RESUMO
BACKGROUND: While the range of possible transmission pathways of severe acute respiratory syndrome coronavirus-2 in various settings has been investigated thoroughly, most authorities have recently acknowledged the role of aerosol spread in its transmission, especially in indoor environments where ventilation is poor. Engineering controls are needed to mitigate aerosol transmission in high-risk settings including hospital wards, classrooms and offices. AIM: To assess the effectiveness of aerosol filtration by portable air cleaning devices with high-efficiency particulate air filters used in addition to a standard building heating ventilation and air conditioning (HVAC) system. METHODS: Test rooms, including a single-bed hospital room, were filled with test aerosol to simulate aerosol movement. Aerosol counts were measured over time with various portable air cleaning devices and room ventilation systems to quantify the overall aerosol clearance rate. FINDINGS: Portable air cleaning devices were very effective for removal of aerosols. The aerosols were cleared five times faster in a small control room with portable air cleaning devices than in the room with HVAC alone. The single-bed hospital room had an excellent ventilation rate (â¼14 air changes per hour) and cleared the aerosols in 20 min. However, with the addition of two air cleaning devices, the clearance time was three times faster. CONCLUSIONS: Inexpensive portable air cleaning devices should be considered for small and enclosed spaces in healthcare settings, such as inpatient rooms and personal protective equipment donning/doffing stations. Portable air cleaning devices are particularly important where there is limited ability to reduce aerosol transmission with building HVAC ventilation.
Assuntos
Poluição do Ar em Ambientes Fechados , COVID-19 , Aerossóis , Ar Condicionado , Filtração , Humanos , SARS-CoV-2 , VentilaçãoRESUMO
OBJECTIVES: Surgical site skin preparation is an effective method to prevent wound complications. The optimal agent has not been established, and guidelines contain conflicting recommendations. METHODS: The aim of alcoholic chlorhexidine or alcoholic iodine skin antisepsis (ACAISA) was to assess the efficacy of surgical site skin preparation with 0.5% chlorhexidine gluconate (w/v) in 70% ethanol (v/v) to 1% iodine (w/v) in 70% ethanol (v/v). This was a cluster randomized, controlled, single-centre, assessor-blinded, superiority trial in patients undergoing elective hip or knee arthroplasty. Each surgeon had a set operating day and the unit of randomization was the day of surgery. The primary outcome was superficial wound complication, defined as a composite endpoint of superficial incisional surgical site infection and/or clinically significant wound ooze in the 30 days following arthroplasty. The secondary outcome was any surgical site infection, including prosthetic joint infection. Outcome ascertainment was undertaken by an independent verification panel. The primary analysis was intention-to-treat, performed at the individual level. Taking into account the clustering effect, analysis of primary and secondary outcomes was undertaken at the level of the surgeon. RESULTS: A total of 780 participants were included; 390 participants were allocated chlorhexidine-alcohol and 390 participants were allocated iodine-alcohol. There was no difference in superficial wound complications: 19 (4.9%) versus 15 (3.8%) respectively (OR 1.28; 95%CI 0.62, 2.63; p 0.50). There was an increased odds of surgical site infection in the chlorhexidine-alcohol group compared to iodine-alcohol: 12 (3.1%) versus four (1.0%) respectively (OR 3.06; 95%CI 1.26, 7.46; p 0.014). The odds of prosthetic joint infection were also increased in the chlorhexidine-alcohol arm compared with iodine-alcohol: seven (1.8%) versus two (0.5%) respectively (OR 3.55; 95%CI 1.20, 10.44; p 0.022). CONCLUSIONS: No difference was observed in the primary outcome of superficial wound complications when chlorhexidine-alcohol and iodine-alcohol were compared. However, on a secondary analysis, iodine-alcohol had greater efficacy than chlorhexidine-alcohol for preventing surgical site infection. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614000177651.
Assuntos
Álcoois/administração & dosagem , Clorexidina/administração & dosagem , Desinfetantes/administração & dosagem , Uso de Medicamentos/estatística & dados numéricos , Iodo/administração & dosagem , Cuidados Pré-Operatórios/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Artroplastia/métodos , Austrália , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto JovemRESUMO
To determine the burden of skin and soft tissue infections (SSTI), the nature of antimicrobial prescribing and factors contributing to inappropriate prescribing for SSTIs in Australian aged care facilities, SSTI and antimicrobial prescribing data were collected via a standardised national survey. The proportion of residents prescribed ⩾1 antimicrobial for presumed SSTI and the proportion whose infections met McGeer et al. surveillance definitions were determined. Antimicrobial choice was compared to national prescribing guidelines and prescription duration analysed using a negative binomial mixed-effects regression model. Of 12 319 surveyed residents, 452 (3.7%) were prescribed an antimicrobial for a SSTI and 29% of these residents had confirmed infection. Topical clotrimazole was most frequently prescribed, often for unspecified indications. Where an indication was documented, antimicrobial choice was generally aligned with recommendations. Duration of prescribing (in days) was associated with use of an agent for prophylaxis (rate ratio (RR) 1.63, 95% confidence interval (CI) 1.08-2.52), PRN orders (RR 2.10, 95% CI 1.42-3.11) and prescription of a topical agent (RR 1.47, 95% CI 1.08-2.02), while documentation of a review or stop date was associated with reduced duration of prescribing (RR 0.33, 95% CI 0.25-0.43). Antimicrobial prescribing for SSTI is frequent in aged care facilities in Australia. Methods to enhance appropriate prescribing, including clinician documentation, are required.
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Antibacterianos/administração & dosagem , Prescrição Inadequada/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Dermatopatias Infecciosas/epidemiologia , Infecções dos Tecidos Moles/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Feminino , Humanos , Masculino , Dermatopatias Infecciosas/microbiologia , Infecções dos Tecidos Moles/microbiologiaRESUMO
BACKGROUND: Many regional and remote ('regional') hospitals are without the specialist services that support antimicrobial stewardship (AMS) programmes in hospitals in major cities. This can impact their ability to implement AMS activities. AIM: To identify factors that impact on the delivery of AMS programmes in regional hospitals. METHODS: Healthcare clinicians who have primary AMS responsibilities or provide AMS support to a health service or across health services with an Australian Statistical Geography Standard Remoteness classification of inner regional, outer regional, remote or very remote were recruited purposively and via snowballing. A series of focus groups and interviews were held, and the discussions were audiotaped and transcribed verbatim. The transcripts were coded by two researchers, and thematic analysis was undertaken using a framework method. FINDINGS: Four focus groups and one interview were conducted (22 participants). Six main themes that impacted on AMS programme delivery were identified: culture of independence and self-reliance by local clinicians, personal relationships, geographical location of the hospital influencing antimicrobial choice, local context, inability to meaningfully benchmark performance, and lack of resources. Possible strategies to support the delivery of AMS programmes in regional hospitals proposed by participants were categorized into two main themes: those that may be best developed or managed centrally, and those that should be a local responsibility. CONCLUSION: AMS programme delivery in regional hospitals is influenced by factors that are not present in hospitals in major cities. These findings provide a strong basis for the development of strategies to support regional hospitals to implement sustainable AMS programmes.
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Gestão de Antimicrobianos/estatística & dados numéricos , Utilização de Instalações e Serviços/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde , Gestão de Antimicrobianos/organização & administração , Austrália , Cidades , Estudos de Avaliação como Assunto , Utilização de Instalações e Serviços/organização & administração , Geografia , Hospitais de Distrito , Humanos , Entrevistas como Assunto , Projetos PilotoRESUMO
BACKGROUND: Reports of Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-Kp) in Australia were previously uncommon, with cases imported sporadically by travellers from higher prevalence countries. AIM: The study institution reported the first outbreak of KPC-Kp in Australia. The aim of this study was to identify risk factors for KPC-Kp colonization and infection using a matched case-control study. METHODS: The study included all hospitalized patients with KPC-Kp colonization or infection from January 2012 to September 2015. FINDINGS: Thirty-four cases of KPC-producing Enterobacteriaceae (including 31 KPC-Kp cases) were matched with 136 controls. Variables associated with KPC-Kp acquisition included: length of hospital stay >28 days in the past 12 months, prior vancomycin-resistant enterococci (VRE) colonization, central venous catheter (CVC), gastrointestinal disease and invasive procedures. Exposure to broad-spectrum antibiotics was also found to be a significant risk factor. In the multi-variate analysis, three factors independently associated with KPC-Kp acquisition were length of hospital stay >28 days in the past 12 months [odds ratio (OR) 23.6, 95% confidence interval (CI) 4.9-113.3], presence of a CVC (OR 15.4, 95% CI 2.7-86.9), and prior VRE colonization (OR 6.0, 95% CI 1.6-23.2). Very few patients had a history of overseas travel. CONCLUSION: This study demonstrates that patients with prolonged hospital exposure are more likely to acquire KPC-Kp in the setting of a local outbreak, and suggests that risk factors for KPC-Kp acquisition may be shared with those for VRE colonization. Local screening strategies targeting overseas travellers would likely miss many cases. The results of this study will help to inform screening policies for carbapenemase-producing Enterobacteriaceae.
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Proteínas de Bactérias/metabolismo , Portador Sadio/epidemiologia , Infecção Hospitalar/epidemiologia , Infecções por Enterobacteriaceae/epidemiologia , Enterobacteriaceae/enzimologia , beta-Lactamases/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Portador Sadio/microbiologia , Estudos de Casos e Controles , Enterobacteriaceae/isolamento & purificação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND: Identifying themes associated with inappropriate prescribing in Australian public and private hospitals will help target future antimicrobial stewardship initiatives. AIMS: To describe current antimicrobial prescribing practices, identify similarities and differences between hospital sectors and provide target areas for improvement specific to each hospital sector. METHODS: All hospitals included in the study were part of the 2014 national antimicrobial prescribing survey and conducted one of the following: a whole hospital point prevalence survey, serial point prevalence surveys or a sample of randomly selected patients. Data on the types of antibiotics used, their indications for use and the quality of prescription based on compliance with national and local prescribing guidelines were collected. RESULTS: Two hundred and two hospitals (166 public and 36 private) comprising 10 882 patients and 15 967 antimicrobial prescriptions were included. Public hospitals had higher proportions of prescriptions for treatment (81.5% vs 48.4%) and medical prophylaxis (8.8% and 4.6%), whilst private hospitals had significantly higher surgical prophylaxis use (9.6% vs 46.9%) (P < 0.001). In public hospitals, the main reasons for non-compliance of treatment prescriptions were spectrum being too broad (30.5%) while in private it was incorrect dosing. Prolonged duration was the main reason for non-compliance among surgical prophylaxis prescriptions in both types of hospitals. CONCLUSIONS: Australian hospitals need to target specific areas to improve antimicrobial use. Specifically, unnecessary broad-spectrum therapy should be a priority area in public hospitals, whilst emphasis on curtailing antimicrobial overuse in surgical prophylaxis needs to be urgently addressed across in the private hospital sector.
Assuntos
Anti-Infecciosos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Hospitais Privados , Hospitais Públicos , Prescrição Inadequada/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Austrália , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Carbapenems are traditionally reserved as the last line of defence for treatment of serious infections with multiresistant Gram-negative bacilli. Reports of Klebsiella pneumoniae carbapenemase (KPC)-producing organisms have been emerging globally, but rare in Australasia to date. We describe an outbreak of KPC-2 producing K. pneumoniae at an Australian hospital. METHODS: After initial detection in October 2012, a retrospective review of patients with meropenem-resistant K. pneumoniae to June 2012, and ongoing prospective surveillance, was undertaken. Included patients were admitted to the hospital after June 2012 and had meropenem-resistant K. pneumoniae isolated from any site. Available isolates underwent detection of the KPC-2 gene by polymerase chain reaction and molecular typing was performed to determine genetic relatedness between isolates. Point-prevalence screening was performed on selected wards to detect asymptomatic carriage. Infection control procedures were implemented to contain the outbreak. RESULTS: Ten cases were identified in the initial cluster. Eight were localised to a single inpatient ward. Point-prevalence screening revealed one extra case. After temporary containment, re-emergence of KPC-producing isolates was observed post October 2013 with 18 further cases identified. Four K. pneumoniae isolates in the 2012 cluster and 16 from the 2013-2014 cluster were referred for further testing. All carried the KPC-2 beta-lactamase gene. The 2012 isolates were genetically similar to the 2014 isolates. CONCLUSION: KPC-2 mediated resistance is an emerging threat in Australia. The re-emergence of KPC despite initial containment emphasises the need for constant vigilance in the microbiology laboratory and ongoing maintenance of infection control and antimicrobial stewardship activity.
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Infecção Hospitalar/tratamento farmacológico , Mortalidade Hospitalar , Infecções por Klebsiella/tratamento farmacológico , Klebsiella pneumoniae/isolamento & purificação , Resistência beta-Lactâmica/genética , beta-Lactamases/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Austrália/epidemiologia , Carbapenêmicos/uso terapêutico , Surtos de Doenças , Feminino , Humanos , Controle de Infecções , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
OBJECTIVE: Total joint arthroplasty (TJA) places a significant economic burden on health care resources. This cohort study examines the costs associated with arthroplasty in 827 patients undergoing hip and knee TJA from January 2011 to June 2012 at a single center in Melbourne, Australia. METHODS: Data included total inpatient, outpatient, and readmissions costs in the 30 days following TJA. Factors associated with cost were modeled using negative binomial regression and extrapolated to the Australian population. RESULTS: The base cost (i.e., the cost for a patient with no modifying factors) over the first 30 days following TJA was $13,060 Australian (AU) (interquartile range $12,126-14,067 AU). The median length of stay was 4 days (range 2-33 days) and 35 patients (4%) were readmitted in the first 30 days following index TJA, the majority of whom had a surgical site infection (SSI) (74%). The following factors were independently associated with increased costs: SSI, preoperative warfarin therapy, American Society of Anesthesiologists score of 3 or 4, hip TJA, increasing operation time, increasing postoperative blood transfusion requirements, other nosocomial infections, postoperative venous thromboembolism (VTE), pressure ulcers, postoperative confusion, and acute urinary retention. Based on data from the present study, the cost of TJA in Australia is estimated to exceed $1 billion AU per year. Preventable postoperative complications were major cost drivers: SSI and VTE added a further $97 million AU and $66 million AU, respectively, to arthroplasty costs in the first 30 days following surgery. CONCLUSION: This unique study has identified important factors influencing TJA costs and providing guidance for future research and resource allocation.
Assuntos
Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Custos Hospitalares , Idoso , Assistência Ambulatorial/economia , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/tendências , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/tendências , Redução de Custos , Análise Custo-Benefício , Feminino , Previsões , Custos Hospitalares/tendências , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Readmissão do Paciente/economia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Sistema de Registros , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , VitóriaRESUMO
BACKGROUND: Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals. AIM: We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors. METHODS: Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors' level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines. RESULTS: The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices. CONCLUSION: A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.
Assuntos
Anti-Infecciosos/uso terapêutico , Atitude do Pessoal de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Prescrição Inadequada/psicologia , Corpo Clínico Hospitalar/psicologia , Padrões de Prática Médica/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Uso de Medicamentos , Fidelidade a Diretrizes/estatística & dados numéricos , Pesquisas sobre Atenção à Saúde , Humanos , Prescrição Inadequada/prevenção & controle , Prescrição Inadequada/estatística & dados numéricos , Unidades de Terapia Intensiva , Internato e Residência , Modelos Psicológicos , Guias de Prática Clínica como Assunto , Queensland , Encaminhamento e Consulta , Inquéritos e Questionários , VitóriaRESUMO
BACKGROUND: In Australia, antimicrobial stewardship programmes are a compulsory component of hospital accreditation. Good documentation around anti-microbial prescribing aids communication and can improve prescribing practice in environments with multiple decision makers. AIM: This study aims to develop and implement an intervention to improve antimicrobial prescribing practice in a 24-bed intensive care unit in a tertiary referral adult hospital. METHODS: We conducted a four-phase (observation, reflection, implementation, evaluation) prospective collaborative before-after quality improvement study. Baseline audits and surveys of antimicrobial prescribing practices identified barriers to and enablers of good prescribing practice. A customised intervention was then implemented over 6 weeks and included a yellow medication record sticker, quarterly education sessions and intensive care unit-specific empiric antimicrobial prescribing guidelines. Post-implementation, the effects were monitored by serial antimicrobial prescribing audits for 1 year. The primary outcomes were clear documentation of the start date, the planned stop date or review date and the indication for an antibiotic. These were all considered the 'minimum standards' for an antimicrobial prescription on the medication record. RESULTS: Documentation of minimum standards specifically addressed by the sticker improved (start date (72% to 90%, P < 0.001), stop date (16% to 63%, P < 0.001), antimicrobial indication documented on medication chart (58% to 83%, P < 0.01)). Overall, adherence to all three minimum standards (start date, stop date and indication) improved from 41/306 (13%) to 306/492 (63%) (P < 0.001). One-year post-implementation, the yellow sticker had become embedded into daily practice. CONCLUSION: A systematic approach to quality improvement combined with the implementation of a tailored, multi-faceted intervention can improve antimicrobial prescribing practices.
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Antibacterianos/administração & dosagem , Cuidados Críticos/métodos , Cuidados Críticos/normas , Fidelidade a Diretrizes , Padrões de Prática Médica/normas , Melhoria de Qualidade , Austrália/epidemiologia , Auditoria Clínica , Comportamento Cooperativo , Pesquisas sobre Atenção à Saúde , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Unidades de Terapia Intensiva , Estudos ProspectivosRESUMO
Tuberculosis (TB) remains an important issue in Australia with more than 85% of active cases contributed by overseas-born persons. Other risk groups include older Australians who acquired TB in the past and indigenous people. Immune suppression is an emerging risk factor for TB, particularly due to the expanding group of conditions for which potent immunosuppressive therapies is now used. Screening for latent TB is recommended in many risk groups including recent contacts of those with transmissible TB, those undergoing immune suppressive therapy, recently arrived refugees or migrants from high-risk countries and indigenous people with high rates of TB in the local community. Interferon-gamma release assay (IGRA) has now been available for several years for the diagnosis of latent TB. It is now used in many clinical situations, and despite the rapid rate of new publications, there are still gaps in our knowledge. This paper reviews the current role of interferon-gamma release assay in various situations, to determine its place in current practice and to explore where uncertainties exist.
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Testes de Liberação de Interferon-gama/métodos , Tuberculose/diagnóstico , Tuberculose/imunologia , Austrália/epidemiologia , Humanos , Hospedeiro Imunocomprometido/imunologia , Tuberculose Latente/diagnóstico , Tuberculose Latente/epidemiologia , Tuberculose Latente/imunologia , Tuberculose/epidemiologiaRESUMO
INTRODUCTION: Wound complications following arthroplasty are associated with significant impact on the patient and healthcare system. Skin cleansing prior to surgical incision is a simple and effective method to prevent wound complications however, the question of which agent is superior for surgical skin antisepsis is unresolved. METHODS AND ANALYSIS: This cluster randomised controlled trial aims to compare the incidence of superficial wound complications in patients undergoing elective prosthetic hip or knee replacement surgery receiving surgical skin antisepsis with either: 0.5% chlorhexidine gluconate (CHG) in 70% alcohol or 10% povidone in 70% alcohol. The trial will be conducted at an Australian tertiary, university affiliated hospital over a 3-year period involving 750 participants. Participants will be drawn from the surgical waiting list. Consent for this study will be 'opt-out' consent. On a given day, all eligible participants will have skin preparation either with 0.5% chlorhexidine in 70% alcohol or 10% povidone iodine in 70% alcohol. The primary outcome is superficial wound complications (comprised of superficial incisional surgical site infections (SSI) and/or prolonged wound ooze) in the first 30â days following prosthetic joint replacement surgery. Secondary outcomes will include the incidence of wound complications according to the joint replaced, assessment of the causative agents of SSI and cost-effectiveness analysis. The primary analysis is an intention-to-treat analysis including all participants who undergo randomisation and will be performed at the individual level taking into account the clustering effect. ETHICS AND DISSEMINATION: The study design and protocol was reviewed and approved by the St Vincent's Hospital Human Research Ethics Committee (HREC-A 016/14 10/3/2014). Study findings will be disseminated in the printed media, and learned forums. A written lay summary will be available to study participants on request. TRIAL REGISTRATION NUMBER: The trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000177651.
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Antissepsia/métodos , Artroplastia de Quadril , Artroplastia do Joelho , Clorexidina/análogos & derivados , Povidona-Iodo/administração & dosagem , Cuidados Pré-Operatórios/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Tópica , Adulto , Idoso , Anti-Infecciosos Locais/administração & dosagem , Clorexidina/administração & dosagem , Combinação de Medicamentos , Etanol , Feminino , Previsões , Humanos , MasculinoRESUMO
AIMS: This study aims to describe the incidence of infective complications, including tumour endoprosthesis infection, in a cohort of patients undergoing tumour endoprosthesis surgery in Victoria, Australia. METHODS: This retrospective cohort study was performed over 15 years (January 1996-December 2010). RESULTS: 121 patients underwent tumour endoprosthesis surgery during the study period. Patients were followed for a median of 34 months (interquartile range [IQR] 17, 80). Overall, 34 patients (28%) experienced infective complications including: bacteraemia in 19 patients (16%) and tumour endoprosthesis infection in 17 (14%). The majority of patients with early and late acute infections (haematogenous) were managed with debridement and retention of the prosthesis in addition to biofilm-active antibiotics. Late chronic infections were predominantly managed by exchange of the prosthesis. The overall success rate of treatment was 71%. The success rate for debridement and retention was 75% compared with 67% for exchange procedures. CONCLUSIONS: There is a significant rate of infective complications following tumour endoprosthesis surgery including 14% of patients experiencing infection involving the tumour endoprosthesis. This study is the first to report on outcomes from debridement and retention of the prosthesis; which had comparable success rates to other treatment modalities.
Assuntos
Neoplasias Ósseas/cirurgia , Neoplasias de Tecido Conjuntivo e de Tecidos Moles/cirurgia , Implantação de Prótese , Infecções Relacionadas à Prótese/epidemiologia , Infecções Estafilocócicas/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Condrossarcoma/cirurgia , Estudos de Coortes , Coinfecção/epidemiologia , Coinfecção/microbiologia , Feminino , Neoplasias Femorais/cirurgia , Tumor de Células Gigantes do Osso/cirurgia , Histiocitoma Fibroso Maligno/cirurgia , Humanos , Úmero/cirurgia , Masculino , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Pessoa de Meia-Idade , Duração da Cirurgia , Osteossarcoma/cirurgia , Ossos Pélvicos/cirurgia , Próteses e Implantes , Infecções Relacionadas à Prótese/microbiologia , Estudos Retrospectivos , Fatores de Risco , Sarcoma de Ewing/cirurgia , Infecções Estafilocócicas/microbiologia , Tíbia/cirurgia , Vitória/epidemiologia , Adulto JovemRESUMO
BACKGROUND AND AIMS: Appropriateness of antimicrobial use is a measure of key importance in evaluating safety and quality of prescribing but has been difficult to define and assess on a wide scale. Published work is limited and has generally focused on tertiary public hospitals, whereas the private sector provides a significant proportion of care in many countries. Information on prescribing in the private hospital context is needed to identify where intervention might be required. An antimicrobial prescribing survey tool was utilised to assess the appropriateness of antimicrobial prescribing among large private hospitals in Australia. METHODS: 'Appropriateness' of antimicrobial therapy was evaluated by a team consisting of an infectious diseases physician and specialist infectious diseases pharmacist based on clear criteria. RESULTS: Thirteen hospital-wide point-prevalence surveys were conducted. Three thousand, four hundred and seventy-two inpatient medication charts were reviewed to identify 1125 (32.4%) inpatients on 1444 antimicrobials. An indication was documented in 911 (63.1%) of surveyed prescriptions, and overall, 757 (52.4%) of antimicrobials were assessed as appropriate. Antimicrobials prescribed for treatment had a higher proportion of appropriateness when compared with antimicrobials prescribed for surgical prophylaxis (80.4% vs 40.6%). The main reason for a treatment prescription to be considered inappropriate was incorrect selection, while prolonged duration (>24 h) was the main reason for inappropriate surgical prophylaxis prescriptions. CONCLUSIONS: This study provides important data on antimicrobial prescribing patterns in Australian private hospitals. Results can be used to target areas for improvement, with documentation of indication and surgical antibiotic prophylaxis requiring initial attention.
Assuntos
Anti-Infecciosos/uso terapêutico , Coleta de Dados/métodos , Hospitais Privados/normas , Prescrição Inadequada , Austrália/epidemiologia , Humanos , Prescrição Inadequada/prevenção & controleRESUMO
BACKGROUND: Prosthetic joint infection (PJI) is associated with significant costs to the healthcare system. Current literature examines the cost of specific treatment modalities without assessing other cost drivers for PJI. AIMS: To examine the overall cost of the treatment of PJI and to identify factors associated with management costs. METHODS: The costs of treatment of prosthetic joint infections were examined in 139 patients across 10 hospitals over a 3-year period (January 2006 to December 2008). Cost calculations included hospitalization costs, surgical costs, hospital-in-the-home costs and antibiotic therapy costs. Negative binomial regression analysis was performed to model factors associated with total cost. FINDINGS: The median cost of treating prosthetic joint infection per patient was Australian $34,800 (interquartile range: 20,305, 56,929). The following factors were associated with increased treatment costs: septic revision arthroplasty (67% increase in treatment cost; P = 0.02), hypotension at presentation (70% increase; P = 0.03), polymicrobial infections (41% increase; P = 0.009), surgical treatment with one-stage exchange (100% increase; P = 0.002) or resection arthroplasty (48% increase; P = 0.001) were independently associated with increased treatment costs. Culture-negative prosthetic joint infections were associated with decreased costs (29% decrease in treatment cost; P = 0.047). Treatment failure was associated with 156% increase in treatment costs. CONCLUSIONS: This study identifies clinically important factors influencing treatment costs that may be of relevance to policy-makers, particularly in the setting of hospital reimbursement and guiding future research into cost-effective preventive strategies.
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Custos de Cuidados de Saúde , Osteoartrite/economia , Infecções Relacionadas à Prótese/economia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite/terapia , Infecções Relacionadas à Prótese/terapia , Estudos RetrospectivosRESUMO
The management of prosthetic joint infections remains a clinical challenge, particularly infections due to methicillin-resistant staphylococci. Previously, this infection was considered a contraindication to debridement and retention strategies. This retrospective cohort study examined the treatment and outcomes of patients with arthroplasty infection by methicillin-resistant staphylococci managed by debridement and retention in conjunction with rifampin-fusidic acid combination therapy. Over an 11-year period, there were 43 patients with infection by methicillin-resistant staphylococci managed with debridement and retention. This consisted of close-interval repeated arthrotomies with pulsatile lavage. Rifampin was combined with fusidic acid for the majority of patients (88%). Patients were monitored for a median of 33.5 months (interquartile range, 20 to 54 months). Overall, 9 patients experienced treatment failure, with 12- and 24-month estimates of infection-free survival of 86% (95% confidence interval [CI], 71 to 93%) and 77% (95% CI, 60 to 87%), respectively. The following factors were associated with treatment failure: methicillin-resistant Staphylococcus aureus (MRSA) arthroplasty infection, a single surgical debridement or ≥4 debridements, and the receipt of less than 90 days of antibiotic therapy. Patients with infection by methicillin-resistant coagulase-negative staphylococci (MR-CNS) were less likely to fail treatment. The overall treatment success rate reported in this study is comparable to those of other treatment modalities for prosthetic joint infections by methicillin-resistant staphylococci. Therefore, the debridement and retention of the prosthesis and rifampin-based antibiotic therapy are a valid treatment option for carefully selected patients.
Assuntos
Antibacterianos/uso terapêutico , Artroplastia , Ácido Fusídico/uso terapêutico , Infecções Relacionadas à Prótese/cirurgia , Rifampina/uso terapêutico , Infecções Estafilocócicas/cirurgia , Idoso , Antibacterianos/farmacologia , Desbridamento/estatística & dados numéricos , Intervalo Livre de Doença , Quimioterapia Combinada , Feminino , Ácido Fusídico/farmacologia , Humanos , Prótese Articular/microbiologia , Masculino , Staphylococcus aureus Resistente à Meticilina , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Estudos Retrospectivos , Rifampina/farmacologia , Infecções Estafilocócicas/tratamento farmacológico , Infecções Estafilocócicas/microbiologia , Infecções Estafilocócicas/mortalidade , Falha de TratamentoRESUMO
Prosthetic joint infection remains one of the most devastating complications of arthroplasty. Debridement and retention of the prosthesis is an attractive management option in carefully selected patients. Despite this, there are no data investigating the cost of this management modality for prosthetic joint infections. The aim of this case-control study was to calculate the cost associated with debridement and retention for management of prosthetic joint infection compared with primary joint replacement surgery without prosthetic joint infection. From 1 January 2008 to 30 June 2010, there were 21 prosthetic joint infections matched to 42 control patients. Controls were matched to cases according to the arthroplasty site, age and sex. Cases had a greater number of unplanned readmissions (100% vs. 7.1%; p <0.001), more additional surgery (3.3 vs. 0.07; p <0.001) and longer total bed days (31.6 vs. 7.9 days; p <0.001). In addition they had more inpatient, outpatient and emergency department visits (p <0.001, respectively). For patients with prosthetic joint infection the total cost, including index operation and costs of management of the prosthetic joint infection, was 3.1 times the cost of primary arthoplasty; the mean cost for cases was Australian dollars (AUD) $69,414 (±29,869) compared with $22,085 (±8147) (p <0.001). The demand for arthroplasty continues to grow and with that, the number of prosthetic joint infections will also increase, placing significant burden on the health system. Our study adds significantly to the growing body of evidence highlighting the substantial costs associated with prosthetic joint infection.
Assuntos
Desbridamento/economia , Desbridamento/métodos , Osteoartrite/economia , Osteoartrite/cirurgia , Infecções Relacionadas à Prótese/economia , Infecções Relacionadas à Prótese/cirurgia , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Artroplastia de Substituição/economia , Artroplastia de Substituição/métodos , Estudos de Casos e Controles , Custos e Análise de Custo , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Readmissão do Paciente/estatística & dados numéricosRESUMO
BACKGROUND: Prosthetic joint infection (PJI) remains a devastating complication of arthroplasty. There are no internationally endorsed consensus management guidelines and treatment approaches differ widely. AIM: The aim of this multicentre study was to examine treatment approaches and predictors of treatment failure in patients with early PJI managed in hospitals in Victoria, Australia. METHODS: This cohort study was conducted across 10 hospitals over a three-year period (January 2006 to December 2008) and involved 147 patients who presented with early PJI. FINDINGS: Most patients (76%) were managed with debridement and retention of the prosthesis. Patients were followed for a median 20 months (interquartile range: 7-36). Overall 43 patients experienced treatment failure with a 12-month infection-free survival estimate of 76% [95% confidence interval (CI): 68-83%]. The following factors were associated with treatment failure: septic revision arthroplasty (hazard ratio: 7.5; 95% CI: 2.4-23.1; P < 0.0001), hypotension at presentation (4.9; 1.5-15.7; P = 0.007), one-stage exchange (3.1; 1.0-9.2; P = 0.048), total duration of antibiotic therapy <90 days: specifically <30 days (18.5; 5.4-63.1; P < 0.001), 30-60 days (8.0; 2.6-23.9; P < 0.001) and 60-90 days (7.3; 2.2-24.4; P = 0.001), respectively. Effective empiric antibiotic therapy was associated with a decreased risk of treatment failure (0.20; 0.09-0.47; P < 0.001). CONCLUSIONS: The management approach in Australia differs from that used elsewhere in the world. We have identified a number of clinically relevant risk factors for treatment failure that may impact on treatment recommendations.
Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Osteoartrite/terapia , Infecções Relacionadas à Prótese/terapia , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Austrália , Estudos de Coortes , Desbridamento , Feminino , Humanos , Masculino , Resultado do TratamentoRESUMO
Prosthetic joint infection is a devastating complication of arthroplasty. Previous epidemiological studies have assessed factors associated with arthroplasty infections but have not assessed the impact of comorbidity on infection at different arthroplasty locations. We used a case-control design to investigate risk factors for prosthetic joint infection with reference to the anatomical site. During an eight-year period at a single hospital, 63 patients developed a prosthetic joint infection (36 hips, 27 knees). Cases of prosthetic hip or knee joint infection were matched 1:2 to controls. The results suggest that factors associated with arthroplasty infections differ with anatomical location. Following knee arthroplasty, wound discharge was associated with an increased risk of prosthetic joint infection whereas the presence of a drain tube reduced the risk. By contrast, increased body mass index, increased drain tube loss and superficial incisional surgical site infections (SSIs) were associated with prosthetic hip infection. When analysed as a combined cohort, systemic steroid use, increased SSI drain tube losses, wound discharge, and superficial incisional SSIs were predictors of infection.
Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Prótese de Quadril/microbiologia , Prótese do Joelho/microbiologia , Infecções Relacionadas à Prótese/microbiologia , Infecção da Ferida Cirúrgica/complicações , Idoso , Estudos de Casos e Controles , Feminino , Bactérias Gram-Negativas/isolamento & purificação , Infecções por Bactérias Gram-Negativas/epidemiologia , Infecções por Bactérias Gram-Negativas/microbiologia , Bactérias Gram-Positivas/isolamento & purificação , Infecções por Bactérias Gram-Positivas/epidemiologia , Infecções por Bactérias Gram-Positivas/microbiologia , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/epidemiologia , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/microbiologiaRESUMO
Information is required about treatment outcomes of Gram-negative prosthetic joint infections treated with prosthesis retention and surgical debridement, especially where biofilm-active antibiotics such as fluoroquinolones are used. The outcome of 17 consecutive patients with an early Gram-negative prosthetic joint infection who had been treated with prosthesis retention and surgical debridement was analysed. Enterobacteriaceae were isolated in 16 patients and infections were mixed with other organisms in 13 (76%) patients. The median joint age was 17 days and the median duration of symptoms before debridement was 7 days. All patients initially received intravenous ß-lactam antibiotic therapy and 14 patients were then treated with oral ciprofloxacin. Treatment failure occurred in two patients over a median period of follow-up of 28 months. In only one patient was a relapsed Gram-negative infection responsible for the failure and this patient had not been treated with ciprofloxacin. The 2-year survival rate free of treatment failure was 94% (95% CI, 63-99%). Prosthesis retention with surgical debridement, in combination with antibiotic regimens including ciprofloxacin, was effective and should be considered for patients with early Gram-negative prosthetic joint infection.