children. FUNDING: Flemish Agency for Innovation through Science and Technology; UZLeuven Clinical Research Fund; Research Foundation Flanders; Methusalem Programme Flemish Government; European Research Council; Fonds-NutsOhra; Erasmus-MC Research Grant; Erasmus Trustfonds.

Cranberry capsules to prevent nosocomial urinary tract bacteriuria after pelvic surgery: a randomised controlled trial.

OBJECTIVE: To evaluate whether cranberries are able to prevent postoperative urinary bacteriuria in patients undergoing pelvic surgery and receiving transurethral catheterisation. DESIGN: Randomised, double-blind, placebo-controlled trial. SETTINGS: French tertiary Care centre, University Hospital. POPULATION: A total of 272 women undergoing pelvic surgery aged 18 or older. METHODS: Participants undergoing pelvic surgery were randomised to 36 mg cranberry (proanthocyanidins, PAC) or placebo once daily for 10 days. Statistical analysis was performed by a chi-square test. MAIN OUTCOME MEASURES: The primary and secondary outcomes were postoperative bacteriuria, defined by a positive urine culture, within the first 15 and 40 days, respectively. RESULTS: Two hundred and fifty-five participants received the intended treatment: 132 (51.8%) received PAC and 123 (48.2%) received placebo. There were no significant differences in baseline demographics, intra-operative characteristics or duration and type of catheterisation between the two groups. PAC prophylaxis did not reduce the risk of bacteriuria treatment within 15 days of surgery [27% bacteriuria with PAC compared with 25% bacteriuria with placebo: relative risk 1.05, 95% CI 0.78-1.4, P = 0.763). The same result was observed on day 40. Bacteriuria occurred more often in older women with increased length of catheterisation. CONCLUSION: Immediate postoperative prophylaxis with PAC does not reduce the risk of postoperative bacteriuria in patients receiving short-term transurethral catheterisation after pelvic surgery. TWEETABLE ABSTRACT: PAC prophylaxis does not reduce the risk of postoperative bacteriuria in patients undergoing pelvic surgery.

Perioperative bleeding management in pediatric patients.

PURPOSE OF REVIEW: Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. RECENT FINDINGS: Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. SUMMARY: This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.

Cohort study of malignancies and hospitalized infectious events in treated and untreated patients with psoriasis and a general population in the United States.

BACKGROUND: Psoriasis is associated with risk of malignancy. Some psoriasis treatments may increase the risk of hospitalized infectious events (HIEs). OBJECTIVES: To evaluate rates of malignancies and HIEs in patients with psoriasis. METHODS: This retrospective cohort study utilized data from MarketScan(®) databases. Cohorts included adult general population (GP), patients with psoriasis, and patients with psoriasis treated with nonbiologics, adalimumab, etanercept, infliximab or phototherapy. Outcomes included incidence rates (IRs) per 10 000 person-years observation (PYO) for all malignancies excluding nonmelanoma skin cancer (NMSC), lymphoma, NMSC, and per 10 000 person-years of exposure (PYE) for HIEs. RESULTS: Incidence rates [95% confidence interval (CI)] for all malignancies except NMSC were 129 (127-130) and 142 (135-149) for GP (PYO = 51 071 587) and psoriasis (PYO = 119 432) cohorts, respectively; 10·9 (10·5-11·3) and 12·9 (10·9-14·8) for lymphoma; and 145 (144-147) and 180 (173-188) for NMSC. Rates for all malignancies excluding NMSC were similar among treatments but variable for lymphoma and NMSC. IRs (95% CI) for HIEs were 332 (256-408) for the nonbiologic cohort (PYE = 3528); 288 (206-370) for etanercept (PYE = 6563); 325 (196-455) for adalimumab (PYE = 2772); 521 (278-765) for infliximab (PYE = 1058); and 334 (242-427) for phototherapy (PYE = 1797). IRs for HIEs were lowest for etanercept and higher in patients on baseline systemic corticosteroids across treatment cohorts. CONCLUSIONS: Malignancy rates were higher in patients with psoriasis than the GP, but these treatments did not appear to increase malignancy risk.

[Selenium metabolism in patients with severe multiple trauma].

GOAL OF THE STUDY: To define a relation between the selenium level and the risk of the development of nosocomial pneumonia in patients with severe multiple trauma depending on the trauma severity and the volume of blood loss. MATERIALS AND METHODS: We measured serum selenium concentration in 40 patients with severe multiple trauma. The ISS score was used to estimate the trauma severity. Patients were divided into 2 groups: group I--25 patients without pneumonia, group II--15 patients with pneumonia. The volume of blood loss was estimated in each group. The oxidative stress was estimated by means of the antioxidant index. RESULTS: For selected groups the significant difference (P < 0.05) in the volume of blood loss was detected. It was shown the significant decrease of selenium concentration (P < 0.05) in both groups in comparison with control for all testing time points (the 6-12 hrs, 24 hrs, 3 and 5-7 days). The mean of selenium concentration in group II was significantly lower in comparison to the group I. A significant difference of selenium concentrations (P < 0.05) between groups were detected on the 6-12 hrs and day 3 from the trauma onset. The antioxidant index was significantly lower in the group II within the 6-12 hrs, 12-24 hrs and 5-7 days (P < 0.05) in comparison to group I. CONCLUSIONS: The severe multiple trauma and severe blood loss lead to a selenium deficiency in the blood serum starting with the first hours from the trauma onset, which leads to the critical level of selenium concentration by the Ist day's end after trauma. It also leads to a pronounced oxidative stress that is reflected in the antioxidant index dynamics. Thus serum selenium concentration may be included in the set of the early prognostic detectors to detect infectious pulmonary complications development at severe multiple trauma, and it could be the basis for the decision to take early prophylaxis using selenium medications.

[Problem of treatment for pyo-inflammatory complications caused by Acinetobacter].

The article deals with analysis of a detection frequency and antibacterial treatment resistance of Acinetobacter spp.of different species affiliation. Strains of bacteria detected in patients with pyo-inflammatory complications after surgeries (period from 2010 to 2012) were involved in the study 137 strains of Acinetobacter spp. were detected and studied Fraction of Acinetobacter spp. in 2010, 2011 and 2012 was 2.3, 3 and 3.4% respectively. Fraction of P. aeruginosain all non-fermentative Gram-negative bacteria (NFGNB) decreased by 120% and fraction of Acinetobacter spp. increased by 200-250%. Acinetobacter spp. detection frequency was not significantly changed in the period from 2006 to 2012. However the fraction of Acinetobacter spp. in NFGNB increased by 150% and was 29% in 2012. Detection frequency of A. baumanii sharply increased in 2012. A study of antibacterial treatment resistance of Acinetobacter spp. (10 antibacterial medicines) showed that Polymyxin B and E (Colistin) was the most effective medicine for A. baumanii and A. calcoaceticus infection. 85-95% of Acinetobacter spp.strains kept sensitivity to this antibacterial medicine. 66-88.9% of A. baumanii strains, 66.7-81.8% of A. alcoaceticus and 66.6% of other Acinetobacter spp. were sensitive to Tigecycline. Dioxidine effectiveness was close to Tigecycline in 66.7-80% of A. baumanii strains. 85-100% of A. calcoaceticus strains were sensitive to Dioxidine. There is a trend of decreasing of A. baumanii sensitivity to Carbapenems by 200%. Fraction of strains sensitive to Meropenem and Imipenem in 2012 was 21.4% and 16.7% respectively. All studied strains of A. lwoffi and A. haemolyticus kept sensitivity to Carbapenems. In 2012 23.8% of A. baumanii and 50% of A. calcoaceticus strains were sensitivity to Amikacin, meanwhile A. lwoffi and A. haemolyticus were not sensitive to this medicine. 31.3% of A. baumanii and 50% of A. calcoaceticus strains were sensitive to Ceftazidime/Sulbactam. 5.3% of A. baumanii and 15.8% of A. calcoaceticus strains were sensitive to Piperacillin/Sulbactam. Gentamicin effectiveness was fixed in 12.5% of A. baumanii and 45.5% of unidentified Acinetobacter-strains. Gentamicin was not effective against A. lwoffii and A. haemolyticus. Thus Polymyxins (in monotherapy or in combination with glycopeptides), Dioxidine and Tigecycline in combination with Carbapenems or Cefiazidime/Sulbactam are to be drugs of choice in treatment for pyo-inflammatory complications caused by Acinetobacter spp.

Risk of developing pneumonia is enhanced by the combined traits of fluoroquinolone resistance and type III secretion virulence in respiratory isolates of Pseudomonas aeruginosa.

OBJECTIVES: To determine the differential association of host characteristics, antimicrobial resistance, and type III secretion system virulence of Pseudomonas aeruginosa isolates with respiratory syndromes in hospitalized adult patients. DESIGN: Retrospective, cohort study. SETTING: Community teaching hospital. PATIENTS: Two hundred eighteen consecutive adult patients with respiratory culture positive for P. aeruginosa between January 2005 to January 2010. INTERVENTIONS: Medical charts were reviewed to obtain demographic, laboratory, radiographic, and clinical information. Isolates were assayed by polymerase chain reaction for genes encoding the type III secretion system effectors (ExoU, ExoS, and PcrV) and for strain relatedness using randomly amplified polymorphic DNA analysis. Levofloxacin susceptibility was determined by broth microdilution. Patients were grouped by colonization, bronchitis, or pneumonia and were compared for differential risk of developing the clinical syndrome with respect to host and microbial characteristics. MEASUREMENTS AND MAIN RESULTS: Half of the study cohort (54%, 117 of 218) had pneumonia, 32% (70 of 218) had bronchitis, and 14% (31 of 218) had colonization; in-hospital mortality was 35%, 11%, and 0%, respectively. Host factors strongly associated with pneumonia development were residence in long-term care facility, healthcare-associated acquisition of P. aeruginosa, higher Acute Physiology and Chronic Health Evaluation II score, presence of enteral feeding tube, mechanical ventilation, and recent history of pneumonia. Fluoroquinolone-resistant (57% vs 34%, 16%; p < 0.0001) and multidrug-resistant (36% vs 26%, 7%; p = 0.0045) strains were more likely to cause pneumonia than bronchitis or colonization, respectively. Analysis of host and microbial factors in a multivariate regression model yielded the combined traits of fluoroquinolone resistance and gene encoding the type III secretion system ExoU effector in P. aeruginosa as the single most significant predictor of pneumonia development. CONCLUSIONS: These results suggest that fluoroquinolone-resistant phenotype in a type III secretion system exoU strain background contributes toward the pathogenesis of P. aeruginosa in pneumonia.

Reorganization of nutritional therapy can markedly reduce the rate of catheter-related blood stream infections in pediatric patients receiving parenteral nutrition - a 7-year prospective follow-up study.

BACKGROUND: Implementation of hygienic measures and simple changes in the structure of medical team may considerably reduce the rate of catheter-related bloodstream infections (CRBSIs) in parenterally nourished patients. AIM: To analyze the effects of organizational changes in parenteral nutrition services on the CRBSI rates in pediatric patients. METHODS: We compared the CRBSI rates documented prior to, during and after the implementation of the organizational changes (introduction of a nutritional support team and related procedures, medical staff training). FINDINGS: A total of 260 courses of parenteral nutrition were offered to 141 pediatric patients during the analyzed period. Thirty CRBSIs were documented during this period. The most frequent etiological factors were staphylococci (21/30), followed by Klebsiella pneumoniae, Escherichia coli and Candida albicans (2/30 each). The reorganization was reflected by more than 8-fold reduction of the CRBSI incidence rate: from the initial value of 10.14 to 6.89 per 1000 catheter days and 1.17 per 1000 catheter days during and after the reorganization, respectively. CONCLUSION: Introduction of a nutritional support team, accompanied by extensive training of medical staff, can result in a marked reduction of CRBSI rate in pediatric patients nourished parenterally in a hospital setting.

Antecedentes: La implementación de medidas higiénicas y cambios sencillos en la estructura del personal médico puede reducir considerablemente la tasa de bacteriemia asociada al catéter (BAC) en pacientes que reciben nutrición parenteral. Objetivo: Analizar el impacto de los cambios organizacionales dentro de los servicios de nutrición parenteral sobre las tasas de BAC en pacientes pediátricos. Métodos: Hemos comparado las tasas de BAC documentadas antes, durante y después de la implementación de los cambios organizacionales (introducción de un grupo de apoyo nutricional y los procedimientos relacionados, formación del personal médico). Descubrimientos: Un total de 260 series de nutrición parenteral fueron ofrecidos a 141 pacientes pediátricos durante el periodo analizado. Se documentaron treinta BAC durante este periodo. Los factores etiológicos más frecuentes eran staphylococci (21/30), seguidos por Klebsiella pneumoniae, Escherichia coli y Candida albicans (2/30 cada uno). Los cambios organizacionales fueron reflejados en una reducción de la incidencia de BAC en más de 8 veces: el valor inicial disminuyó desde 10.14 hasta 6.89 por 1000 días-catéter y hasta 1.17 por 1000 días-catéter durante y después de la reorganización, respectivamente. Conclusión: La introducción de un grupo de apoyo nutricional, acompañada de una extensa formación del personal médico puede resultar en una reducción considera ble de la tasa de BAC en pacientes pediátricos que reciben nutrición parenteral en en un entorno hospitalario.

Applying mindful evidence-based practice at the bedside: using catheter-associated urinary tract infection as a model.

We introduce a mindful evidence-based practice model to operationalize mindfulness to improve bedside infection prevention practices. Using catheter-associated urinary tract infection prevention as an example, we illustrate how clinicians can be more mindful about appropriate catheter indications and timely catheter removal.

Infectious complications related to intrathecal drug delivery system and spinal cord stimulator system implantations at a comprehensive cancer pain center.

BACKGROUND: Intrathecal drug delivery (IDD) and spinal cord stimulator (SCS) systems are implantable devices for the management of both chronic and cancer pain. Although these therapies have favorable long-term outcomes, they are associated with occasional complications including infection. The incidence of infectious complications varies from 2 - 8% and frequently requires prolonged antibiotics and device revision or removal. Cancer patients are particularly susceptible to infectious complications because they are immunocompromised, malnourished, and receiving cytotoxic cancer-related therapies. OBJECTIVE: Determine if cancer pain patients have a higher incidence of infectious complications following implantation of IDD or SCS systems than non-cancer pain patients. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary comprehensive cancer hospital. METHODS: Following local Institutional Review Board (IRB) approval, we collected data on infectious complications for IDD and SCS systems implanted at MD Anderson Cancer Center for the treatment of cancer and chronic pain. The examined implants were performed from July 15, 2006, to July 14, 2009. In addition, we obtained data regarding patient comorbidities and perioperative risk factors to assess their impact on infectious complications. RESULTS: One hundred forty-two devices were implanted in 131 patients during the examined period. Eighty-three of the devices were IDD systems and 59 were SCS systems. Eighty percent of the patients had a diagnosis of cancer. Four infectious complications were noted with an overall infectious risk of 2.8%. The infection rate was 2.4% for IDD systems versus 3.4% for SCS systems (P = 1). All infections were at the implantable pulse generator (IPG) or pump pocket site. The rate of infection was 2.7% for cancer patients and 3.3% for non-cancer patients (P = 1). Neither the perioperative administration of prophylactic antibiotics (P = 0.4) nor the National Nosocomial Infection Surveillance (NNIS) risk level for individual patients (P = 0.15) were statistically associated with infectious complication. The mean surgical time was longer for cases with infection at 215 ± 93 minutes versus 132 ± 52 minutes for those without infection which was statistically significant (P = 0.02). LIMITATIONS: The major limitation of this study is that it was a retrospective analysis. An additional limitation is that 51(38.9%) of our patients either died or were lost to follow-up during the year following implantation which may have led to an underestimation of our infection rates. CONCLUSIONS: The experience of this tertiary cancer pain center demonstrates that infectious complications following implantation of IDD and SCS systems are relatively rare events in cancer patients. Contrary to our initial hypothesis, no difference was found in the infection rate between cancer and non-cancer patients. The main factor associated with increased risk of infectious complications was increased surgical time, indicating a need to minimize patient time in the operating room. The low infectious complication rate seen in this series compared to previous reports in non-cancer patients is likely multifactorial in nature.