RESUMEN
BACKGROUND: Infection control practice compliance is commonly monitored by measuring hand hygiene compliance. The limitations of this approach were recognized in 1 acute health care organization that led to the development of an Infection Control Continuous Quality Improvement tool. METHODS: The Pronovost cycle, Barriers and Mitigation tool, and Hexagon framework were used to review the existing monitoring system and develop a quality improvement data collection tool that considered the context of care delivery. RESULTS: Barriers and opportunities for improvement including ambiguity, consistency and feasibility of expectations, the environment, knowledge, and education were combined in a monitoring tool that was piloted and modified in response to feedback. Local adaptations enabled staff to prioritize and monitor issues important in their own workplace. The tool replaced the previous system and was positively evaluated by auditors. Challenges included ensuring staff had time to train in use of the tool, time to collect the audit, and the reporting of low scores that conflicted with a target-based performance system. CONCLUSIONS: Hand hygiene compliance monitoring alone misses other important aspects of infection control compliance. A continuous quality improvement tool was developed reflecting specific organizational needs that could be transferred or adapted to other organizations.
Asunto(s)
Infección Hospitalaria/prevención & control , Adhesión a Directriz , Control de Infecciones/normas , Garantía de la Calidad de Atención de Salud/métodos , Mejoramiento de la Calidad , Adulto , Femenino , Higiene de las Manos/normas , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: The extent of transmission of influenza in hospital settings is poorly understood. Next generation sequencing may improve this by providing information on the genetic relatedness of viral strains. OBJECTIVES: We aimed to apply next generation sequencing to describe transmission in hospital and compare with methods based on routinely-collected data. METHODS: All influenza samples taken through routine care from patients at University College London Hospitals NHS Foundation Trust (September 2012 to March 2014) were included. We conducted Illumina sequencing and identified genetic clusters. We compared nosocomial transmission estimates defined using classical methods (based on time from admission to sample) and genetic clustering. We identified pairs of cases with space-time links and assessed genetic relatedness. RESULTS: We sequenced influenza sampled from 214 patients. There were 180 unique genetic strains, 16 (8.8%) of which seeded a new transmission chain. Nosocomial transmission was indicated for 32 (15.0%) cases using the classical definition and 34 (15.8%) based on genetic clustering. Of the 50 patients in a genetic cluster, 11 (22.0%) had known space-time links with other cases in the same cluster. Genetic distances between pairs of cases with space-time links were lower than for pairs without spatial links (P < .001). CONCLUSIONS: Genetic data confirmed that nosocomial transmission contributes significantly to the hospital burden of influenza and elucidated transmission chains. Prospective next generation sequencing could support outbreak investigations and monitor the impact of infection and control measures.
Asunto(s)
Infección Hospitalaria/transmisión , Infección Hospitalaria/virología , Gripe Humana/transmisión , Gripe Humana/virología , Orthomyxoviridae/fisiología , Adolescente , Adulto , Anciano , Niño , Preescolar , Análisis por Conglomerados , Infección Hospitalaria/epidemiología , Estudios Transversales , Femenino , Genoma Viral/genética , Hospitales , Humanos , Control de Infecciones , Gripe Humana/epidemiología , Londres/epidemiología , Masculino , Persona de Mediana Edad , Orthomyxoviridae/clasificación , Orthomyxoviridae/genética , ARN Viral/genética , Estudios Retrospectivos , Análisis de Secuencia de ADN , Adulto JovenRESUMEN
BACKGROUND: Hand hygiene is monitored by direct observation to improve practice, but this approach can potentially cause information, selection, and confounding bias, threatening the validity of findings. The aim of this study was to identify and describe the potential biases in hand hygiene compliance monitoring by direct observation; develop a typology of biases and propose improvements to reduce bias; and increase the validity of compliance measurements. METHODS: This systematic review of hospital-based intervention studies used direct observation to monitor health care workers' hand hygiene compliance. RESULTS: Seventy-one publications were eligible for review. None was free of bias. Selection bias was present in all studies through lack of data collection on the weekends (nâ¯=â¯61, 86%) and at night (nâ¯=â¯46, 65%) and observations undertaken in single-specialty settings (nâ¯=â¯35, 49%). We observed inconsistency of terminology, definitions of hand hygiene opportunity, criteria, tools, and descriptions of the data collection. Frequency of observation, duration, or both were not described or were unclear in 58 (82%) publications. Observers were trained in 56 (79%) studies. Inter-rater reliability was measured in 26 (37%) studies. CONCLUSIONS: Published research of hand hygiene compliance measured by direct observation lacks validity. Hand hygiene should be measured using methods that produce a valid indication of performance and quality. Standardization of methodology would expedite comparison of hand hygiene compliance between clinical settings and organizations.
Asunto(s)
Métodos Epidemiológicos , Adhesión a Directriz/estadística & datos numéricos , Adhesión a Directriz/normas , Higiene de las Manos/métodos , Higiene de las Manos/normas , Personal de Salud , Observación/métodos , Hospitales , HumanosRESUMEN
Background: Norovirus places a substantial burden on healthcare systems, arising from infected patients, disease outbreaks, beds kept unoccupied for infection control, and staff absences due to infection. In settings with high rates of bed occupancy, opportunity costs arise from patients who cannot be admitted due to beds being unavailable. With several treatments and vaccines against norovirus in development, quantifying the expected economic burden is timely. Methods: The number of inpatients with norovirus-associated gastroenteritis in England was modeled using infectious and noninfectious gastrointestinal Hospital Episode Statistics codes and laboratory reports of gastrointestinal pathogens collected at Public Health England. The excess length of stay from norovirus was estimated with a multistate model and local outbreak data. Unoccupied bed-days and staff absences were estimated from national outbreak surveillance. The burden was valued conventionally using accounting expenditures and wages, which we contrasted to the opportunity costs from forgone patients using a novel methodology. Results: Between July 2013 and June 2016, 17.7% (95% confidence interval [CI], 15.6%â21.6%) of primary and 23.8% (95% CI, 20.6%â29.9%) of secondary gastrointestinal diagnoses were norovirus attributable. Annually, the estimated median 290000 (interquartile range, 282000â297000) occupied and unoccupied bed-days used for norovirus displaced 57800 patients. Conventional costs for the National Health Service reached £107.6 million; the economic burden approximated to £297.7 million and a loss of 6300 quality-adjusted life-years annually. Conclusions: In England, norovirus is now the second-largest contributor of the gastrointestinal hospital burden. With the projected impact being greater than previously estimated, improved capture of relevant opportunity costs seems imperative for diseases such as norovirus.
Asunto(s)
Infecciones por Caliciviridae/economía , Brotes de Enfermedades/economía , Gastroenteritis/economía , Hospitalización/economía , Control de Infecciones/economía , Absentismo , Adulto , Anciano , Anciano de 80 o más Años , Infecciones por Caliciviridae/epidemiología , Costo de Enfermedad , Infección Hospitalaria/economía , Infección Hospitalaria/epidemiología , Infección Hospitalaria/virología , Brotes de Enfermedades/prevención & control , Inglaterra/epidemiología , Femenino , Gastroenteritis/epidemiología , Gastroenteritis/virología , Humanos , Pacientes Internos , Masculino , Persona de Mediana Edad , Norovirus/aislamiento & purificaciónRESUMEN
BACKGROUND: Monitoring results showing poor hand hygiene compliance in a major, busy emergency department prompted a quality improvement initiative to improve hand hygiene compliance. PURPOSE: To identify, remove, and reduce barriers to hand hygiene compliance in an emergency department. METHODS: A barrier identification tool was used to identify key barriers and opportunities associated with hand hygiene compliance. Hand hygiene imperatives were developed and agreed on with clinicians, and a framework for monitoring and improving hand hygiene compliance was developed. RESULTS: Barriers to compliance were ambiguity about when to clean hands, the pace and urgency of work in some areas of the department, which left little time for hand hygiene and environmental and operational issues. Sore hands were a problem for some staff. Expectations of compliance were agreed on with staff, and changes were made to remove barriers. A monitoring tool was designed to monitor progress. Gradual improvement occurred in all areas, except in emergency situations, which require further improvement work. CONCLUSIONS: The context of care and barriers to compliance should be reflected in hand hygiene expectations and monitoring. In the emergency department, the requirement to deliver urgent live-saving care can supersede conventional hand hygiene expectations.
Asunto(s)
Servicio de Urgencia en Hospital/normas , Higiene de las Manos/normas , Adhesión a Directriz , Desinfección de las Manos/normas , Humanos , Control de Infecciones , Cuerpo Médico de HospitalesRESUMEN
Diarrhoea is common in Intensive Care Unit (ICU) patients, with a reported prevalence of 15-38%. Many factors may cause diarrhoea, including Clostridium difficile, drugs (e.g. laxatives, antibiotics) and enteral feeds. Diarrhoea impacts on patient dignity, increases nursing workload and healthcare costs, and exacerbates morbidity through dermal injury, impaired enteral uptake and subsequent fluid imbalance. We analysed a cohort of 9331 consecutive patients admitted to a mixed general intensive care unit to establish the prevalence of diarrhoea in intensive care unit patients, and its relationship with infective aetiology and clinical outcomes. We provide evidence that diarrhoea is common (12.9% (1207/9331) prevalence) in critically ill patients, independently associated with increased intensive care unit length of stay (mean (standard error) 14.8 (0.26) vs 3.2 (0.09) days, p < 0.001) and mortality (22.0% (265/1207) vs 8.7% (705/8124), p < 0.001; adjusted hazard ratio 1.99 (95% CI 1.70-2.32), p < 0.001) compared to patients without diarrhoea even after adjusting for potential confounding factors, and infrequently caused by infective aetiology (112/1207 (9.2%)) such as Clostridium difficile (97/1048 (9.3%) tested) or virological causes (9/172 (5.7%) tested). Our findings suggest non-infective causes of diarrhoea in ICU predominate and pathophysiology of diarrhoea in critically ill patients warrants further investigation.
Asunto(s)
Clostridioides difficile , Enfermedad Crítica , Diarrea/epidemiología , Diarrea/etiología , Enterocolitis Seudomembranosa/epidemiología , Enterocolitis Seudomembranosa/microbiología , Adulto , Anciano , Diarrea/diagnóstico , Diarrea/mortalidad , Enterocolitis Seudomembranosa/diagnóstico , Enterocolitis Seudomembranosa/mortalidad , Femenino , Humanos , Unidades de Cuidados Intensivos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Prevalencia , Pronóstico , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Diagnosis of Clostridium difficile infection is controversial because of many laboratory methods, compounded by two reference methods. Cytotoxigenic culture detects toxigenic C difficile and gives a positive result more frequently (eg, because of colonisation, which means that individuals can have the bacterium but no free toxin) than does the cytotoxin assay, which detects preformed toxin in faeces. We aimed to validate the reference methods according to clinical outcomes and to derive an optimum laboratory diagnostic algorithm for C difficile infection. METHODS: In this prospective, multicentre study, we did cytotoxigenic culture and cytotoxin assays on 12,420 faecal samples in four UK laboratories. We also performed tests that represent the three main targets for C difficile detection: bacterium (glutamate dehydrogenase), toxins, or toxin genes. We used routine blood test results, length of hospital stay, and 30-day mortality to clinically validate the reference methods. Data were categorised by reference method result: group 1, cytotoxin assay positive; group 2, cytotoxigenic culture positive and cytotoxin assay negative; and group 3, both reference methods negative. FINDINGS: Clinical and reference assay data were available for 6522 inpatient episodes. On univariate analysis, mortality was significantly higher in group 1 than in group 2 (72/435 [16·6%] vs 20/207 [9·7%], p=0·044) and in group 3 (503/5880 [8·6%], p<0·001), but not in group 2 compared with group 3 (p=0·4). A multivariate analysis accounting for potential confounders confirmed the mortality differences between groups 1 and 3 (OR 1·61, 95% CI 1·12-2·31). Multistage algorithms performed better than did standalone assays. INTERPRETATION: We noted no increase in mortality when toxigenic C difficile alone was present. Toxin (cytotoxin assay) positivity correlated with clinical outcome, and so this reference method best defines true cases of C difficile infection. A new diagnostic category of potential C difficile excretor (cytotoxigenic culture positive but cytotoxin assay negative) could be used to characterise patients with diarrhoea that is probably not due to C difficile infection, but who can cause cross-infection.
Asunto(s)
Clostridioides difficile/aislamiento & purificación , Diarrea/diagnóstico , Diarrea/microbiología , Enterocolitis Seudomembranosa/diagnóstico , Enterocolitis Seudomembranosa/microbiología , Adolescente , Adulto , Anciano , Área Bajo la Curva , Niño , Preescolar , Clostridioides difficile/genética , ADN Bacteriano/química , ADN Bacteriano/genética , Enterotoxinas/análisis , Heces/microbiología , Femenino , Glutamato Deshidrogenasa/análisis , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Sensibilidad y Especificidad , Adulto JovenRESUMEN
A vaccine to prevent pneumococcal meningitis (PM) has recently been introduced. However, contemporary data to inform cost-effectiveness analysis and justify its routine use are sparse. We examined the cognitive, educational, psychological and social outcomes of PM in childhood. We completed a population-based case-control study in two regions of the UK. Children and young people currently between 3 and 20 years of age that had been diagnosed with PM ≤14 years of age were identified from active regional surveillance. Controls were siblings or neighbours of similar age. Standardised questionnaires and neuropsychological testing was administered to assess IQ, educational attainments, memory, psychological distress, quality of life and hearing impairment. Data were available on 97 patients and 93 controls. Eighty-four patients had a sibling/neighbour-matched control. Both matched and unmatched analyses were completed, and results of the 84 matched comparisons were highly similar to the unmatched. For the total sample, controls were similar in age, ethnicity and socioeconomic status. Median age at meningitis was 11 months. Median time between meningitis and assessment was 6.0 years. In the matched analysis, partial or profound hearing impairment was reported in 14% of patients and 1% of controls. Patients had significantly lower mean full-scale IQ (p = 0.05), verbal IQ (p = 0.0008), numeracy (p = 0.02), total quality of life (p = 0.04), school functioning (p = 0.005), psychosocial functioning (p = 0.001) and psychological difficulties (p = 0.01). Parents of patients reported greater functional disability (p = 0.008), impairment in all aspects of quality of life (p = 0.001) and psychological difficulties (p < 0.0006). Findings for IQ were not materially different when analyses were repeated only in those without hearing impairment. In multivariate regression analysis that included both case-control status and hearing status, both being a patient (p = 0.001) and having profound hearing impairment (p = 0.001) were independently associated with lower full-scale IQ. Conclusions Pneumococcal meningitis is associated with major sequelae. Our findings strongly support the introduction of pneumococcal conjugate vaccine as part of routine childhood vaccination programmes internationally.
Asunto(s)
Meningitis Neumocócica/complicaciones , Meningitis Neumocócica/psicología , Adolescente , Estudios de Casos y Controles , Niño , Preescolar , Escolaridad , Femenino , Pérdida Auditiva/etiología , Humanos , Lactante , Inteligencia , Masculino , Memoria , Trastornos Mentales/etiología , Análisis Multivariante , Pruebas Neuropsicológicas , Vigilancia de la Población , Calidad de Vida , Análisis de Regresión , Encuestas y Cuestionarios , Reino Unido , Adulto JovenRESUMEN
OBJECTIVE: We examined the physical, cognitive, educational, social, and psychological outcomes of invasive meningococcal disease in adolescence, as well as demographic and disease factors associated with outcomes. METHODS: A population-based, matched-cohort study was performed. A total of 101 gender- and age-matched case-control pairs (15-19 years of age at the time of disease; 46% male) from 6 regions of England underwent follow-up evaluations 18 to 36 months after invasive meningococcal disease. Educational, social, and vocational function, mental health, social support, self-efficacy, and quality-of-life data were collected by using standardized questionnaires and neuropsychological tests. RESULTS: Fifty-seven percent of case subjects (n = 58) had major physical sequelae. Survivors had greater depressive symptoms, greater fatigue, less social support, greater reduction in quality of life, and lower educational attainment compared with control subjects. Survivors with serogroup C disease had greater physical sequelae than did those with serogroup B disease. Greater cognitive deficits were associated with younger age at diagnosis. Only 53 of 101 case subjects reported any medical follow-up care after invasive meningococcal disease. CONCLUSIONS: Survivors of invasive meningococcal disease in adolescence have a disturbing series of deficits, including poorer physical and mental health, quality of life, and educational achievement. Serogroup C is associated with poorer outcomes. Invasive meningococcal disease attributable to serogroup B disease remains a major cause of morbidity and death among adolescents. Medical care is poor after discharge from the hospital. Routine follow-up care of adolescent survivors may prevent or ameliorate physical and psychosocial morbidity after invasive meningococcal disease.
Asunto(s)
Meningitis Meningocócica/complicaciones , Adolescente , Cuidados Posteriores , Estudios de Casos y Controles , Trastornos del Conocimiento/diagnóstico , Trastornos del Conocimiento/etiología , Estudios de Cohortes , Depresión/diagnóstico , Depresión/etiología , Evaluación de la Discapacidad , Escolaridad , Inglaterra , Fatiga/diagnóstico , Fatiga/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Meningitis Meningocócica/diagnóstico , Meningitis Meningocócica/rehabilitación , Neisseria meningitidis Serogrupo B , Neisseria meningitidis Serogrupo C , Pruebas Neuropsicológicas , Estudios Prospectivos , Calidad de Vida , Rehabilitación Vocacional , Autoeficacia , Apoyo Social , Adulto JovenRESUMEN
AIM: To estimate the overall long-term health related quality of life implications of an episode of pneumococcal meningitis in childhood. METHOD: Cases were identified through two regional UK surveillance studies and traced via their general practitioners (GPs) or local hospital paediatrician. Siblings were used as controls where available. Health related quality of life was assessed using the health utilities index (HUI). Mean utility scores were compared between cases and controls and univariate linear regression was used to identify factors that influenced the overall utility scores. RESULTS: HUI data were available for 71 cases and 66 controls. The mean overall utility score for cases 0.774 (95% CI 0.711- 0.837) was significantly lower than for controls 0.866 (95% CI 0.824-0.907) (p-value = 0.0185). Hearing was the most significantly affected health attribute (p-value < 0.006). In cases, males had lower quality of life scores than females (p-value = 0.018), however this was not seen in controls. CONCLUSION: An episode of pneumococcal meningitis results in a long-term decrement in overall health related quality of life and is significantly related to hearing loss.
Asunto(s)
Meningitis Neumocócica/rehabilitación , Calidad de Vida , Adolescente , Adulto , Estudios de Casos y Controles , Niño , Preescolar , Femenino , Encuestas Epidemiológicas , Pérdida Auditiva/etiología , Humanos , Modelos Lineales , Masculino , Meningitis Neumocócica/complicaciones , Sobrevivientes/estadística & datos numéricos , Adulto JovenRESUMEN
Mathematical models have proved to be useful tools for addressing questions about the process of infection. This is because the model allows the investigation of the mathematical link between invisible events (transmission of infection between individuals) and more visible ones (incidence of clinical infection, seroprevalence data etc.). A useful model is often one that is simple enough to provide answers that are applicable to as general a context as possible, but also complex enough so that it can address the most relevant questions. Thus, relatively simple models of viral (or hospital acquired-) infection were used to establish the existence of critical thresholds of immunisation (or antibiotic usage) coverage, although more complex models were needed for the investigation of the impact of infection control practices within more specific contexts. Mathematical models have the potential to elucidate key determinants of the epidemiology of infectious disease arising in infants nursed in neonatal intensive care units.
Asunto(s)
Diseño de Investigaciones Epidemiológicas , Infecciones/epidemiología , Modelos Teóricos , Humanos , Infecciones/transmisiónRESUMEN
AIMS: To study the incidence of hypernatraemia (plasma sodium >145 mmol/L), identify predisposing factors to and associated complications of hypernatraemia in preterm infants born less than 27 weeks gestation in the first 5 days of life. METHODS: Preterm infants less than 27 week gestation over an 18-month period were studied by retrospective analysis of patient records. Data were collected on gestation, birthweight, sex, antenatal steroid use, phototherapy, incubator humidity, time of transfer to incubator, plasma sodium, urea and creatinine. Actual fluid and sodium intake was calculated for the first 5 days of life. Data were collected on chronic lung disease, patent ductus arteriosus, intraventricular haemorrhage, necrotising enterocolitis and death. RESULTS: In this study 46 (69.7%) of 66 infants studied developed hypernatraemia (>145 mmol/L), occurring most frequently between 24 and 48 h of age. The median gestation of hypernatraemic babies was significantly lower. There was no significant difference in median birthweight, or factors associated with increased insensible water loss between the hypernatraemic and the non-hypernatraemic groups. Fluid intake was significantly higher on days 2, 3 and 4 in the hypernatraemic group. There was no difference in sodium intake between the two groups. More hypernatraemic babies compared with controls developed chronic lung disease, patent ductus arteriosus, significant intraventricular haemorrhage, necrotising enterocolitis and died, but was not significant. CONCLUSION: Hypernatraemia occurs commonly in preterm infants less than 27 weeks gestation and was not associated with significant morbidity. The more immature infants developed hypernatraemia and all cases resolved after increasing fluid intake.
Asunto(s)
Hiponatremia/epidemiología , Enfermedades del Prematuro/epidemiología , Peso al Nacer , Creatina/sangre , Conducto Arterioso Permeable/epidemiología , Conducto Arterioso Permeable/mortalidad , Conducto Arterioso Permeable/terapia , Enterocolitis Necrotizante/epidemiología , Enterocolitis Necrotizante/mortalidad , Femenino , Fluidoterapia , Humanos , Hiponatremia/mortalidad , Hiponatremia/terapia , Incidencia , Recién Nacido , Recien Nacido Prematuro , Enfermedades del Prematuro/mortalidad , Enfermedades del Prematuro/terapia , Enfermedades Pulmonares/epidemiología , Masculino , Estudios Retrospectivos , Sodio/sangre , Sodio/farmacocinética , Urea/sangreRESUMEN
BACKGROUND AND OBJECTIVES: A large number of patients with thalassemia major have been born and treated exclusively in Cyprus. They have been managed according to standard international practice, but few have been transplanted. In 1999, a combination chelation regime with desferrioxamine and deferiprone was introduced. We analyzed survival trends in Cypriots and tried to identify factors associated with prolonged survival. DESIGN AND METHODS: We had incomplete information on births pre-1974 and complete information from 1974 onwards. Clinical data were incomplete pre-1980 and complete thereafter. We analyzed data on 539 patients born after 1960 and followed over the period 1980 to the end of 2004. RESULTS: There were 58 deaths, 31 (53.4%) of which where due to cardiac causes. In the complete birth cohort of 284 patients born after 1974, survival (95% CI) at 10, 20 and 30 years was 100% (0); 98.5% (96.1-99.4) and 92.7% (86.7-96.1) respectively. There was a significant trend of increasing cardiac deaths between 1980 and 2000 (p<0.001) and a decline after 2000 (p=0.06). In multivariate survival analysis, protective effects were found for female sex (hazard ratio, 0.37, 95% CI 0.21-0.66; p<0.001), and post-2000 follow-up (hazard ratio, 0.44, 95% CI 0.20-0.99; p<0.05), but not for genotype, treatment center or birth cohort. INTERPRETATION AND CONCLUSIONS: Most patients born after 1974 survive to at least the age of 30. There has been a marked improvement in survival for patients of all ages since 2000, which may be due to the introduction of combination chelation therapy.
Asunto(s)
Talasemia/tratamiento farmacológico , Talasemia/epidemiología , Chipre/epidemiología , Deferiprona , Deferoxamina/uso terapéutico , Quimioterapia Combinada , Femenino , Humanos , Quelantes del Hierro/uso terapéutico , Masculino , Piridonas/uso terapéutico , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Talasemia/mortalidadRESUMEN
OBJECTIVE: To examine biological and social risk factors for meningococcal disease in adolescents. DESIGN: Prospective, population based, matched cohort study with controls matched for age and sex in 1:1 matching. Controls were sought from the general practitioner. SETTING: Six contiguous regions of England, which represent some 65% of the country's population. PARTICIPANTS: 15-19 year olds with meningococcal disease recruited at hospital admission in six regions (representing 65% of the population of England) from January 1999 to June 2000, and their matched controls. METHODS: Blood samples and pernasal and throat swabs were taken from case patients at admission to hospital and from cases and matched controls at interview. Data on potential risk factors were gathered by confidential interview. Data were analysed by using univariate and multivariate conditional logistic regression. RESULTS: 144 case control pairs were recruited (74 male (51%); median age 17.6). 114 cases (79%) were confirmed microbiologically. Significant independent risk factors for meningococcal disease were history of preceding illness (matched odds ratio 2.9, 95% confidence interval 1.4 to 5.9), intimate kissing with multiple partners (3.7, 1.7 to 8.1), being a university student (3.4, 1.2 to 10) and preterm birth (3.7, 1.0 to 13.5). Religious observance (0.09, 0.02 to 0.6) and meningococcal vaccination (0.12, 0.04 to 0.4) were associated with protection. CONCLUSIONS: Activities and events increasing risk for meningococcal disease in adolescence are different from in childhood. Students are at higher risk. Altering personal behaviours could moderate the risk. However, the development of further effective meningococcal vaccines remains a key public health priority.
Asunto(s)
Infecciones Meningocócicas/epidemiología , Adolescente , Adulto , Aglomeración , Inglaterra/epidemiología , Métodos Epidemiológicos , Conductas Relacionadas con la Salud , Humanos , Recién Nacido , Actividades Recreativas , Estilo de Vida , Infecciones Meningocócicas/prevención & control , Vacunas Meningococicas , Religión , Asunción de Riesgos , Conducta Sexual , Parejas Sexuales , Factores SocioeconómicosRESUMEN
Post-herpetic neuralgia (PHN) following acute herpes zoster remains a significant cause of neuropathic pain especially in the elderly. Early treatment of the zoster rash with antiviral agents, such as aciclovir remains one of the few measures proven to reduce the incidence and duration of PHN albeit only in a subset of patients. It is therefore crucial that the physician who first sees a case of zoster identifies those patients who are most likely to develop long-term pain and treats them accordingly. In particular, prodrugs such as famciclovir and valaciclvoir may be more beneficial in reducing PHN than the shorter acting aciclovir, but can be more expensive. Measures that could be used to predict patients likely to develop PHN would also facilitate the evaluation of early use of antiepileptic, anti-inflammatory and analgesic agents in the prevention of PHN. In a prospective study of 280 herpes zoster (HZ) cases seen by the general practitioner (GP) we evaluated the predictive value of five clinical factors identified in clinical trials as associated with a higher likelihood of PHN. A visual analogue score (VAS) over 5 and/or age over 50 correctly identified all subjects with PHN at 3 and 6 months, respectively. However, the specificity of this prediction was low because as many as 81% and 85% of those aged over 50 recovered within 3 and 6 months, respectively. Better methods are needed to identify patients over 50 at most risk of PHN that enable GPs to better allocate their resources with respect to HZ treatment.
Asunto(s)
Herpes Zóster/complicaciones , Herpes Zóster/patología , Neuralgia Posherpética/etiología , Neuralgia Posherpética/prevención & control , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Niño , Estudios de Cohortes , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Pautas de la Práctica en Medicina , Valor Predictivo de las Pruebas , Factores de Riesgo , Factores SexualesRESUMEN
Problems with antibiotic resistant bacteria are increasing in the hospital and particularly in the intensive care unit. Methicillin-resistant Staphylococcus aureus, Acinetobacter baumanii and extended spectrum beta-lactamase producing gram-negative bacilli constitute a therapeutic and infection control challenge. Early enteral feeding improves survival in patients in the intensive care unit. Prokinetic agents are routinely used in patients with inappropriate gastrointestinal motility. The use of erythromycin at sub-therapeutic doses as a prokinetic agent is a cause of concern for the following reasons: it can increase the emergence and spread of antibiotic resistance and the likelihood of Clostridium difficile disease. The use of an antibiotic as a prokinetic agent does not constitute prudent antimicrobial prescribing and should be avoided. Alternative agents, whenever possible, should be used.
Asunto(s)
Infecciones Bacterianas/terapia , Resistencia a Medicamentos , Nutrición Enteral , Eritromicina/efectos adversos , Eritromicina/uso terapéutico , Antibacterianos/efectos adversos , Antibacterianos/uso terapéutico , Infecciones Bacterianas/tratamiento farmacológico , Cuidados Críticos , Enfermedades Gastrointestinales/terapia , Motilidad Gastrointestinal , Humanos , Resistencia a la MeticilinaRESUMEN
BACKGROUND: Passive smoking appears to increase the risk of meningococcal disease (MD) in adolescents. Whether this effect is attributable to exposure to cigarette smoke or contact with smokers is unknown. METHODS: We conducted a prospective population-based case-control study with age, sex matched-controls in 1:1 matching. Participants were 15-19 year old with MD recruited at hospital admission in six regions (65% of the population of England) from January 1999 through June 2000, and their matched controls. Data on potential risk factors were gathered by confidential interview, including seven passive smoking variables. Factor analysis was performed to assess the dimensionality of the passive smoking exposure variables. The data were analysed with univariate and multivariate conditional logistic regression. RESULTS: 144 case-control pairs were recruited (51% male; median age 17.6). Factor analysis identified two independent factors representing passive smoking (P < 0.01), one associated with 'exposure to smoke', the other with 'smoker contact'. Only smoker contact was a significant risk factor for MD (OR = 1.8; 95% CI 1.0-3.3; P = 0.05). In multivariate analysis this factor was still associated with MD independently of potential confounders such as active smoker status and household crowding. CONCLUSION: Contact with smokers is associated with increased risk of MD in adolescents. This is more likely to be due to higher carriage rates in smokers than to exposure to smoke and emphasizes the importance of public health measures to stop smoking. In epidemiological studies that assess risk from passive smoking, exposure to smoke should be differentiated where possible from contact with smokers.
Asunto(s)
Infecciones Meningocócicas/etiología , Fumar , Contaminación por Humo de Tabaco/efectos adversos , Adolescente , Adulto , Inglaterra/epidemiología , Exposición a Riesgos Ambientales/efectos adversos , Exposición a Riesgos Ambientales/análisis , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Infecciones Meningocócicas/epidemiología , Infecciones Meningocócicas/transmisión , Contaminación por Humo de Tabaco/estadística & datos numéricosRESUMEN
Bacteria may colonize a carrier with more than one strain of a species at any one time. Attempts to determine multiple colonization are labour intensive because of the large number of colonies per carrier which need to be tested. A possible solution -- in which only 3 colonies per carrier are initially tested and only multiple-strain carriers are re-sampled -- was recently described. We evaluated the accuracy of the "re-sampling method" devised by Cespedes et al. with 500,000 stochastic simulations per scenario. Re-sampling is acceptable where > or = 5 colonies are initially tested or where one strain predominates over others in colony counts. The method introduces bias towards overestimation which decreases with the number of available carriers, increases with the proportion of truly multiple carriers, with decreasing number of colonies available for testing, and with decreasing number of colonies tested per carrier. Initial testing of 5-8 colonies tested with re-sampling are adequate for a large study (>100 carriers), or a small study where it is suspected that no strain predominates over the other in colony counts. Testing 9-20 colonies with re-sampling is necessary for small studies where one strain predominates over others. Re-sampling is unnecessary where >20 colonies are tested.
Asunto(s)
Bacterias/aislamiento & purificación , Portador Sano/microbiología , Modelos Biológicos , Bacterias/clasificación , Técnicas Bacteriológicas/métodos , Sesgo , Recuento de Colonia Microbiana , Humanos , Meticilina , Staphylococcus aureus/efectos de los fármacos , Staphylococcus aureus/aislamiento & purificación , SimbiosisRESUMEN
OBJECTIVE: To determine whether suboptimal management in hospital could contribute to poor outcome in children admitted with meningococcal disease. DESIGN: Case-control study of childhood deaths from meningococcal disease, comparing hospital care in fatal and non-fatal cases. SETTING: National statistics and hospital records. SUBJECTS: All children under 17 years who died from meningococcal disease (cases) matched by age with three survivors (controls) from the same region of the country. MAIN OUTCOME MEASURES: Predefined criteria defined optimal management. A panel of paediatricians blinded to the outcome assessed case records using a standardised form and scored patients for suboptimal management. RESULTS: We identified 143 cases and 355 controls. Departures from optimal (per protocol) management occurred more frequently in the fatal cases than in the survivors. Multivariate analysis identified three factors independently associated with an increased risk of death: failure to be looked after by a paediatrician, failure of sufficient supervision of junior staff, and failure of staff to administer adequate inotropes. Failure to recognise complications of the disease was a significant risk factor for death, although not independently of absence of paediatric care (P = 0.002). The odds ratio for death was 8.7 (95% confidence interval 2.3 to 33) with two failures, increasing with multiple failures. CONCLUSIONS: Suboptimal healthcare delivery significantly reduces the likelihood of survival in children with meningococcal disease. Improved training of medical and nursing staff, adherence to published protocols, and increased supervision by consultants may improve the outcome for these children and also those with other life threatening illnesses.
Asunto(s)
Atención a la Salud/estadística & datos numéricos , Infecciones Meningocócicas/mortalidad , Adolescente , Niño , Preescolar , Atención a la Salud/normas , Servicios Médicos de Urgencia/normas , Métodos Epidemiológicos , Humanos , Lactante , Recién Nacido , Infecciones Meningocócicas/terapia , Reino Unido/epidemiologíaRESUMEN
The aims of this study were to determine reference ranges for the urinary calcium (UCa/Cr) and phosphate (UPO(4)/Cr) creatinine ratios and to study factors influencing these ratios in a representative population of preterm infants managed according to current nutritional guidelines. Spot urine samples were obtained from 186 preterm infants (gestation 24-34 weeks) for measurement of UCa/Cr and UPO(4)/Cr ratios as part of a routine metabolic bone screening program, once every 2-4 weeks from the 3rd to the 18th week of life. Data were also collected on gender, appropriate or small for gestational age (SGA), nutrition [total parenteral nutrition (TPN), preterm or term formula, and breast milk], plasma Ca, P0(4), urea, and electrolytes and on the use of drugs (frusemide, dexamethasone, and theophylline). Data from infants treated with any of these three drugs were analyzed separately and not included in establishing the reference ranges for UCa/Cr and UPO(4)/Cr. The mean gestational age of the study population was 28 weeks (range 24-34 weeks). The 95th percentile for UCa/Cr at 3 weeks of age was 3.8 mmol/mmol and decreased significantly with increasing postnatal age (P<0.001). The 95th per-centile for UPO(4)/Cr was 26.69 mmol/mmol at 3 weeks of age, but this did not change significantly with increasing postnatal age (P=0.296). On univariate analysis there was no significant association of UCa/Cr and UPO(4)/Cr with gender and type of enteral nutrition. The UCa/Cr was lower in infants who were SGA (P=0.013) and with low plasma Ca (P=0.008). Infants on TPN had significantly higher UCa/Cr (P =0.019) and lower UPO(4)/Cr ratios(P<0.001). Multivariate analysis confirmed the decrease in UCa/Cr ratio with increasing postnatal age, but the SGA effect was eliminated. The use of furosemide(P<0.001) and theophylline (P=0.003) was associated with a significant increase in the UCa/Cr ratio. The use of dexamethasone was also associated with an increase in UCa/Cr ratio, but this did not achieve statistical significance (P=0.339). The use of furosemide, theophylline,and dexamethasone had no effect on UPO(4)/Cr. We report a reference range for UCa/Cr and UPO(4)/Cr ratios and factors influencing these ratios in a representative population of preterm infants between 24 and 34 weeks gestation, managed according to current nutritional guide-lines.