Economic burden of respiratory syncytial and parainfluenza viruses in children of upper-middle-income countries: a systematic review.

OBJECTIVE: To identify and assess the current evidence available about the costs of managing hospitalized pediatric patients diagnosed with Respiratory Syncytial Virus (RSV) and Parainfluenza Virus Type 3 (PIV3) in upper-middle-income countries. METHODS: The authors conducted a systematic review across seven key databases from database inception to July 2022. Costs extracted were converted into 2022 International Dollars using the Purchasing Power Parity-adjusted. PROSPERO identifier: CRD42020225757. RESULTS: No eligible study for PIV3 was recovered. For RSV, cost analysis and COI studies were performed for populations in Colombia, China, Malaysia, and Mexico. Comparing the total economic impact, the lowest cost per patient at the pediatric ward was observed in Malaysia ($ 347.60), while the highest was in Colombia ($ 709.66). On the other hand, at pediatric ICU, the lowest cost was observed in China ($ 1068.26), while the highest was in Mexico ($ 3815.56). Although there is no consensus on the major cost driver, all included studies described that the medications (treatment) consumed over 30% of the total cost. A high rate of inappropriate prescription drugs was observed. CONCLUSION: The present study highlighted how RSV infection represents a substantial economic burden to health care systems and to society. The findings of the included studies suggest a possible association between baseline risk status and expenditures. Moreover, it was observed that an important amount of the cost is destinated to treatments that have no evidence or support in most clinical practice guidelines.

Economic burden of respiratory syncytial and parainfluenza viruses in children of upper-middle-income countries: a systematic review

Abstract Objective: To identify and assess the current evidence available about the costs of managing hospitalized pediatric patients diagnosed with Respiratory Syncytial Virus (RSV) and Parainfluenza Virus Type 3 (PIV3) in upper-middle-income countries. Methods: The authors conducted a systematic review across seven key databases from database inception to July 2022. Costs extracted were converted into 2022 International Dollars using the Purchasing Power Parity-adjusted. PROSPERO identifier: CRD42020225757. Results: No eligible study for PIV3 was recovered. For RSV, cost analysis and COI studies were performed for populations in Colombia, China, Malaysia, and Mexico. Comparing the total economic impact, the lowest cost per patient at the pediatric ward was observed in Malaysia ($ 347.60), while the highest was in Colombia ($ 709.66). On the other hand, at pediatric ICU, the lowest cost was observed in China ($ 1068.26), while the highest was in Mexico ($ 3815.56). Although there is no consensus on the major cost driver, all included studies described that the medications (treatment) consumed over 30% of the total cost. A high rate of inappropriate prescription drugs was observed. Conclusion: The present study highlighted how RSV infection represents a substantial economic burden to health care systems and to society. The findings of the included studies suggest a possible association between baseline risk status and expenditures. Moreover, it was observed that an important amount of the cost is destinated to treatments that have no evidence or support in most clinical practice guidelines.

Hospitalization costs of coronaviruses diseases in upper-middle-income countries: A systematic review.

BACKGROUND: COVID-19, SARS and MERS are diseases that present an important health burden worldwide. This situation demands resource allocation to the healthcare system, affecting especially middle- and low-income countries. Thus, identifying the main cost drivers is relevant to optimize patient care and resource allocation. OBJECTIVE: To systematically identify and summarize the current status of knowledge on direct medical hospitalization costs of SARS, MERS, or COVID-19 in Upper-Middle-Income Countries. METHODS: We conducted a systematic review across seven key databases (PubMed, EMBASE, BVS Portal, CINAHL, CRD library, MedRxiv and Research Square) from database inception to February 2021. Costs extracted were converted into 2021 International Dollars using the Purchasing Power Parity-adjusted. The assessment of quality was based on the protocol by the BMJ and CHEERS. PROSPERO 2020: CRD42020225757. RESULTS: No eligible study about SARS or MERS was recovered. For COVID-19, five studies presented cost analysis performed in Brazil, China, Iran, and Turkey. Regarding total direct medical costs, the lowest cost per patient at ward was observed in Turkey ($900.08), while the highest in Brazil ($5,093.38). At ICU, the lowest was in Turkey ($2,984.78), while the highest was in China ($52,432.87). Service care was the most expressive (58% to 88%) cost driver of COVID-19 patients at ward. At ICU, there was no consensus between service care (54% to 87%) and treatment (72% to 81%) as key burdens of total cost. CONCLUSION: Our findings elucidate the importance of COVID-19 on health-economic outcomes. The marked heterogeneity among studies leaded to substantially different results and made challenging the comparison of data to estimate pooled results for single countries or regions. Further studies concerning cost estimates from standardized analysis may provide clearer data for a more substantial analysis. This may help care providers and policy makers to organize care for patients in the most efficient way.

Performance of a multidisciplinary team and the impact of bundles for reducing health care associated infections in adult intensive care unit: 22 years of experience.

A retrospective cohort study was conducted to evaluate the bundle of techniques developed by the multidisciplinary team to minimize infections in an adult intensive care unit over a 22-year span. Two periods were analyzed: 1996-2006 and 2007-2017. Bloodstream infections, urinary tract infections, and ventilator-associated pneumonia declined 58.6%, 56.7%, and 82.6%, respectively (P < .05) from 2007 to 2017 compared with these same infections during 1996-2006.

Severe Strongyloides stercoralis infection in kidney transplant recipients: A multicenter case-control study.

BACKGROUND: Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection. METHODOLOGY/PRINCIPAL FINDINGS: This was a retrospective, multicenter, case-control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5-965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05-18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2-7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001-1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46-2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83-35316.61). CONCLUSIONS/SIGNIFICANCE: Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment.

Severe Strongyloides stercoralis infection in kidney transplant recipients: a multicenter case-control study

BACKGROUND: Severe Strongyloides stercoralis infection in kidney transplant recipients is associated with considerable morbidity and mortality, although little is known about the risk factors for such infection. METHODOLOGY/Principal findings This was a retrospective, multicenter, case­control study in which we assessed the risk factors for and clinical outcomes of severe S. stercoralis infections in kidney transplant recipients in Brazil. We included 138 kidney transplant recipients: 46 cases and 92 controls. Among the cases, the median number of days from transplantation to diagnosis was 117 (interquartile range [IQR], 73.5­965) and the most common clinical findings were gastrointestinal symptoms (in 78.3%) and respiratory symptoms (in 39.1%), whereas fever and eosinophilia were seen in only 32.6% and 43.5%, respectively. The 30-day all-cause mortality among the cases was 28.3% overall and was significantly higher among the cases of infection occurring within the first three months after transplantation (47% vs. 17.2%, P = 0.04). The independent risk factors were receiving a transplant from a deceased donor (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 2.05­18.5), a history of bacterial infection (OR = 3.04, 95% CI = 1.2­7.5), and a cumulative corticosteroid dose (OR = 1.005, 95% CI = 1.001­1.009). The independent predictors of mortality were respiratory failure (OR = 98.33, 95% CI = 4.46­2169.77) and concomitant bacteremia (OR = 413.00, 95% CI = 4.83­35316.61). CONCLUSIONS/Significance Severe S. stercoralis infections are associated with considerable morbidity and mortality after kidney transplantation. In endemic areas, such infection may occur late after transplantation, although it seems to be more severe when it occurs earlier after transplantation. Specific risk factors and clinical manifestations can identify patients at risk, who should receive prophylaxis or early treatment. (AU)

A randomized clinical trial comparing Nitrofurazone-coated and uncoated urinary catheters in kidney transplant recipients: Results from a pilot study.

BACKGROUND: Urinary tract infections are frequent complications early after kidney transplantation, and the use of antimicrobial coated catheters in settings other than transplantation has shown promising results for infection prevention. The purpose of this study was to compare the efficacy of Nitrofurazone-coated silicone urinary catheters with non-impregnated silicone urinary catheters in reducing bacteriuria and urinary tract infections in kidney transplant recipients. METHODS: This single-center study, randomized controlled trial at the Hospital do Rim, a tertiary referral center in kidney transplantation, located in São Paulo, Brazil. Subjects involved living donor kidney transplant recipients, and were randomized 1:1 ratio with a computer-generated system to a Nitrofurazone-coated silicone urinary catheter and non-impregnated silicone urinary catheter from March 2013 to December 2014. Patients with asymptomatic bacteriuria or urinary tract infection at baseline, deceased kidney transplant donors, patients with known hypersensitivity to nitrofurantoin, pregnancy, and those refusing to sign the informed consent form were excluded from the study. RESULTS: Two hundred fourteen subjects were randomized and one hundred seventy-six completed the study. There were no differences in the rates of asymptomatic bacteriuria (12.5% in the Nitrofurazone group and 11.4% in the control group, P = 0.99) and urinary tract infection (8% and 6.8%, P = 0.99) and the incidence of side effects was more frequent in the Nitrofurazone-impregnated silicone urinary catheter group (46.6% and 26.1%, P = 0.007). CONCLUSION: The study suggests that there is no beneficial effect of the employment of Nitrofurazone-coated urinary catheter. TRIAL REGISTRATION NUMBER: ISRCTN57888785.

Risk factors for mortality in ventilator-associated tracheobronchitis: a case-control study.

Objective: To describe the microbiological characteristics and to assess the risk factors for mortality of ventilator-associated tracheobronchitis in a case-control study of intensive care patients. Methods: This case-control study was conducted over a 6-year period in a 40-bed medical-surgical intensive care unit in a tertiary care, private hospital in São Paulo, Brazil. Case patients were identified using the Nosocomial Infection Control Committee database. For the analysis of risk factors, matched control subjects were selected from the same institution at a 1:8.8 ratio, between January 2006 and December 2011. Results: A total of 40 episodes of ventilator-associated tracheobronchitis were evaluated in 40 patients in the intensive care unit, and 354 intensive care patients who did not experience tracheobronchitis were included as the Control Group. During the 6-year study period, a total of 42 organisms were identified (polymicrobial infections were 5%) and 88.2% of all the microorganisms identified were Gram-negative. Using a logistic regression model, we found the following independent risk factors for mortality in ventilator-associated tracheobronchitis patients: Acute Physiology and Chronic Health Evaluation I score (odds ratio 1.18 per unit of score; 95%CI: 1.05-1.38; p=0.01), and duration of mechanical ventilation (odds ratio 1.09 per day of mechanical ventilation; 95%CI: 1.03-1.17; p=0.004). Conclusion: Our study provided insight into the risk factors for mortality and microbiological characteristics of ventilator-associated tracheobronchitis.

Objetivo: Descrever as características microbiológicas e avaliar os fatores de risco para mortalidade na traqueobronquite associada à ventilação mecânica em um estudo caso-controle de pacientes de terapia intensiva. Métodos: Estudo realizado ao longo de 6 anos em uma unidade de terapia intensiva médico-cirúrgica de 40 leitos, em um hospital privado e de nível terciário em São Paulo, Brasil. O Grupo Caso foi identificado usando o banco de dados da Comissão de Controle de Infecção Hospitalar. O Grupo Controle foi pareado na proporção de 1:8,8 entre janeiro de 2006 e dezembro de 2011. Resultados: Quarenta episódios de traqueobronquites associadas à ventilação foram avaliados em 40 pacientes na unidade de terapia intensiva, e 354 pacientes não apresentaram traqueobronquite Grupo Controle. Foram identificados 42 microrganismos (dos quais 5% foram infecções polimicrobianas), sendo que 88,2% de todos os microrganismos eram bactérias Gram-negativas. Usando um modelo de regressão logística, encontramos os seguintes fatores de risco independentes para mortalidade em pacientes com traqueobronquites associadas à ventilação: pontuação da Acute Physiology and Chronic Health Evaluation I (odds ratio 1,18 por uma unidade de pontuação; IC95%: 1,05-1,38; p=0,01) e duração da ventilação mecânica (odds ratio 1,09 por dia de ventilação mecânica; IC95%: 1,03-1,17; p=0,004). Conclusão: Nosso estudo forneceu informações sobre os fatores de risco para mortalidade e características microbiológicas da traqueobronquite associada à ventilação mecânica.

Risk factors for mortality in ventilator-associated tracheobronchitis: a case-control study / Fatores de risco para mortalidade em traqueobronquite associada à ventilação mecânica: estudo caso-controle

ABSTRACT Objective To describe the microbiological characteristics and to assess the risk factors for mortality of ventilator-associated tracheobronchitis in a case-control study of intensive care patients. Methods This case-control study was conducted over a 6-year period in a 40-bed medical-surgical intensive care unit in a tertiary care, private hospital in São Paulo, Brazil. Case patients were identified using the Nosocomial Infection Control Committee database. For the analysis of risk factors, matched control subjects were selected from the same institution at a 1:8.8 ratio, between January 2006 and December 2011. Results A total of 40 episodes of ventilator-associated tracheobronchitis were evaluated in 40 patients in the intensive care unit, and 354 intensive care patients who did not experience tracheobronchitis were included as the Control Group. During the 6-year study period, a total of 42 organisms were identified (polymicrobial infections were 5%) and 88.2% of all the microorganisms identified were Gram-negative. Using a logistic regression model, we found the following independent risk factors for mortality in ventilator-associated tracheobronchitis patients: Acute Physiology and Chronic Health Evaluation I score (odds ratio 1.18 per unit of score; 95%CI: 1.05-1.38; p=0.01), and duration of mechanical ventilation (odds ratio 1.09 per day of mechanical ventilation; 95%CI: 1.03-1.17; p=0.004). Conclusion Our study provided insight into the risk factors for mortality and microbiological characteristics of ventilator-associated tracheobronchitis.

RESUMO Objetivo Descrever as características microbiológicas e avaliar os fatores de risco para mortalidade na traqueobronquite associada à ventilação mecânica em um estudo caso-controle de pacientes de terapia intensiva. Métodos Estudo realizado ao longo de 6 anos em uma unidade de terapia intensiva médico-cirúrgica de 40 leitos, em um hospital privado e de nível terciário em São Paulo, Brasil. O Grupo Caso foi identificado usando o banco de dados da Comissão de Controle de Infecção Hospitalar. O Grupo Controle foi pareado na proporção de 1:8,8 entre janeiro de 2006 e dezembro de 2011. Resultados Quarenta episódios de traqueobronquites associadas à ventilação foram avaliados em 40 pacientes na unidade de terapia intensiva, e 354 pacientes não apresentaram traqueobronquite Grupo Controle. Foram identificados 42 microrganismos (dos quais 5% foram infecções polimicrobianas), sendo que 88,2% de todos os microrganismos eram bactérias Gram-negativas. Usando um modelo de regressão logística, encontramos os seguintes fatores de risco independentes para mortalidade em pacientes com traqueobronquites associadas à ventilação: pontuação da Acute Physiology and Chronic Health Evaluation I (odds ratio 1,18 por uma unidade de pontuação; IC95%: 1,05-1,38; p=0,01) e duração da ventilação mecânica (odds ratio 1,09 por dia de ventilação mecânica; IC95%: 1,03-1,17; p=0,004). Conclusão Nosso estudo forneceu informações sobre os fatores de risco para mortalidade e características microbiológicas da traqueobronquite associada à ventilação mecânica.

High rate of Candida deep-seated infection in patients under chronic hemodialysis with extended central venous catheter use / Altas tasas de infección profunda por Candida en pacientes en hemodiálisis crónica con catéter venoso central de uso prolongado

Background. Hemodialysis has been described as an important risk factor for the development of candidemia in patients suffering from chronic renal failure. Aims. The aim of this study was to evaluate the epidemiology of candidemia in outpatients with renal replacement therapy (RRT) by hemodialysis where the fungemia clearly represents a healthcare-associated infection. Methods. We retrospectively collected clinical and laboratory data from patients undergoing at least 3 months of RRT by hemodialysis who developed candidemia within 48 h of hospital admission. Results. We identified 14 patients with candidemia with central venous catheters (CVC) in place for 11-277 days before developing fungemia. Deep-seated infection was documented in 6 out of 14 candidiasis cases (43%), including 5 cases of endocarditis (36%). Conclusions. CVC in patients under RRT should be promptly replaced by fistulas and grafts to avoid bloodstream infections. Facing a case of candidemia, adequate source control and prompt initiation of antifungal therapy are mandatory to avoid morbidity and mortality (AU)

Antecedentes. La hemodiálisis se ha descrito como un importante factor de riesgo para el desarrollo de candidemia en pacientes con insuficiencia renal crónica. Objetivos. El objetivo de este estudio fue evaluar la epidemiología de la candidemia en pacientes en hemodiálisis con terapia renal sustitutiva (TRS), en la que la fungemia representa claramente una infección asociada a los cuidados hospitalarios. Métodos. Se recogieron retrospectivamente datos clínicos y microbiológicos de pacientes con, al menos, 3 meses de hemodiálisis con TRS que desarrollaron candidemia dentro de las primeras 48 horas tras la admisión hospitalaria. Resultados. Identificamos a 14 pacientes con candidemia asociada con el uso de catéter venoso central (CVC) durante períodos de 11 a 277 días previos al desarrollo de la fungemia. En 6 de los 14 casos de candidemia, el diagnóstico fue de candidiasis invasiva (43%), incluidos 5 casos de endocarditis (36%). Conclusiones. Los CVC en pacientes con TRS deberían ser sustituidos inmediatamente por fístulas o injertos arteriovenosos para evitar infecciones del torrente sanguíneo. Ante los casos de candidemia, un control adecuado de las posibles fuentes de infección y el comienzo inmediato de la terapia antifúngica deberían ser imperativos para reducir tanto la morbilidad como la mortalidad (AU)

High rate of Candida deep-seated infection in patients under chronic hemodialysis with extended central venous catheter use.

BACKGROUND: Hemodialysis has been described as an important risk factor for the development of candidemia in patients suffering from chronic renal failure. AIMS: The aim of this study was to evaluate the epidemiology of candidemia in outpatients with renal replacement therapy (RRT) by hemodialysis where the fungemia clearly represents a healthcare-associated infection. METHODS: We retrospectively collected clinical and laboratory data from patients undergoing at least 3 months of RRT by hemodialysis who developed candidemia within 48h of hospital admission. RESULTS: We identified 14 patients with candidemia with central venous catheters (CVC) in place for 11-277 days before developing fungemia. Deep-seated infection was documented in 6 out of 14 candidiasis cases (43%), including 5 cases of endocarditis (36%). CONCLUSIONS: CVC in patients under RRT should be promptly replaced by fistulas and grafts to avoid bloodstream infections. Facing a case of candidemia, adequate source control and prompt initiation of antifungal therapy are mandatory to avoid morbidity and mortality.

The changing epidemiology of Acinetobacter spp. producing OXA carbapenemases causing bloodstream infections in Brazil: a BrasNet report.

We evaluated the epidemiology of Acinetobacter spp. recovered from patients diagnosed with bloodstream infections in 9 tertiary hospitals located in all Brazilian geographic regions between April and August 2014. Although OXA-23-producing Acinetobacter baumannii clones were disseminated in most hospitals, it was observed for the first time the spread of OXA-72 among clonally related A. baumannii isolated from distinct hospitals. Interestingly, Acinetobacter pittii was the most frequent species found in a Northern region hospital. Contrasting with the multisusceptible profile displayed by A. pittii isolates, the tetracyclines and polymyxins were the only antimicrobials active against all A. baumannii isolates.

Ochrobactrum anthropi bacteremia in a preterm infant with cystic fibrosis.

Ochrobactrum anthropi infection in newborn patients is rare, and the treatment is challenging because of its widespread and unpredictable resistance to antimicrobial agents and discrepancies between in vitro susceptibility and in vivo efficacy. We report the clinical and microbiological characteristics of Ochrobactrum anthropi bacteremia in a preterm patient.

Ochrobactrum anthropi bacteremia in a preterm infant with cystic fibrosis

Ochrobactrum anthropi infection in newborn patients is rare, and the treatment is challenging because of its widespread and unpredictable resistance to antimicrobial agents and discrepancies between in vitro susceptibility and in vivo efficacy. We report the clinical and microbiological characteristics of Ochrobactrum anthropi bacteremia in a preterm patient.

Nosocomial bloodstream infections in Brazilian pediatric patients: microbiology, epidemiology, and clinical features.

BACKGROUND: Nosocomial bloodstream infections (nBSIs) are an important cause of morbidity and mortality and are the most frequent type of nosocomial infection in pediatric patients. METHODS: We identified the predominant pathogens and antimicrobial susceptibilities of nosocomial bloodstream isolates in pediatric patients (≤16 years of age) in the Brazilian Prospective Surveillance for nBSIs at 16 hospitals from 12 June 2007 to 31 March 2010 (Br SCOPE project). RESULTS: In our study a total of 2,563 cases of nBSI were reported by hospitals participating in the Br SCOPE project. Among these, 342 clinically significant episodes of BSI were identified in pediatric patients (≤16 years of age). Ninety-six percent of BSIs were monomicrobial. Gram-negative organisms caused 49.0% of these BSIs, Gram-positive organisms caused 42.6%, and fungi caused 8.4%. The most common pathogens were Coagulase-negative staphylococci (CoNS) (21.3%), Klebsiella spp. (15.7%), Staphylococcus aureus (10.6%), and Acinetobacter spp. (9.2%). The crude mortality was 21.6% (74 of 342). Forty-five percent of nBSIs occurred in a pediatric or neonatal intensive-care unit (ICU). The most frequent underlying conditions were malignancy, in 95 patients (27.8%). Among the potential factors predisposing patients to BSI, central venous catheters were the most frequent (66.4%). Methicillin resistance was detected in 37 S. aureus isolates (27.1%). Of the Klebsiella spp. isolates, 43.2% were resistant to ceftriaxone. Of the Acinetobacter spp. and Pseudomonas aeruginosa isolates, 42.9% and 21.4%, respectively, were resistant to imipenem. CONCLUSIONS: In our multicenter study, we found a high mortality and a large proportion of gram-negative bacilli with elevated levels of resistance in pediatric patients.

A hospital-based matched case-control study to identify clinical outcome and risk factors associated with carbapenem-resistant Klebsiella pneumoniae infection.

BACKGROUND: Healthcare-associated infections caused by Klebsiella pneumoniae isolates are increasing and few effective antibiotics are currently available to treat patients. We observed decreased carbapenem susceptibility among K. pneumoniae isolated from patients at a tertiary private hospital that showed a phenotype compatible with carbapenemase production although this group of enzymes was not detected in any sample. The aim of this study was to describe the epidemiology and clinical outcomes associated with carbapenem-resistant K. pneumoniae and to determine the antimicrobial resistance mechanisms. METHODS: Risk factors associated with carbapenem-resistant K. pneumoniae infections were investigated by a matched case-control study from January 2006 through August 2008. A cohort study was also performed to evaluate the association between carbapenem resistance and in-hospital mortality. Bacterial identification and antimicrobial susceptibility were determined by Vitek 2 and Etest. Carbapenemase activity was detected using spectrophotometric assays. Production of beta-lactamases and alterations in genes encoding K. pneumoniae outer membrane proteins, OmpK35 and OmpK36, were analyzed by PCR and DNA sequencing, as well as SDS-Page. Genetic relatedness of carbapenem resistant isolates was evaluated by Pulsed Field Gel Electrophoresis. RESULTS: Sixty patients were included (20 cases and 40 controls) in the study. Mortality was higher for patients with carbapenem-resistant K. pneumoniae infections compared with those with carbapenem-susceptible K. pneumoniae (50.0% vs 25.7%). The length of central venous catheter use was independently associated with carbapenem resistance in the multivariable analysis. All strains, except one, carried blaCTX-M-2, an extended-spectrum betalactamase gene. In addition, a single isolate also possessed blaGES-1. Genes encoding plasmid-mediated AmpC beta-lactamases or carbapenemases (KPC, metallo-betalactamases or OXA-carbapenemases) were not detected. CONCLUSIONS: The K. pneumoniae multidrug-resistant organisms were associated with significant mortality. The mechanisms associated with decreased K. pneumoniae carbapenem susceptibility were likely due to the presence of cephalosporinases coupled with porin alterations, which resulted from the presence of the insertion sequences in the outer membrane encoding genes.

Secular trends in the epidemiology of Clostridium difficile infection (CDI): relationship with alcohol gel and antimicrobial usage in a hospital.

BACKGROUND: Clostridium difficile-associated diarrhea (CDAD) has shown increasing incidence, morbidity, and mortality in recent years. We assessed the number of CDAD tests requested, CDAD positivity rates, the use of alcohol-based hand rubs, and antimicrobial utilization. METHODS: We collected information on every adult patient (>18 years) who developed diarrhea and had a positive stool test for C. difficile toxin from June 2005 to December 2009 at a tertiary care hospital. A time-series analysis was performed using monthly data on the incidence of C. difficile infection (CDI) (i.e., cases of infection per 1000 patient-days), as well as the consumption of alcohol-based hand rubs (in liters/1000-patient days) and antibiotics (in defined daily doses per 1000 patient-days). RESULTS: The mean number of annual requests for C. difficile tests was 1031, and the rates per 1000 patient-days for each year from 2005 to 2009 were 0.30, 0.46, 0.39, 0.31, and 0.40 overall in the hospital, and 0.18, 0.10, 0.53, 0.38, and 0.37 in the intensive care unit (ICU). The use of alcohol-based hand rubs per 1000 patient-days increased from 37.4 to 73.0, and from 41.5 to 129.4 in the hospital and in the ICU, respectively. CONCLUSIONS: The incidence of CDI in the hospital and ICU remained low, despite the increased use of alcohol-based hand rubs and antimicrobials.

Catheter related bloodstream infection (CR-BSI) in ICU patients: making the decision to remove or not to remove the central venous catheter.

BACKGROUND: Approximately 150 million central venous catheters (CVC) are used each year in the United States. Catheter-related bloodstream infections (CR-BSI) are one of the most important complications of the central venous catheters (CVCs). Our objective was to compare the in-hospital mortality when the catheter is removed or not removed in patients with CR-BSI. METHODS: We reviewed all episodes of CR-BSI that occurred in our intensive care unit (ICU) from January 2000 to December 2008. The standard method was defined as a patient with a CVC and at least one positive blood culture obtained from a peripheral vein and a positive semi quantitative (>15 CFU) culture of a catheter segment from where the same organism was isolated. The conservative method was defined as a patient with a CVC and at least one positive blood culture obtained from a peripheral vein and one of the following: (1) differential time period of CVC culture versus peripheral culture positivity of more than 2 hours, or (2) simultaneous quantitative blood culture with ≥ 5:1 ratio (CVC versus peripheral). RESULTS: 53 CR-BSI (37 diagnosed by the standard method and 16 by the conservative method) were diagnosed during the study period. There was a no statistically significant difference in the in-hospital mortality for the standard versus the conservative method (57% vs. 75%, p = 0.208) in ICU patients. CONCLUSION: In our study there was a no statistically significant difference between the standard and conservative methods in-hospital mortality.