Costs and length of stay associated with antimicrobial resistance in acute kidney injury patients with bloodstream infection.

INTRODUCTION: Antimicrobial resistance negatively impacts on prognosis. Intensive care unit (ICU) patients, and particularly those with acute kidney injury (AKI), are at high risk for developing nosocomial bloodstream infections (BSI) due to multi-drug-resistant strains. Economic implications in terms of costs and length of stay (LOS) attributable to antimicrobial resistance are underevaluated. This study aimed to assess whether microbial susceptibility patterns affect costs and LOS in a well-defined cohort of ICU patients with AKI undergoing renal replacement therapy (RRT) who developed nosocomial BSI. METHODS: Historical study (1995-2004) enrolling all adult RRT-dependent ICU patients with AKI and nosocomial BSI. Costs were considered as invoiced in the Belgian reimbursement system, and LOS was used as a surrogate marker for hospital resource allocation. RESULTS: Of the 1330 patients with AKI undergoing RRT, 92 had microbiologic evidence of nosocomial BSI (57/92, 62% due to a multi-drug-resistant microorganism). Main patient characteristics were equal in both groups. As compared to patients with antimicro-4 bial-susceptible BSI, patients with antimicrobial-resistant BSI were more likely to acquire Gram-positive infection (72.6% vs 25.5%, P<0.001). No differences were found neither in LOS (ICU before BSI, ICU, hospital before BSI, hospital, hospital after BSI, and time on RRT; all P>0.05) or hospital costs (all P>0.05) when comparing patients with antimicrobial-resistant vs antimicrobial-susceptible BSI. However, although not statistically significant, patients with BSI caused by resistant Gram-negative-, Candida-, or anaerobic bacteria incurred substantial higher costs than those without. CONCLUSION: In a cohort of ICU patients with AKI and nosocomial BSI undergoing RRT, patients with antimicrobial-resistant vs antimicrobial-susceptible Gram-positive BSI did not have longer hospital stays, or higher hospital costs. Patients with resistant "other" (i.e. Gram-negative, Candida, or anaerobic) BSI were found to have a distinct trend towards increased resources use as compared to patients with susceptible "other" BSI, respectively.

Hyperglycaemia upon onset of ICU-acquired bloodstream infection is associated with adverse outcome in a mixed ICU population.

This study aimed to assess whether a relationship exists between hyperglycaemia and outcome in a mixed cohort of critically ill patients with nosocomial bloodstream infection (BSI), and to evaluate patterns of blood glucose levels between survivors and non-survivors. A historical observational cohort study was conducted in the intensive care unit (ICU) of a tertiary care referral centre. One-hundred-and-thirty patients with a microbiologically documented ICU-acquired BSI (period 2003 to 2004) were included. For the study, morning blood glucose levels were evaluated from one day prior until five days after onset of BSI. The contribution of hyperglycaemia, divided in three subgroups (> or = 150 mg/dl, > or = 175 mg/dl and > or = 200 mg/dl), to in-hospital mortality was estimated by logistic regression. In-hospital mortality was 36.2%. Over the seven study days, no differences were found in daily morning blood glucose levels between survivors (n = 83) and non-survivors (n = 47). Nevertheless, the trend of blood glucose levels upon onset of BSI showed a remarkable increase in the non-survivors, whereas it decreased in the survivors. Hyperglycaemia (> or = 175 mg/dl and > or = 200 mg/dl) was observed more often among the non-survivors. Multivariate logistic regression showed that APACHE II (P = 0.002), antibiotic resistance (P = 0.004) and hyperglycaemia (> or = 175 mg/dl) upon onset of BSI (P = 0.017) were independently associated with in-hospital mortality, whereas a history of diabetes (P = 0.041) was associated with better outcome. Hyperglycaemia (> or = 175 mg/dl) upon onset of ICU-acquired BSI is associated with worse outcome in a heterogeneous ICU population. Patterns of morning blood glucose levels have only limited value in the prediction of the individual course.

Critical care nurses' knowledge of evidence-based guidelines for preventing infections associated with central venous catheters: an evaluation questionnaire.

BACKGROUND: Lack of adherence to recommended evidence-based guidelines for preventing infections associated with use of central venous catheters may be due to nurses' lack of knowledge of the guidelines. OBJECTIVE: To develop a reliable and valid questionnaire for evaluating critical care nurses' knowledge of evidence-based guidelines for preventing infections associated with central venous catheters. METHODS: A total of 10 nursing-related strategies were identified from current evidence-based guidelines for preventing infections associated with use of central venous catheters. Face and content validation were determined for selected interventions and multiple-choice questions (1 question per intervention). The test results of 762 critical care nurses were evaluated for item difficulty, item discrimination, and quality of the response alternatives or options for answers (possible responses). RESULTS: All 10 items had face and content validity. Values for item difficulty ranged from 0.1 to 0.9. Values for item discrimination ranged from 0.05 to 0.41. The quality of the response alternatives (0.0-0.8) indicated widespread misconceptions among the critical care nurses in the sample. CONCLUSION: The questionnaire is reliable and has face and content validity. Findings from surveys in which this questionnaire is used can lead to better educational programs for critical care nurses on infections associated with use of central venous catheters.

Critical care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: an evaluation questionnaire.

BACKGROUND: Nurses' lack of knowledge may be a barrier to adherence to evidence-based guidelines for preventing ventilator-associated pneumonia. OBJECTIVE: To develop a reliable and valid questionnaire for evaluating critical care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia. METHODS: Ten nursing-related interventions were identified from a review of evidence-based guidelines for preventing ventilator-associated pneumonia. Selected interventions and multiple-choice questions (1 question per intervention) were subjected to face and content validation. Item difficulty, item discrimination, and the quality of the response alternatives or options for answers (possible responses) were evaluated on the test results of 638 critical care nurses. RESULTS: Face and content validity were achieved for 9 items. Values for item difficulty ranged from 0.1 to 0.9. Values for item discrimination ranged from 0.10 to 0.65. The quality of the response alternatives led to the detection of widespread misconceptions among critical care nurses. CONCLUSION: The questionnaire is reliable and has face and content validity. Results of surveys with this questionnaire can be used to focus educational programs on preventing ventilator-associated pneumonia.

Severe infection, sepsis and acute kidney injury.

Both severe infection and acute kidney injury (AKI) have a high, and rising incidence in critically ill patients admitted to the intensive care unit (ICU), and are associated with increased in-hospital mortality. Septic AKI patients are more severely ill compared to non-septic AKI patients and have worse outcome. Severe infection is a major cause of AKI in ICU patients, while conversely, AKI patients are at increased risk for infection. The dogma from the past relates the development of AKI in sepsis patients to decreased renal blood flow. However, current data suggest that there is no impairment of renal blood flow in patients with sepsis. The pathogenesis of AKI in sepsis is probably related to cytotoxic effects of inflammation, and impaired microcirculation. In addition, hyperglycaemia, and antimicrobial agent-induced drug nephrotoxicity may contribute to the development of AKI. On the other hand, AKI patients are at greater risk for infection as a result of volume overload, dialysis catheter insertion and secondary manipulation, inflammation of the kidneys leading to'organ cross talk', and impaired host immunity.

Acute kidney injury, length of stay, and costs in patients hospitalized in the intensive care unit.

Acute kidney injury (AKI) in patients hospitalized in the intensive care unit (ICU) results in increased morbidity, mortality, and as a consequence, higher health-care costs. The bad prognosis associated with this condition and limited health-care budgets both have raised the issue of how much therapy should be dedicated to ICU patients with AKI. As no universally-agreed standardized definition for AKI is available, wide ranges of incidence are reported and precise estimates of its associated excess of costs are, therefore, difficult to explore. Nonetheless, significantly prolonged hospital length of stay (LOS) and higher costs in ICU patients whose course was complicated with AKI are reported. Moreover, among survivors, even greater requirements of in-hospital and post-hospitalization care was noted. Notwithstanding the high health-economic burden, full supportive intensive care treatment is justified in this particular cohort of patients. Major efforts are highly required in terms of public health prevention initiatives and the early recognition and timely management of AKI, in ICU hospitalized patients in particular.