The impact of antimicrobial stewardship program designed to shorten antibiotics use on the incidence of resistant bacterial infections and mortality.

Reassessing the continuing need for and choice of antibiotics by using an antibiotic "time out'' program may reduce unnecessary treatment. This study aimed to explore the effect of an antibiotic stewardship program (ASP) on the antibiotics consumption, incidence of resistant bacterial infections and overall hospital mortality in a tertiary medical center during the study period 2012-2014. An ASP composed of multidisciplinary strategies including pre-prescription approval and post-approval feedback and audit, and a major "time out'' intervention (shorten the default antibiotic prescription duration) usage was introduced in year 2013. Consumption of antibiotics was quantified by calculating defined daily doses (DDDs). Interrupted time series (ITS) analysis was used to explore the changes of antibiotics consumption before and after intervention, accounting for temporal trends that may be unrelated to intervention. Our results showed that following the intervention, DDDs showed a decreased trend in overall (in particular the major consumed penicillins and cephalosporins), in both intensive care unit (ICU) and non-ICU, and in non-restrictive versus restrictive antibiotics. Importantly, ITS analysis showed a significantly slope change since intervention (slope change p value 0.007), whereas the incidence of carbapenem-resistant and vancomycin-resistant pathogens did not change significantly. Moreover, annual overall mortality rates were 3.0%, 3.1% and 3.1% from 2012 to 2014, respectively. This study indicates that implementing a multi-disciplinary strategy to shorten the default duration of antibiotic prescription can be an effective manner to reduce antibiotic consumption while not compromising resistant infection incidence or mortality rates.

Incidence and mortality of healthcare-associated infections in hospitalized patients with moderate to severe burns.

PURPOSE: This study was to examine the incidence of different types, and isolated pathogens, of healthcare-associated infections (HAIs), and also to determine their prognostic factors for mortality. METHODS: Prospective surveillance was conducted in a medical center from 2005 through to 2016. Multiple logistic regression analysis was performed to assess prognostic factors of mortality. RESULTS: A total of 709 patients with moderate to severe burns were hospitalized. There were 83 patients (11.7%) with HAIs (158 episodes) and 203 isolated pathogens. The most common HAI types were bloodstream infection (BSI) at 39.2% (8.7% of all patients) and central line-associated BSI (mean 4.8 per 1000 central line days). Overall, S. aureus (13.8%) were the most common isolated pathogens, while the most commonly found type of multidrug-resistant pathogen was carbapenems-resistant Enterobacteriaceae (23%). The crude mortality rate was 15.7%, and the independent factors (p < .05) for mortality were BSI (Odds ratio [OR] 2.70), intensive care unit (OR 5.19) and total body surface area with full-thickness injuries ≥50% (OR 5.22). CONCLUSIONS: Burn patients with BSI were the most common HAI sites, and this was an independent factor for mortality. Effective integrated care and appropriate infection control can reduce the incidence of infection and death.

[Risk Factors of Retained Central Venous Catheter Associated Bloodstream Infections in Hospitalized Patients].

BACKGROUND: Despite recent efforts in Taiwan to reduce the risk and incidence of central venous catheter associated bloodstream infections (CABSI), the results as reported by the Taiwan Centers for Disease Control, when compared with the results achieved in the USA, indicate that Taiwan must promote the central venous catheter bundle approach more effectively. Furthermore, the risk factors for CABSI should be explored further in order to facilitate the development and implementation of effective related improvement strategies. PURPOSE: To explore the risk factors for CABSI after adjusting for confounding factors and to analyze the appropriate protocol for applying retained central venous catheters in hospitalized patients and the impact of CABSI. METHODS: The ethics committee approved this retrospective case-control study. Hospitalized patients who were older than 20 years of age and were currently experiencing their first instance of CABSI were recruited between March 1, 2014 to October 31, 2014 as the case group. In addition, a control group was recruited in a 1:2 ratio from a random sample of patients listed in the medical order system who had received a central venous catheter but did not experience CABSI. Anyone who did not meet the above criteria was excluded. Data collected included basic demographic characteristics, basic catheter information, and the main reason for the catheter being in situ during the 48 hours prior to contracting CABSI or catheter removal. RESULTS: A total of 65 patients with CABSI comprised the case group and 130 patients without CABSI comprised the control group. After controlling for potentially confounding factors using logistic regression analysis, the independent risk factors of CABSI (p < .05) were identified as: staying in the intensive care unit, having a high APACHE II (acute physiology and chronic health evaluation II) score, and having diabetes mellitus. Moreover, while having inappropriate central venous catheter in situ was found to not significantly influence CABSI (OR, 2.41; 95% CI [0.65-8.91]), we identified that about 10.8% of retained central venous catheter applications were unnecessary due to the lack of sufficient indications for use. CONCLUSIONS: We recommend that nursing staffs should remind physicians to evaluate carefully the need to use central venous catheters and should fully implement sterile protocols to protect the health of high-risk patients. In addition, nursing staffs should assess the central venous catheter daily and should remind physicians to remove the catheter as soon as possible in the absence of indications for use.

An Outbreak of Ralstonia pickettii Bloodstream Infection Associated with an Intrinsically Contaminated Normal Saline Solution.

OBJECTIVE Ralstonia pickettii has caused contamination of pharmaceutical solutions in many countries, resulting in healthcare infections or outbreak events. We determined the source of the outbreak of R. pickettii bloodstream infection (BSI). METHODS This study was conducted in a 3,000-bed tertiary referral medical center in Taiwan with >8,500 admissions during May 2015. Patients had been treated in the injection room or chemotherapy room at outpatient departments, emergency department, or hospital wards. All patients who were culture positive for R. pickettii from May 3 to June 11, 2015, were eligible for the study. The aim of the survey was to conduct clinical epidemiological and microbiological investigations to identify possible sources of infection. RESULTS We collected 57 R. pickettii-positive specimens from 30 case patients. We performed 24 blood cultures; 14 of these revealed >2 specimens and 6 used fluid withdrawn from Port-a-Cath implantable venous access devices. All patients received an injection of 20 mL 0.9% normal saline via catheter flushing. In addition, 2 unopened ampules of normal saline solution (20 mL) were confirmed positive for R. pickettii. The Taiwan Centers for Disease Control and Prevention performed sampling and testing of the same manufactured batch and identified the same strain of R. pickettii. Pulsed-field gel electrophoresis tests revealed that all clinical isolates had similarity of >90%, validating the outbreak of the same clone of R. pickettii. CONCLUSIONS R. pickettii can grow in saline solutions and cause bloodstream infections. Hospital monitoring mechanisms are extremely important measures in identifying and ending such outbreaks. Infect Control Hosp Epidemiol 2017;38:444-448.

Association between the RAD51 135 G>C polymorphism and risk of cancer: a meta-analysis of 19,068 cases and 22,630 controls.

BACKGROUND: RAD51 135G>C can modify promoter activity and the penetrance of BRCA1/2 mutations, which plays vital roles in the etiology of various cancer. To date, previous published data on the association between RAD51 135G>C polymorphism and cancer risk remained controversial. Recent meta-analysis only analyzed RAD51 135G>C polymorphism with breast cancer risk, but the results were also inconsistent. METHODS: A meta-analysis based on 39 case-control studies was performed to investigate the association between cancer susceptibility and RAD51 135G>C. Odds ratios (OR) with 95% confidence intervals (CIs) were used to assess the association in different inheritance models. Heterogeneity among studies was tested and sensitivity analysis was applied. RESULTS: Overall, no significant association was found between RAD51 135G>C polymorphism and cancer susceptibility in any genetic model. In further stratified analysis, significantly elevated breast cancer risk was observed in BRCA2 mutation carriers (recessive model: OR = 4.88, 95% CI = 1.10-21.67; additive model: OR = 4.92, 95% CI = 1.11-21.83). CONCLUSIONS: This meta-analysis suggests that RAD51 variant 135C homozygote is associated with elevated breast cancer risk among BRCA2 mutation carriers. Moreover, our work also points out the importance of new studies for RAD51 135G>C association in acute myeloid leukemia, especially in Caucasians, where at least some of the covariates responsible for heterogeneity could be controlled, to obtain a more conclusive understanding about the function of the RAD51 135G>C polymorphism in cancer development.

[Clinical characteristics and therapy of pan-drug resistant Acinetobacter baumannii infection].

OBJECTIVE: To analyze clinical characteristics and therapy of pan-resistant Acinetobacter baumannii (PDRAB) infection and explore the methods for effective therapy and prevention of this infection. METHODS: Nine hospitalized patients with PDRAB infection confirmed by pathogen and susceptibility testing were analyzed for the risk factors and the treatment outcomes were assessed by case analysis. RESULTS: PDRAB infections occurred mainly in patients with severe complications, most of whom had complications by diabetes or hypertension or damaged mucosal integrity due to mechanical ventilation, surgery and catheterization. The polymyxin sensitivity were 100% for these infections, but all the bacteria identified showed a antimicrobial resistance rates of 100%. The majority of the infections were acquired during hospitalization occurring mainly in the lungs; all the patients had prolonged hospitalization and received antibiotic treatments with high proportions of broad-spectrum antimicrobial agents especially third-generation cephalosporins and quinolones. Exclusive or sequential use of carbapenems and sulbactam in combination with quinolone or aminoglycoside produced favorable effects. CONCLUSIONS: The prevalence of hospital-acquired pan-resistance of PDRAB infections increased significantly in recent years, particularly in patients with high risk factors. The widespread use of broad-spectrum antibiotics may have some relevance to drug resistant occurrence. The application of carbapenems or sulbactam, or their sequential use, in combination with other agents may produce good effects.

[Analysis of therapeutic effectiveness of Nanfang ALL 99 protocol in childhood acute lymphoblastic leukemia patients].

OBJECTIVE: With more precise diagnostic criteria and risk classifications, more effective therapy administered in clinical trials, and better supportive care, the outcome of children with acute lymphoblastic leukemia (ALL) has been improved dramatically. Today, approximately 80% of children treated for this disease in developed countries enjoy long-term event free survival (EFS) and in most instances, would be cured. In this study, treatment outcome of 82 childhood ALL patients in the hospital were analyzed, and ways for how to improve the EFS rate in childhood ALL were explored. METHODS: Eighty-two patients with ALL were enrolled into the Nanfang ALL 99 protocol which derived from German BFM ALL 95 and Hong Kong-Singapore acute lymphoblastic leukemia 97 (HK-SG ALL 97). Dexamethasone instead of hydrocortisone was used for triple intrathecal therapy. Standard at risk patients who had been irregularly treated in other hospitals for short periods of time were classified as at intermediate risk. When ANC was > or = 1.0 x 10(9)/L and platelet > or = 100 x 10(9)/L, chemotherapy was started. Life table method was used to estimate survival rate and statistical analysis was done by using software SPSS for Windows. RESULTS: From March 1999 to September 2003, 82 childhood ALL patients were treated with the Nanfang ALL 99 protocol and 78 (95.1%) patients attained complete remission (CR) in a median time of 33 days. Out of 82 patients, 13 patients dropped out of the the Nanfang ALL 99 protocol because of financial difficulty or other reasons. Sixty nine patients were consecutively treated with the Nanfang ALL 99 protocol. The overall EFS rate at 2 years, 3 years and 5 years were 91.3%, 85.9% and 75.2%, respectively, with a median observation duration of 34 months. Three patients died of complications (4.3%). The disease relapsed in 6 patients and they died finally. CONCLUSION: The outcome of patients treated with the Nanfang ALL 99 protocol was favorable, and the mortality rate of this chemotherapeutic protocol was low. This protocol was well tolerated by Chinese patients and therefore the protocol is worthy of application in China.