Risk factors for development of intestinal colonization with imipenem-resistant Pseudomonas aeruginosa in the intensive care unit setting.

Risk factors for development of intestinal colonization by imipenem-resistant Pseudomonas aeruginosa (IRPA) may differ between those who acquire the organism via patient-to-patient transmission versus by antibiotic selective pressure. The aim of this study was to quantify potential risk factors for the development of IRPA not due to patient-to-patient transmission.

Targeted surveillance of methicillin-resistant Staphylococcus aureus and its potential use to guide empiric antibiotic therapy.

The present study aimed to determine the frequency of methicillin-resistant Staphylococcus aureus (MRSA)-positive clinical culture among hospitalized adults in different risk categories of a targeted MRSA active surveillance screening program and to assess the utility of screening in guiding empiric antibiotic therapy. We completed a prospective cohort study in which all adults admitted to non-intensive-care-unit locations who had no history of MRSA colonization or infection received targeted screening for MRSA colonization upon hospital admission. Anterior nares swab specimens were obtained from all high-risk patients, defined as those who self-reported admission to a health care facility within the previous 12 months or who had an active skin infection on admission. Data were analyzed for the subcohort of patients in whom an infection was suspected, determined by (i) receipt of antibiotics within 48 h of admission and/or (ii) the result of culture of a sample for clinical analysis (clinical culture) obtained within 48 h of admission. Overall, 29,978 patients were screened and 12,080 patients had suspected infections. A total of 46.4% were deemed to be at high risk on the basis of the definition presented above, and 11.1% of these were MRSA screening positive (colonized). Among the screening-positive patients, 23.8% had a sample positive for MRSA by clinical culture. Only 2.4% of patients deemed to be at high risk but found to be screening negative had a sample positive for MRSA by clinical culture, and 1.6% of patients deemed to be at low risk had a sample positive for MRSA by clinical culture. The risk of MRSA infection was far higher in those who were deemed to be at high risk and who were surveillance culture positive. Targeted MRSA active surveillance may be beneficial in guiding empiric anti-MRSA therapy.

Prevalence of methicillin-resistant Staphylococcus aureus and Acinetobacter baumannii in a long-term acute care facility.

BACKGROUND: Patients in long-term acute care (LTAC) facilities often have many known risk factors for acquisition of antibiotic-resistant bacteria. However, the prevalence of resistance in these facilities has not been well described. METHODS: We performed a single-day, point-prevalence study of a 180-bed, university-affiliated LTAC facility in Baltimore to assess the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii in the anterior nares, perirectal area, sputum, and wounds. RESULTS: Among the 147 patients evaluated, we found a high prevalence of colonization by both MRSA (28%) and A baumannii (30%). Of the A baumannii isolates, 90% were susceptible to imipenem and 92% were susceptible to ampicillin-sulbactam. No isolates were resistant to both imipenem and ampicillin-sulbactam. CONCLUSION: The high prevalence of resistance found in this study supports the need for increased surveillance of patients in the LTAC environment. The fact that these patients are often frequently transferred to tertiary care facilities also supports the need for coordination and collaboration among facilities within the same health care system and the broader geographic area.

Risk factors for colonization with extended-spectrum beta-lactamase-producing bacteria and intensive care unit admission.

Extended-spectrum beta-lactamase (ESBL)-producing bacteria are emerging pathogens. To analyze risk factors for colonization with ESBL-producing bacteria at intensive care unit (ICU) admission, we conducted a prospective study of a 3.5-year cohort of patients admitted to medical and surgical ICUs at the University of Maryland Medical Center. Over the study period, admission cultures were obtained from 5,209 patients. Of these, 117 were colonized with ESBL-producing Escherichia coli and Klebsiella spp., and 29 (25%) had a subsequent ESBL-positive clinical culture. Multivariable analysis showed the following to be statistically associated with ESBL colonization at admission: piperacillin-tazobactam (odds ratio [OR] 2.05, 95% confidence interval [CI] 1.36-3.10), vancomycin (OR 2.11, 95% CI 1.34-3.31), age > 60 years (OR 1.79, 95% CI 1.24-2.60), and chronic disease score (OR 1.15; 95% CI 1.04-1.27). Coexisting conditions and previous antimicrobial drug exposure are thus predictive of colonization, and a large percentage of these patients have subsequent positive clinical cultures for ESBL-producing bacteria.

Impact of empiric antibiotic therapy on outcomes in patients with Pseudomonas aeruginosa bacteremia.

The impact of appropriate empirical antimicrobial therapy for Pseudomonas aeruginosa bacteremia on patient outcomes has not been clearly established. We assessed the effect of appropriate empirical therapy on in-hospital mortality and length of stay (LOS) among patients with P. aeruginosa bacteremia. This was a retrospective cohort study of inpatients with a positive blood culture for P. aeruginosa between January 2001 and June 2005. Empirical therapy was defined as appropriate if the patient received an antibiotic the organism was susceptible to between 8 h before culture collection and the time the susceptibility results were available. The severity of the illness was measured 24 h before culture collection. The data were analyzed using logistic regression (in-hospital mortality) and linear regression (LOS). Overall, there were 167 episodes of P. aeruginosa bacteremia, 123 (86%) of which received appropriate empirical antibiotics. Sixty-one patients died (36.5%). The median time from culture collection to susceptibility results was 3.4 days. After we adjusted for age, severity of illness, and time at risk, we found that the appropriate empirical therapy was not significantly associated with mortality (odds ratio = 0.96; 95% confidence interval = 0.31 to 2.93). There was a 7% reduction in the mean LOS for patients who had received appropriate therapy at the time susceptibility results were available compared to those who did not (P = 0.74). These data suggest that the use of appropriate empirical therapy, i.e., before susceptibility results are known may not be as critical to patient outcomes as other studies have suggested.