Guidelines for preventing urinary retention and bladder damage during hospital care.

AIMS AND OBJECTIVES: To develop evidence-based guidelines for adult patients in order to prevent urinary retention and to minimise bladder damage and urinary tract infection. BACKGROUND: Urinary retention causing bladder damage is a well known complication in patients during hospital care. The most common treatment for urinary retention is an indwelling urinary catheter, which causes 80% of hospital-acquired urinary tract infections. Appropriate use of bladder ultrasonography can reduce the rate of bladder damage as well as the need to use an indwelling urinary catheter. It can also lead to a decrease in the rate of urinary tract infections, a lower risk of spread of multiresistant Gram-negative bacteria, and lower hospital costs. DESIGN: An expert group was established, and a literature review was performed. METHODS: On the basis of literature findings and consensus in the expert group, guidelines for clinical situations were constructed. RESULTS: The main points of the guidelines are the following: identification of risk factors for urinary retention, managing patients at risk of urinary retention, strategies for patients with urinary retention and patient documentation and information. CONCLUSION: Using literature review and consensus technique based on a multiprofessional group of experts, evidence-based guidelines have been developed. Although consensus was reached, there are parts of the guidelines where the knowledge is weak. RELEVANCE TO CLINICAL PRACTICE: These guidelines are designed to be easy to use in clinical work and could be an important step towards minimising bladder damage and hospital-acquired urinary tract infections and their serious consequences, such as bacteraemia and the spread of multidrug-resistant bacteria in hospitals.

UVA-riboflavin photochemical therapy of bacterial keratitis: a pilot study.

BACKGROUND: The aim of this work as to investigate the photochemical interaction used in corneal crosslinking (CXL) as the primary therapy for bacterial keratitis. METHODS: A prospective non-randomized study was conducted including 16 patients with a clinical diagnosis of bacterial keratitis. No patient had any prior antibiotic treatment for the current infection. Photography and microbial culturing of the infected cornea were performed. Riboflavin was topically administered for 20 min and ultraviolet light (UVA) exposure settings for treatment of keratoconus were used. After the procedure, clinical examinations were done at least once daily until signs of improvement had been established. The frequency of examinations was thereafter reduced. Antibiotic therapy was initiated if infectious progression was suspected. The trial was registered at ISCRTN.org (no: 21432643). RESULTS: All eyes responded to the photochemical treatment with improvement in symptoms and signs of reduced inflammation. Epithelial healing was achieved in all cases. Antibiotic administration was necessary in two cases. One patient required a human amniotic membrane transplant. CONCLUSIONS: This trial illustrates that photosensitization of riboflavin using UVA at 365 nm has the potential to induce healing in patients with microbial keratitis. The results from the treatment of these 16 patients with corneal ulcers indicate that UVA-riboflavin photochemical therapy merits a controlled study in order to assess its efficacy and safety compared to antibiotics.

Indications of Th1 and Th17 responses in cerebrospinal fluid from patients with Lyme neuroborreliosis: a large retrospective study.

BACKGROUND: Previous studies indicate that successful resolution of Lyme neuroborreliosis (NB) is associated with a strong T helper (Th) 1-type cytokine response in the cerebrospinal fluid (CSF) followed by a down-regulating Th2 response, whereas the role of the recently discovered Th17 cytokine response is unknown. METHODS: To investigate the relative contribution of different Th associated cytokine/chemokine responses, we used a multiple bead array to measure the levels of CXCL10 (Th1 marker), CCL22 (Th2 marker), IL-17 (Th17 marker) and CXCL8 (general inflammation marker), in serum and in CSF from untreated patients with confirmed NB (n = 133), and non-NB patients (n = 96), and related the findings to clinical data. Samples from patients with possible early NB (n = 15) and possible late NB (n = 19) were also analysed, as well as samples from an additional control group with orthopaedic patients (n = 17), where CSF was obtained at spinal anaesthesia. RESULTS: The most prominent differences across groups were found in the CSF. IL-17 was elevated in CSF in 49% of the patients with confirmed NB, but was not detectable in the other groups. Patients with confirmed NB and possible early NB had significantly higher CSF levels of CXCL10, CCL22 and CXCL8 compared to both the non-NB group and the control group (p < 0.0001 for all comparisons). Patients in the early NB group, showing a short duration of symptoms, had lower CCL22 levels in CSF than did the confirmed NB group (p < 0.0001). Furthermore, patients within the confirmed NB group showing a duration of symptoms <2 weeks, tended to have lower CCL22 levels in CSF than did those with longer symptom duration (p = 0.023). Cytokine/chemokine levels were not correlated with clinical parameters or to levels of anti-Borrelia-antibodies. CONCLUSION: Our results support the notion that early NB is dominated by a Th1-type response, eventually accompanied by a Th2 response. Interestingly, IL-17 was increased exclusively in CSF from patients with confirmed NB, suggesting a hitherto unknown role for Th17 in NB. However, for conclusive evidence, future prospective studies are needed.

The rate of influenza immunization to people aged 65 years and older was increased from 45% to 70% by a primary health care-based multiprofessional approach.

For many years, Swedish health authorities have recommended yearly influenza immunization to persons in medical risk groups and to people aged 65 years and older. Despite this recommendation, the vaccination coverage has been lower than 50% in Jönköping County, as in all other counties of Sweden. To increase the rate of influenza immunization in Jönköping County, we established a multiprofessional action group and designed a primary health care-based program. Important elements in the project were free of charge vaccination; an education program targeting primary health nurses; mass media information through advertisements in newspapers, local TV, posters, and handouts; and instituting and implementing a computerized registry with easy access to summary statistics by which each unit could compare its achievements with others. Personal invitation letters were not used because of economical reasons. The vaccination was performed in the county's health centers and to lesser extent in the hospitals. Most of the health centers are owned and run by the county council. A few health centers are private but have contract with the county council. Economical incentives to the providers were not used. During a 4-year period, the immunization rate among all inhabitants of the county aged 65 years increased from 45% to 70%. All the 13 municipalities in the county increased their vaccination rate; their recent figures vary between 61% and 74%. The vaccination rate among people aged 65 years in Jönköping County is now the highest in Sweden, but still not as high as in some other European countries. Our influenza immunization campaign can act as an example for other healthcare providers.

Sustained low incidence of central venous catheter-related infections over six years in a Swedish hospital with an active central venous catheter team.

BACKGROUND: There are limited data on the long-term effects of implementing a central venous catheter (CVC) program for prevention of CVC infections. The aims of this study were to evaluate the incidence of CVC colonization, catheter-related infections (CRI), catheter-related bloodstream infections (CRBSI), and their risk factors over a 6-year period in a hospital with an active CVC team. METHODS: We conducted a continuous prospective study aiming to include all CVCs used at our hospital during the years 2004 to 2009, evaluating colonization, CRI, CRBSI, and possible risk factors. RESULTS: A total of 2,772 CVCs was used during the study period. Data on culture results and catheterization time were available for 2,045 CVCs used in 1,674 patients. The incidences of colonization, CRI, and CRBSI were 7.0, 2.2, and 0.6 per 1,000 CVC-days, respectively. Analysis of quarterly incidences revealed 1 occasion with increasing infection rates. Catheterization time was a risk factor for CRI but not for CRBSI. Other risk factors for CRI were hemodialysis and CVC use in the internal jugular vein compared with the subclavian vein. Hemodialysis was the only risk factor for CRBSI. CONCLUSION: We found that a CRI prevention program led by an active CVC team and adhered to by the entire staff at a county hospital is successful in keeping CVC infections at a low rate over a long period of time.

Legionella pneumophila serogroup 1 antibody kinetics in patients with Legionnaires' disease: implications for serological diagnosis.

To evaluate current serological criteria for Legionella pneumophila serogroup 1 (Lp1), the antibody response was prospectively studied in all patients hospitalized for Legionnaires' disease in a Swedish county during 11 y (n = 62). A 4-fold or greater rise in antibody titre to > or = 128 (the minimum convalescent antibody level for diagnosis, as recommended by the Centers for Disease Control and Prevention), using the indirect immunofluorescence antibody test, was found in 21/52 (40%) of tested patients. By referring to the titre levels in healthy residents from the local population (World Health Organization criteria), 45/52 (87%) cases were confirmed serologically. In 21 patients followed longitudinally for 10 y, the median antibody titre fell from 256 (range 32-1024) to 16 (range 2-128) in 3 y. No booster reactions were observed in any patient. After 10 y, the geometric mean titre of this clinical cohort had reached the same level as observed in the background population 5 y earlier. Titre levels in subjects exposed to Legionella from a municipal water system indicate that only 1 out of 10 of all infections are identified clinically. Indirect immunofluorescent antibody testing with local reference sera is a sensitive method for laboratory confirmation of Lp1 in an unselected pneumonia population.