Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study.

OBJECTIVES: Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS. DESIGN: This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation. SETTING: Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital. PARTICIPANTS: Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days. INTERVENTION: Implementation of a CDSS. OUTCOME MEASURES: The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence. MAIN RESULTS: Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31). CONCLUSIONS: Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality. TRIAL REGISTRATION NUMBER: ISRCTN54598675.

Computer-assisted decision support for changing practice in severe sepsis and septic shock.

Computer-assisted decision support systems (CDSS) are designed to improve infection management. The aim of this prospective, clinical pre- and post-intervention study was to investigate the influence of CDSS on infection management of severe sepsis and septic shock in intensive care units (ICUs). Data were collected for a total of 180 days during two study periods in 2006 and 2007. Of the 186 patients with severe sepsis or septic shock, 62 were stratified into a low adherence to infection management standards group (LAG) and 124 were stratified into a high adherence group (HAG). ICU mortality was significantly increased in LAG versus HAG patients (Kaplan-Meier analysis). Following CDSS implementation, adherence to standards increased significantly by 35%, paralleled with improved diagnostics, more antibiotic-free days and a shortened time until antibiotics were administered. In conclusion, adherence to infection standards is beneficial for patients with severe sepsis or septic shock and CDSS is a useful tool to aid adherence.

Key performance indicators in intensive care medicine. A retrospective matched cohort study.

Expert panel consensus was used to develop evidence-based process indicators that were independent risk factors for the main clinical outcome parameters of length of stay in the intensive care unit (ICU) and mortality. In a retrospective, matched data analysis of patients from five ICUs at a tertiary university hospital, agreed process indicators (sedation monitoring, pain monitoring, mean arterial pressure [MAP] >or= 60 mmHg, tidal volume [TV] or= 80 and or= 60 mmHg and BG >or= 80 mg/dl were relevant for survival. Linear regression of the 634 patients showed that analgesia monitoring, PIP or= 60 mmHg, BG >or= 80 mg/dl and

Adherence to standard operating procedures is crucial for intensive care unit survival of elderly patients.

Elderly patients account for 42-52% of intensive care unit (ICU) admissions and for almost 60% of all ICU days in the USA and up to 50% receive inappropriate antibiotic treatment. The aim of this study was to evaluate whether adherence to Standard Operating Procedures (SOPs) reduced ICU mortality in an elderly population. The study included consecutive patients (n = 228) aged > or = 60 years with an ICU stay of > 72 h. SOPs were based on evidence-based medicine guidelines for diagnosis and treatment of infections, and on local resistance rates. According to preset indicators of quality management standards and assessment of different degrees of adherence, an implementation rate > 70% was considered adherent (high adherence group [HAG]) and < or = 70% was considered non-adherent (low adherence group [LAG]). Patients in the HAG (n = 137) had significantly reduced mortality compared with LAG patients (n = 91): 5.8% versus 19.8%, respectively. It was concluded that adherence to SOPs based on evidence-based medicine that consider local resistance rates for antibiotic treatment in elderly ICU patients is associated with a lower mortality rate.

Highly efficient selection of phage antibodies mediated by display of antigen as Lpp-OmpA' fusions on live bacteria.

Delayed infectivity panning (DIP) is a novel approach for the in vivo isolation of interacting protein pairs. DIP combines phage display and cell surface display of polypeptides as follows: an antigen is displayed in many copies on the surface of F(+) Escherichia coli cells by fusing it to a Lpp-OmpA' hybrid. To prevent premature, non-specific infection by phage, the cells are rendered functionally F(-) by growth at 16 degrees C. The antigen-displaying cells are used to capture antibody-displaying phage by virtue of the antibody-antigen interaction. Following removal of unbound phage, infection of the cells by bound phage is initiated by raising the temperature to 37 degrees C that facilitates F pilus expression. The phage then dissociate from the antigen and infect the bacteria through the F pilus. Using specific scFv antibodies and the human ErbB2 proto-oncogene and IL2-Ralpha chain as model antibody-antigen pairs, we demonstrate enrichment of those phage that display a specific antibody over phage that display an irrelevant antibody of over 1,000,000 in a single DIP cycle. We further show the successful isolation of anti-toxin, anti-receptor, anti-enzyme and anti-peptide antibodies from several immune phage libraries, a shuffled library and a large synthetic human library. The effectiveness of DIP makes it suitable for the isolation of rare clones present in large libraries. Since DIP can be applied for most of the phage libraries already existing, it could be a powerful tool for the rapid isolation and characterization of binders in numerous protein-protein interactions.

Isolation of a Candida albicans DNA sequence conferring adhesion and aggregation on Saccharomyces cerevisiae.

Candida albicans is an opportunistic pathogen which may give rise to superficial and systemic infections. In the present study, C. albicans adhesion was studied by expression of C. albicans DNA sequences encoding adhesion functions in a nonadherent strain of Saccharomyces cerevisiae. Adherent transformant cells of S. cerevisiae harbouring a C. albicans genomic library cloned in a yeast-Escherichia coli shuttle vector were selected by using tissue culture-treated polystyrene as the attachment substratum. One transformant exhibited enhanced adhesion to treated and untreated polystyrene as well as autoaggregation, unlike control cells bearing the vector alone. Analysis of this clone revealed an insert of ca. 4.5 kb from C. albicans. Curing of the plasmid resulted in loss of adhesion and autoaggregation properties. A subclone bearing a reduced insert of 3.3 kb retained the ability to autoaggregate, to bind to treated and untreated polystyrene, and to adhere to buccal epithelial cells, unlike appropriate controls. Further subcloning of the insert to 2.7- and 1.9-kb fragments resulted in incremental decreases in adhesion and autoaggregation, whereas smaller fragments did not confer these properties. Hybridization of the 2.7-kb segment with C. albicans and S. cerevisiae DNA confirmed its origin as a single-copy sequence in the C. albicans genome as well as the absence of a homologous sequence in the genome of S. cerevisiae. The data suggest that the adhesion and aggregation phenomena of the transformant cells are related to expression of a C. albicans surface antigen encoded by the cloned DNA fragment.

Analysis of a Candida albicans gene that encodes a novel mechanism for resistance to benomyl and methotrexate.

The pathogenic yeast, Candida albicans, is insensitive to the anti-mitotic drug, benomyl, and to the dihydrofolate reductase inhibitor, methotrexate. Genes responsible for the intrinsic drug resistance were sought by transforming Saccharomyces cerevisiae, a yeast sensitive to both drugs, with genomic C. albicans libraries and screening on benomyl or methotrexate. Restriction analysis of plasmids isolated from benomyl- and methotrexate-resistant colonies indicated that both phenotypes were encoded by the same DNA fragment. Sequence analysis showed that the fragments were nearly identical and contained a long open reading frame of 1694 bp (ORF1) and a small ORF of 446 bp (ORF2) within ORF1 on the opposite strand. By site-directed mutagenesis, it was shown that ORF1 encoded both phenotypes. The protein had no sequence similarity to any known proteins, including beta-tubulin, dihydrofolate reductase, and the P-glycoprotein of the multi-drug resistance family. The resistance gene was detected in several C. albicans strains and in C. stellatoidea by DNA hybridization and by the polymerase chain reaction.

RNA polymerase activity in virions from Ustilago maydis.

RNA polymerase activity is associated with the double-stranded RNA virions of Ustilago maydis. The reaction products of the polymerase activity are single-stranded RNA molecules. The RNA molecules synthesized are homologous to the three classes of double-stranded RNA molecules that typify the viral genome. The single-stranded RNA synthesized is released from the virions. The molecular weight of the single-stranded RNA transcripts is about half the size of the double-stranded RNA segments, and thus, it appears that in the in vitro reaction, full-length transcripts can be obtained.

The exclusion among the Ustilago viruses - A dsRNA restriction modification system?

Specific exclusion relations are know among the three Ustilago maydis viruses that are associated with the cytoplasmically transmitted 'killer phemomenon'. Of the three viruses P1, P4 and P6, only P1, and P4 cancoexist in one host cell. Mutual exclusion occurs between P1 and P6 and P4 unilaterally excludes P6. The exclusion relations were originally defined among the wild-type viruses. Those relations can be modified by two specific segments that are a part of the P4 dsRNA genome and were also found in some sensitive strains that contained part of the viral genome. Also, deletion of the dsRNA segment that is assumed to encode the toxin information permits the formation of hybrid genomes that otherwise cannot be formed. The data is interpreted in terms of a dsRNA restriction modification system in which the killer toxin or a toxin-linked function acts as the restriction factor and segments H3 and H4 or H4 alone contain the necessary information for the modification of certain sites on the M and L segments of the P1 and P4 viruses but not on the P6 segments.

Mutational analysis of natural alleles in and affecting the B incompatibility factor of Schizophyllum.

Primary mutations in the alleles of alpha 1 and beta 7 of the B incompatibility factor of Schizophyllum were induced with X rays. An additional mutation unlinked to the B factor and affecting its regulatory function was detected. This mutation is effective in monokaryons with most B-factor specificities. The spectra of induced mutations in different alleles is discussed in reference to a polarity in the expression of the recognition function and the regulatory function by each locus of the B incompatibility factor.