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BACKGROUND: The impact of healthcare personnel hand contamination in multidrug-resistant organism (MDRO) transmission is important and well studied; however, the role of patient hand contamination needs to be characterized further. METHODS: Patients from 2 hospitals in southeast Michigan were recruited within 24 hours of arrival to their room and followed prospectively using microbial surveillance of nares, dominant hand, and 6 high-touch environmental surfaces. Sampling was performed on admission, days 3 and 7, and weekly until discharge. Paired samples of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the patients' hand and room surfaces were evaluated for relatedness using pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec, and Panton-Valentine leukocidin typing. RESULTS: A total of 399 patients (mean age, 60.8 years; 49% male) were enrolled and followed for 710 visits. Fourteen percent (n = 56/399) of patients were colonized with an MDRO at baseline; 10% (40/399) had an MDRO on their hands. Twenty-nine percent of rooms harbored an MDRO. Six percent (14/225 patients with at least 2 visits) newly acquired an MDRO on their hands during their stay. New MDRO acquisition in patients occurred at a rate of 24.6/1000 patient-days, and in rooms at a rate of 58.6/1000 patient-days. Typing demonstrated a high correlation between MRSA on patient hands and room surfaces. CONCLUSIONS: Our data suggest that patient hand contamination with MDROs is common and correlates with contamination on high-touch room surfaces. Patient hand hygiene protocols should be considered to reduce transmission of pathogens and healthcare-associated infections.
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Infecções Bacterianas/transmissão , Infecção Hospitalar/transmissão , Farmacorresistência Bacteriana Múltipla , Mãos/microbiologia , Adulto , Idoso , Bactérias/isolamento & purificação , Infecções Bacterianas/microbiologia , Infecções Bacterianas/prevenção & controle , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Equipamentos e Provisões Hospitalares/microbiologia , Feminino , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
A genomic epidemiologic investigation of a putative carbapenem-resistant Enterobacter cloacae outbreak revealed few plausible instances of nosocomial transmission, highlighting instead the frequent importation of E. cloacae into our hospital. Searching for genetic determinants of carbapenem resistance demonstrated that most resistance is due to convergent mutations in phylogenetically diverse E. cloacae.
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Carbapenêmicos/farmacologia , Surtos de Doenças , Farmacorresistência Bacteriana/genética , Endoscopia/efeitos adversos , Enterobacter cloacae/efeitos dos fármacos , Enterobacter cloacae/genética , Antibacterianos/farmacologia , Proteínas de Bactérias/genética , Técnicas de Tipagem Bacteriana , Enterobacteriáceas Resistentes a Carbapenêmicos/efeitos dos fármacos , Enterobacteriáceas Resistentes a Carbapenêmicos/genética , Infecção Hospitalar/etiologia , Infecção Hospitalar/microbiologia , Infecções por Enterobacteriaceae/etiologia , Infecções por Enterobacteriaceae/transmissão , Contaminação de Equipamentos , Variação Genética , Genômica , Humanos , Testes de Sensibilidade Microbiana , Tipagem de Sequências Multilocus , Mutação , beta-Lactamases/biossíntese , beta-Lactamases/genéticaRESUMO
Rapid diagnostic testing with matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) decreases the time to organism identification by 24 to 36 h compared to the amount of time required by conventional methods. However, there are limited data evaluating the impact of MALDI-TOF with real-time antimicrobial stewardship team (AST) review and intervention on antimicrobial prescribing and outcomes for patients with bacteremia and blood cultures contaminated with coagulase-negative Staphylococcus (CoNS). A quasiexperimental study was conducted to analyze the impact of rapid diagnostic testing with MALDI-TOF plus AST review and intervention for adult hospitalized patients with blood cultures positive for CoNS. Antibiotic prescribing patterns and clinical outcomes were compared before and after implementation of MALDI-TOF with AST intervention for patients with CoNS bacteremia and CoNS contamination. A total of 324 patients with a positive CoNS blood culture were included; 246 were deemed to have contaminated cultures (117 in the preintervention group and 129 in AST the intervention group), and 78 patients had bacteremia (46 in the preintervention group and 32 in the AST intervention group). No differences in demographics were seen between the groups, and similar rates of contamination occurred between the preintervention and AST intervention groups (64.3% versus 72.6%, P = 0.173). Patients with bacteremia were initiated on optimal therapy sooner in the AST intervention group (58.7 versus 34.4 h, P = 0.030), which was associated with a similarly decreased mortality (21.7% versus 3.1%, P = 0.023). Patients with CoNS-contaminated cultures had similar rates of mortality, lengths of hospitalization, recurrent bloodstream infections, and 30-day hospital readmissions, but the AST intervention group had a decreased duration of unnecessary antibiotic therapy (1.31 versus 3.89 days, P = 0.032) and a decreased number of vancomycin trough assays performed (0.88 versus 1.95, P < 0.001). In patients with CoNS bacteremia, rapid pathogen identification integrated with real-time stewardship interventions improved timely organism identification and initiation of antibiotic therapy. Patients in the AST group with blood cultures contaminated with CoNS had decreased inappropriate antimicrobial prescribing and decreased unnecessary serum vancomycin trough assays.
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Antibacterianos/uso terapêutico , Bacteriemia/microbiologia , Técnicas Bacteriológicas/métodos , Uso de Medicamentos/normas , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz/métodos , Infecções Estafilocócicas/microbiologia , Staphylococcus/efeitos dos fármacos , Adulto , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Coagulase/deficiência , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus/isolamento & purificação , Análise de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
Tigecycline is one of the few remaining therapeutic options for extensively drug-resistant (XDR) Gram-negative bacilli (GNB). MICs of tigecycline to Acinetobacter baumannii have been reported to be elevated when determined by the Etest compared to determinations by the broth microdilution (BMD) method. The study aim was to compare the susceptibility of GNB to tigecycline by four different testing methods. GNB were collected from six health care systems (25 hospitals) in southeast Michigan from January 2010 to September 2011. Tigecycline MICs among A. baumannii, carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae, and susceptible Enterobacteriaceae isolates were determined by Etest, BMD, Vitek-2, and MicroScan. Nonsusceptibility was categorized as a tigecycline MIC of ≥4 µg/ml for both A. baumannii and Enterobacteriaceae. The study included 4,427 isolates: 2,065 ESBL-producing Enterobacteriaceae, 1,105 A. baumannii, 888 susceptible Enterobacteriaceae, and 369 CRE isolates. Tigecycline nonsusceptibility among A. baumannii isolates was significantly more common as determined by Etest compared to that determined by BMD (odds ratio [OR], 10.3; P<0.001), MicroScan (OR, 12.4; P<0.001), or Vitek-2 (OR, 9.4; P<0.001). These differences were not evident with the other pathogens. Tigecycline MICs varied greatly according to the in vitro testing methods among A. baumannii isolates. Etest should probably not be used by laboratories for tigecycline MIC testing of A. baumannii isolates, since MICs are significantly elevated with Etest compared to those determined by the three other methods.
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Bactérias Gram-Negativas/efeitos dos fármacos , Minociclina/análogos & derivados , Acinetobacter baumannii/efeitos dos fármacos , Antibacterianos/farmacologia , Carbapenêmicos/farmacologia , Enterobacteriaceae/efeitos dos fármacos , Humanos , Michigan , Testes de Sensibilidade Microbiana/métodos , Minociclina/farmacologia , Tigeciclina , beta-Lactamases/metabolismoRESUMO
Background: Human adenoviruses (HAdVs) can cause outbreaks of flu-like illness in university settings. Most infections in healthy young adults are mild; severe illnesses rarely occur. In Fall 2022, an adenovirus outbreak was identified in university students. Methods: HAdV cases were defined as university students 17-26 years old who presented to the University Health Service or nearby emergency department with flu-like symptoms (eg, fever, cough, headache, myalgia, nausea) and had confirmed adenovirus infections by polymerase chain reaction (PCR). Demographic and clinical characteristics were abstracted from electronic medical records; clinical severity was categorized as mild, moderate, severe, or critical. We performed contact investigations among critical cases. A subset of specimens was sequenced to confirm the HAdV type. Results: From 28 September 2022 to 30 January 2023, 90 PCR-confirmed cases were identified (51% female; mean age, 19.6 years). Most cases (88.9%) had mild illness. Seven cases required hospitalization, including 2 critical cases that required intensive care. Contact investigation identified 44 close contacts; 6 (14%) were confirmed HAdV cases and 8 (18%) reported symptoms but never sought care. All typed HAdV-positive specimens (n = 36) were type 4. Conclusions: While most students with confirmed HAdV had mild illness, 7 otherwise healthy students had severe or critical illness. Between the relatively high number of hospitalizations and proportion of close contacts with symptoms who did not seek care, the true number of HAdV cases was likely higher. Our findings illustrate the need to consider a wide range of pathogens, even when other viruses are known to be circulating.
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BACKGROUND: Integration of rapid diagnostic testing via matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) with antimicrobial stewardship team (AST) intervention has the potential for early organism identification, customization of antibiotic therapy, and improvement in patient outcomes. The objective of this study was to assess the impact of this combined approach on clinical and antimicrobial therapy-related outcomes in patients with bloodstream infections. METHODS: A pre-post quasi-experimental study was conducted to analyze the impact of MALDI-TOF with AST intervention in patients with bloodstream infections. The AST provided evidence-based antibiotic recommendations after receiving real-time notification following blood culture Gram stain, organism identification, and antimicrobial susceptibilities. Outcomes were compared to a historic control group. RESULTS: A total of 501 patients with bacteremia or candidemia were included in the final analysis: 245 patients in the intervention group and 256 patients in the preintervention group. MALDI-TOF with AST intervention decreased time to organism identification (84.0 vs 55.9 hours, P < .001), and improved time to effective antibiotic therapy (30.1 vs 20.4 hours, P = .021) and optimal antibiotic therapy (90.3 vs 47.3 hours, P < .001). Mortality (20.3% vs 14.5%), length of intensive care unit stay (14.9 vs 8.3 days) and recurrent bacteremia (5.9% vs 2.0%) were lower in the intervention group on univariate analysis, and acceptance of an AST intervention was associated with a trend toward reduced mortality on multivariable analysis (odds ratio, 0.55, P = .075). CONCLUSION: MALDI-TOF with AST intervention decreased time to organism identification and time to effective and optimal antibiotic therapy.
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Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Bactérias/isolamento & purificação , Candida/isolamento & purificação , Candidemia/diagnóstico , Uso de Medicamentos/normas , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Bacteriemia/tratamento farmacológico , Bactérias/química , Bactérias/classificação , Candida/química , Candida/classificação , Candidemia/tratamento farmacológico , Prescrições de Medicamentos/normas , Feminino , Humanos , Masculino , Técnicas Microbiológicas/métodos , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Tracheostomies are highly aerosolizing procedures yet are often indicated in patients with COVID-19 who require prolonged intubation. Robust investigations of the safety of tracheostomy protocols and provider adherence and evaluations are limited. OBJECTIVES: To determine the rate of COVID-19 infection of health care personnel involved in COVID-19 tracheostomies under a multidisciplinary safety protocol and to investigate health care personnel's attitudes and suggested areas for improvement concerning the protocol. METHODS: All health care personnel involved in tracheostomies in COVID-19-positive patients from April 9 through July 11, 2020, were sent a 22-item electronic survey. RESULTS: Among 107 health care personnel (80.5%) who responded to the survey, 5 reported a positive COVID-19 test result (n = 2) or symptoms of COVID-19 (n = 3) within 21 days of the tracheostomy. Respondents reported 100% adherence to use of adequate personal protective equipment. Most (91%) were familiar with the tracheostomy protocol and felt safe (92%) while performing tracheostomy. Suggested improvements included creating dedicated tracheostomy teams and increasing provider choices surrounding personal protective equipment. CONCLUSIONS: Multidisciplinary engagement in the development and implementation of a COVID-19 tracheostomy protocol is associated with acceptable safety for all members of the care team.
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COVID-19 , Humanos , Traqueostomia/efeitos adversos , SARS-CoV-2 , Equipamento de Proteção Individual , Atenção à SaúdeRESUMO
BACKGROUND: Vulvar pseudotumoral herpes infections have been reported in HIV-positive patients. A 32-year-old HIV-negative woman presented with a 6-month history of a vulvar pseudotumor that had been unresponsive to oral acyclovir and valacyclovir, as well as topical imiquimod. OBJECTIVE: This study aimed to evaluate the therapeutic efficacy of a multidrug regimen for vulvar pseudotumor herpes infection in an HIV-negative patient. METHODS: Histology revealed multinucleated giant cells, consistent with a herpes infection. The patient's herpes simplex virus type 2 was resistant to acyclovir. Immunomodulatory agents (thalidomide and topical imiquimod) were started. RESULTS: The lesion enlarged after 6 weeks of treatment. Topical cidofovir 1% gel was added. There was gradual decrease in the pseudotumor size. After 7 months, the Pseudotumor had resolved. CONCLUSION: This is the first reported case of vulvar pseudotumoral herpes in an immunocompetent, HIV-negative patient. Oral thalidomide, in association with topical imiquimod and topical cidofovir, was effective in treating acyclovir-resistant pseudotumoral herpes of the vulva.
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The challenges in managing patients with infection in the intensive care unit are increased in an era where there are dwindling antimicrobial choices for multidrug-resistant pathogens. Clinicians in the intensive care unit must balance between choosing appropriate antimicrobial treatment for patients with suspected infection and utilizing antimicrobials in a judicious fashion. Improving antimicrobial utilization is a critical component to reducing antimicrobial resistance. Although providing effective antimicrobial therapy and improving antimicrobial utilization may seem to be competing goals, there are effective strategies to accomplish both. Antimicrobial stewardship programs provide an organized way to implement these strategies and can enhance the intensive care unit physician's success in improving patient outcomes and combating antimicrobial resistance in the intensive care unit.
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Resistência Microbiana a Medicamentos , Unidades de Terapia Intensiva , Antibacterianos/administração & dosagem , Relação Dose-Resposta a Droga , Farmacoeconomia , Formulários de Hospitais como Assunto , Humanos , Relações Interprofissionais , Testes de Sensibilidade Microbiana , Guias de Prática Clínica como AssuntoRESUMO
We describe a cluster of 4 bloodstream infections with Mycobacterium neoaurum and 5 additional cases from the literature. Infections occurred mainly in immunocompromised hosts who had central venous catheters. Fever was universal at presentation, but local signs of inflammation were rare. Combination antimicrobial therapy and catheter removal resulted in clinical cure.
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Bacteriemia/etiologia , Bacteriemia/terapia , Cateterismo Venoso Central/efeitos adversos , Hospedeiro Imunocomprometido , Infecções por Mycobacterium não Tuberculosas/etiologia , Infecções por Mycobacterium não Tuberculosas/terapia , Antibacterianos/administração & dosagem , Bacteriemia/imunologia , Patógenos Transmitidos pelo Sangue/isolamento & purificação , Pré-Escolar , Análise por Conglomerados , Terapia Combinada , Remoção de Dispositivo , Feminino , Seguimentos , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Infecções por Mycobacterium não Tuberculosas/imunologia , Neoplasias/imunologia , Neoplasias/terapia , Micobactérias não Tuberculosas/classificação , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
OBJECTIVE: To describe the rate of infection, associated organisms, and potential risk factors for ventilator-associated pneumonia (VAP) in patients receiving mechanical ventilation at home. DESIGN: Retrospective cohort study. SETTING: University-affiliated home care service. PATIENTS: Patients receiving mechanical ventilation at home from June 1995 through December 2001. RESULTS: Fifty-seven patients underwent ventilation at home for a total of 50,762 ventilator-days (mean +/- SD, 890.6 +/- 644.43 days; range, 76-2,458 days). Seventy-nine episodes of VAP occurred in 27 patients (rate, 1.55 episodes per 1,000 ventilator-days). The first episode of VAP occurred after a mean (+/-SD) of 245 +/- 318.07 ventilator-days. VAP was most common during the first 500 days of ventilation. Rates of VAP were higher among patients who required ventilation for longer daily durations, compared with those who required it for shorter daily durations. There was no association of VAP with age, sex, underlying disease, reason for ventilation, antacid therapy, or steroid use. Microorganisms isolated from 33 episodes of VAP with available culture results included Pseudomonas species (17 isolates), Staphylococcus aureus (11), Serratia species (7), and Stenotrophomonas species (5). Eight patients died during the study; no deaths were attributed to pneumonia. CONCLUSIONS: Although the organisms associated with VAP in the home setting are similar to those associated with hospital-acquired VAP, the incidence and mortality is much lower in the home care setting. Interventions to reduce the risk of VAP among patients receiving home care should be focused on patients who require ventilation for longer daily durations or who are new to receiving mechanical ventilation at home.
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Serviços de Assistência Domiciliar , Assistência Domiciliar , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Incidência , Lactente , Masculino , Michigan/epidemiologia , Estudos RetrospectivosRESUMO
BACKGROUND Peripherally inserted central catheters (PICCs) are associated with central-line-associated bloodstream infections (CLABSIs). However, no tools to predict risk of PICC-CLABSI have been developed. OBJECTIVE To operationalize or prioritize CLABSI risk factors when making decisions regarding the use of PICCs using a risk model to estimate an individual's risk of PICC-CLABSI prior to device placement. METHODS Using data from the Michigan Hospital Medicine Safety consortium, patients that experienced PICC-CLABSI between January 2013 and October 2016 were identified. A Cox proportional hazards model with robust sandwich standard error estimates was then used to identify factors associated with PICC-CLABSI. Based on regression coefficients, points were assigned to each predictor and summed for each patient to create the Michigan PICC-CLABSI (MPC) score. The predictive performance of the score was assessed using time-dependent area-under-the-curve (AUC) values. RESULTS Of 23,088 patients that received PICCs during the study period, 249 patients (1.1%) developed a CLABSI. Significant risk factors associated with PICC-CLABSI included hematological cancer (3 points), CLABSI within 3 months of PICC insertion (2 points), multilumen PICC (2 points), solid cancers with ongoing chemotherapy (2 points), receipt of total parenteral nutrition (TPN) through the PICC (1 point), and presence of another central venous catheter (CVC) at the time of PICC placement (1 point). The MPC score was significantly associated with risk of CLABSI (P<.0001). For every point increase, the hazard ratio of CLABSI increased by 1.63 (95% confidence interval, 1.56-1.71). The area under the receiver-operating-characteristics curve was 0.67 to 0.77 for PICC dwell times of 6 to 40 days, which indicates good model calibration. CONCLUSION The MPC score offers a novel way to inform decisions regarding PICC use, surveillance of high-risk cohorts, and utility of blood cultures when PICC-CLABSI is suspected. Future studies validating the score are necessary. Infect Control Hosp Epidemiol 2017;38:1155-1166.
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Bacteriemia/epidemiologia , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/microbiologia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Cateteres Venosos Centrais/microbiologia , Idoso , Comorbidade , Bases de Dados Factuais , Tomada de Decisões , Feminino , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Medição de Risco/métodos , Fatores de RiscoRESUMO
OBJECTIVE Inappropriate treatment of asymptomatic bacteriuria (ASB) in the hospital setting is common. We sought to evaluate the treatment rate of ASB at the 3 hospitals and assess the impact of a hospitalist-focused improvement intervention. DESIGN Prospective, interventional trial. SETTING Two community hospitals and a tertiary-care academic center. PATIENTS Adult patients with a positive urine culture admitted to hospitalist services were included in this study. Exclusions included pregnancy, intensive care unit admission, history of a major urinary procedure, and actively being treated for a urinary tract infection (UTI) at the time of admission or >48 hours prior to urine collection. INTERVENTIONS An educational intervention using a pocket card was implemented at all sites followed by a pharmacist-based intervention at the academic center. Medical records of the first 50 eligible patients at each site were reviewed at baseline and after each intervention for signs and symptoms of UTI, microbiological results, antimicrobials used, and duration of treatment for positive urine cultures. Diagnosis of ASB was determined through adjudication by 2 hospitalists and 2 infectious diseases physicians. RESULTS Treatment rates of ASB decreased (23.5%; P=.001) after the educational intervention. Reductions in treatment rates for ASB differed by site and were greatest in patients without classic signs and symptoms of UTI (34.1%; P<.001) or urinary catheters (31.2%; P<.001). The pharmacist-based intervention was most effective at reducing ASB treatment rates in catheterized patients. CONCLUSIONS A hospitalist-focused educational intervention significantly reduced ASB treatment rates. The impact varied across sites and by patient characteristics, suggesting that a tailored approach may be useful. Infect Control Hosp Epidemiol 2016;37:1044-1051.
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Antibacterianos/uso terapêutico , Bacteriúria/tratamento farmacológico , Bacteriúria/epidemiologia , Médicos Hospitalares/educação , Prescrição Inadequada/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitais Comunitários , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , Estudos Prospectivos , Centros de Atenção Terciária , Cateterismo Urinário , Urina/microbiologia , Adulto JovemRESUMO
BACKGROUND: Although antimicrobial stewardship programs (ASPs) are uniquely positioned to improve treatment of Clostridium difficile infection (CDI) through targeted interventions, studies to date have not rigorously evaluated the influence of ASP involvement on clinical outcomes attributed to CDI. METHODS: We performed a quasiexperimental study of adult patients with CDI before (n = 307) and after (n = 285) a real-time ASP review was initiated. In the intervention group, an ASP pharmacist was notified of positive CDI results and consulted with the care team to initiate optimal therapy, minimize concomitant antibiotic and acid-suppressive therapy, and recommend surgical/infectious diseases consultation in complicated cases. The primary outcome was a composite of attributable 30-day mortality, intensive care unit admission, colectomy/ileostomy, and recurrence. RESULTS: A higher percentage of patients in the ASP intervention group had acid-suppressive therapy discontinued (30% vs 13%; P < .01). Among patients with severe CDI, more patients in the intervention group received an infectious diseases consultation (17% vs 10%; P = .04), received appropriate therapy with oral vancomycin (87% vs 59%; P <.01), and vancomycin was initiated earlier (mean, 1.1 vs 1.7 days; P <.01). Incidence of the composite outcome was not significantly different between the 2 groups (12.3% vs 14.7%; P = .40). CONCLUSIONS: ASP review and intervention improved CDI process measures. A decrease in composite outcomes was not found, which may be due to low baseline rates of attributable complications in our institution.
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Antibacterianos/administração & dosagem , Clostridioides difficile/efeitos dos fármacos , Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/tratamento farmacológico , Infecções por Clostridium/microbiologia , Tratamento Farmacológico/normas , Uso de Medicamentos/normas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções por Clostridium/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Análise de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
Treatment of asymptomatic bacteriuria contributes to antimicrobial overuse in hospitalized patients. Indications for urine culture, treatment, and targets for improvement were evaluated in 153 patients. Drivers of antimicrobial overuse included fever with an alternative source, altered mental status, and leukocytosis, which led 435 excess days of antimicrobial therapy.
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Infecções Assintomáticas/terapia , Bacteriúria/tratamento farmacológico , Uso Excessivo dos Serviços de Saúde/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Infecção Hospitalar/tratamento farmacológico , Feminino , Humanos , Prescrição Inadequada/prevenção & controle , Prescrição Inadequada/estatística & dados numéricos , Masculino , Uso Excessivo dos Serviços de Saúde/prevenção & controle , Pessoa de Meia-Idade , Melhoria de Qualidade , Adulto JovemRESUMO
BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) are clinically challenging, threaten patient safety, and represent an emerging public health issue. CRE reporting is not mandated in Michigan. METHODS: The Michigan Department of Community Health-led CRE Surveillance and Prevention Initiative enrolled 21 facilities (17 acute care and 4 long-term acute care facilities) across the state. Baseline data collection began September 1, 2012, and ended February 28, 2013 (duration, 6 months). Enrolled facilities voluntarily reported cases of Klebsiella pneumoniae and Escherichia coli according to the surveillance algorithm. Patient demographic characteristics, laboratory testing, microbiology, clinical, and antimicrobial information were captured via standardized data collection forms. Facilities reported admissions and patient-days each month. RESULTS: One-hundred two cases over 957,220 patient-days were reported, resulting in a crude incidence rate of 1.07 cases per 10,000 patient-days. Eighty-nine case patients had test results positive for K. pneumoniae, whereas 13 had results positive for E. coli. CRE case patients had a mean age of 63 years, and 51% were male. Urine cultures (61%) were the most frequently reported specimen source. Thirty-five percent of cases were hospital onset; sixty-five percent were community onset (CO), although 75% of CO case patients reported healthcare exposure within the previous 90 days. Cardiovascular disease, renal failure, and diabetes mellitus were the most frequently reported comorbid conditions. Common ris k factors included surgery within the previous 90 days, recent infection or colonization with a multidrug-resistant organism, and recent exposures to antimicrobials, especially third- or fourth-generation cephalosporins. CONCLUSIONS: CRE are found throughout Michigan healthcare facilities. Implementing a regional, coordinated surveillance and prevention initiative may prevent CRE from becoming hyperendemic in Michigan.
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Antibacterianos/uso terapêutico , Carbapenêmicos/uso terapêutico , Farmacorresistência Bacteriana , Infecções por Enterobacteriaceae/epidemiologia , Enterobacteriaceae/isolamento & purificação , Vigilância da População , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/farmacologia , Carbapenêmicos/farmacologia , Intervalos de Confiança , Infecção Hospitalar , Enterobacteriaceae/efeitos dos fármacos , Infecções por Enterobacteriaceae/tratamento farmacológico , Feminino , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Adulto JovemRESUMO
The prevalence of carbapenemase-producing Enterobacteriaceae (CPE) in our hospital increased beginning in 2009. We aimed to study the clinical and molecular epidemiology of these emerging isolates. We performed a retrospective review of all adult patients with clinical cultures confirmed as CPE by positive modified Hodge test from 5/2009- 5/2010 at the University of Michigan Health System (UMHS). Clinical information was obtained from electronic medical records. Available CPE isolates were analyzed by polymerase chain reaction (PCR) and sequencing of the 16S rRNA encoding gene and bla KPC locus. Multilocus sequence typing (MLST) was used to characterize Klebsiella pneumoniae isolates. Twenty six unique CPE isolates were obtained from 25 adult patients. The majority were Klebsiella pneumoniae (n=17). Other isolates included K. oxytoca (n=3), Citrobacter freundii (n=2), Enterobacter cloacae (n=2), Enterobacter aerogenes (n=1) and Escherichia coli (n=1). Molecular characterization of 19 available CPE isolates showed that 13 (68%) carried the KPC-3 allele and 6 (32%) carried the KPC-2 allele. Among 14 available K. pneumoniae strains, 12 (86%) carried the KPC-3 allele and belonged to a common lineage, sequence type (ST) 258. The other 2 (14%) K. pneumoniae isolates carried the KPC-2 allele and belonged to two unique STs. Among these ST 258 strains, 67% were isolated from patients with prior exposures to health care settings outside of our institution. In contrast, all CPE isolates carrying the KPC-2 allele and all non ST 258 CPE isolates had acquisition attributable to our hospital. Molecular epidemiology of carbapenemase producing K. pneumoniae suggests that KPC-3 producing K. pneumoniae isolates of a common lineage, sequence type (ST 258), are emerging in our hospital. While ST 258 is a dominant sequence type throughout the United States, this study is the first to report its presence in Michigan.
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Urine cultures are frequently obtained for hospitalized patients. We reviewed documented indications for culture and compared these with professional society guidelines. Lack of documentation and important clinical scenarios (before orthopedic procedures and when the patient has altered mental status without a urinary catheter) are highlighted as areas of use outside of current guidelines.
Assuntos
Testes Diagnósticos de Rotina/normas , Fidelidade a Diretrizes , Procedimentos Desnecessários/estatística & dados numéricos , Urinálise/normas , Infecções Urinárias/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Testes Diagnósticos de Rotina/estatística & dados numéricos , Feminino , Hospitalização , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Melhoria de Qualidade , Estudos Retrospectivos , Urinálise/estatística & dados numéricos , Urina/microbiologia , Adulto JovemRESUMO
OBJECTIVE: To determine relative rates of blood culture contamination for 3 skin antisepsis interventions-10% povidone iodine aqueous solution (PI), 2% iodine tincture (IT), and 2% chlorhexidine gluconate in 70% isopropyl alcohol (CHG)-when used by dedicated phlebotomy teams to obtain peripheral blood cultures. DESIGN: Randomized crossover trial with hospital floor as the unit of randomization. SETTING: Teaching hospital with 885 beds. PATIENTS: All adult patients undergoing peripheral blood culture collection on 3 medical-surgical floors from May 2009 through September 2009. INTERVENTION: Each antisepsis intervention was used for 5 months on each study floor, with random crossover after a 1-month washout period. Phlebotomy teams collected all peripheral blood cultures. Each positive blood culture was adjudicated by physicians blinded to the intervention and scored as a true positive or contaminated blood culture. The primary outcome was the rate of blood culture contamination for each antisepsis agent. RESULTS: In total, 12,904 peripheral blood culture sets were evaluated, of which 735 (5.7%) were positive. There were 98 contaminated cultures, representing 13.3% of all positive cultures. The overall blood culture contamination rate for the study population was 0.76%. Intent-to-treat rates of contaminated blood cultures were not significantly different among the 3 antiseptics ([Formula: see text]), yielding 0.58% with PI (95% confidence interval [CI], 0.38%-0.86%), 0.76% with IT (95% CI, 0.52%-1.07%), and 0.93% with CHG (95% CI, 0.67%-1.27%). CONCLUSION: Choice of antiseptic agent does not impact contamination rates when blood cultures are obtained by a phlebotomy team and should, therefore, be based on costs or preference. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01216761 .
Assuntos
Anti-Infecciosos Locais , Antissepsia/métodos , Flebotomia/métodos , Pele/microbiologia , 2-Propanol , Idoso , Clorexidina/análogos & derivados , Estudos Cross-Over , Reações Falso-Positivas , Humanos , Iodo , Funções Verossimilhança , Modelos Logísticos , Pessoa de Meia-Idade , Povidona-Iodo , Estudos Prospectivos , Método Simples-CegoRESUMO
Infection after breast implant surgery occurs in 1.1% to 2.5% of procedures performed for augmentation and up to 35% of procedures performed for reconstruction after mastectomy. Most infections result from skin organisms and occur in the immediate postoperative period, although infections can occasionally present after many years. Diagnosis of breast implant infection relies on the clinical presentation of breast pain, swelling, erythema, and drainage in conjunction with ultrasound-guided cultures of periprosthetic fluid. Management commonly involves implant removal, with device salvage attempted in select situations.