Risk factors for excessively prolonged meropenem use in the intensive care setting: a case-contol study.

BACKGROUND: Inappropriate use of broad-spectrum antimicrobials affects adversely both the individual patient and the general public. The aim of the study was to identify patients at risk for excessively prolonged carbapenem treatment in the ICU as a target for antimicrobial stewardship interventions. METHODS: Case-control study in a network of 11 ICUs of a university hospital. Patients with uninterrupted meropenem therapy (MT) > 4 weeks were compared to controls. Controls were defined as patients who stayed on the ICU > 4 weeks and received meropenem for ≤ 2 weeks. Associations between case-control status and potential risk factors were determined in a multivariate logistic regression model. RESULTS: Between 1st of January 2013 and 31st of December 2015, we identified 36 patients with uninterrupted MT > 4 weeks. Patients with prolonged MT were more likely to be surgical patients (72.2% of cases vs. 31.5% of controls; p ≤ 0.001) with peritonitis being the most common infection (n = 16, 44.4%). In the multivariate logistic regression model colonization with multidrug-resistant (MDR) Gram-negative bacteria (OR 7.52; 95% CI 1.88-30.14, p = 0.004) and the type of infection (peritonitis vs. pneumonia: OR 16.96, 95% CI 2.95-97.49) were associated with prolonged MT. CONCLUSION: Surgical patients with peritonitis and patients with known colonization with MDR Gram-negative bacteria are at risk for excessively prolonged carbapenem therapy and represent an important target population for antimicrobial stewardship interventions.

Burden and spectrum of infectious disease in Germany 2009-2014: a multicentre study from Berlin's Municipal Hospitals.

PURPOSE: This study aimed at assessing the burden and spectrum of infectious diseases (ID) in a Metropolitan population in Germany. METHODS: A discharge database using ICD-10 codes enabled the identification of hospitalizations with infection-related diagnoses. All hospital admissions between 2009 and 2014 were analysed from 9 municipal hospitals serving approximately one-third of an urban population of 3.5 million people. RESULTS: We identified 114,168 admissions with a primary (first-listed) ID diagnosis and 220,483 admissions with any-listed ID diagnosis, accounting for 8.9 % [95 % confidence interval (CI) 8.9-9.0 %] and 17.2 % (95 % CI 17.1-17.3) of all 1,284,559 admissions, respectively. Annually, 439,837 bed-days (range 413,707-488,520) were occupied by patients with an ID diagnosis, utilizing 22.8 % of total bed capacity. The median length of stay for patients with primary ID diagnosis and secondary ID diagnosis was 6 days (IQR 3-11) and 10 days (IQR 5-19), respectively. The most common diagnosis across all age groups was "pneumonia" (22.8 and 16.2 % of ID admissions as primary and secondary diagnosis, respectively). In-hospital mortality was 6.8 % (95 % CI 6.6-6.9) and 8.9 % (95 % CI 8.7-9.1) for ID as primary and secondary diagnosis, respectively. CONCLUSION: Infectious diseases contribute significantly to the overall burden of disease in a health system caring for an urban German population. In view of the magnitude of ID's contribution, establishing more specialists in ID medicine and adjusting the reimbursements for managing infection-related admissions should be made a public health priority in Germany.

Cryptococcosis in HIV-infected hospitalized patients in Germany: Evidence for routine antigen testing.

OBJECTIVES: To investigate the diagnostic value of routine cryptococcal antigen (CRAG) testing in HIV-infected patients in a low prevalence setting. METHODS: Retrospective single centre cohort study of a 10-year period (2005-2014). RESULTS: 5461 patients tested for CRAG were included. Cryptococcal antigenaemia was found in 1.6% and 1.1% of patients with CD4 counts of ≤100/µl and 101-200/µl, respectively. The positive predictive values for identifying clinically relevant cryptococcal disease was 96% and 100%, respectively. Half of the patients had a non-specific presentation and median time-to-diagnosis was high (5 days, range 1-44 days). The median time-to-diagnosis in direct admissions to our centre with routine CRAG testing was significantly shorter: 1 day (range: 1-17) vs. 7 days (range: 2-44), p = 0.003. Prevalence of cryptococcal antigenaemia was 2.8% in patients with pneumocystis pneumonia and median time-to-diagnosis of cryptococcosis was significantly longer in this subgroup (15 days; range: 1-44 vs. 3 days; range: 1-17; p = 0.008). CRAG titres ≥1:512 were associated with disseminated disease (OR 21.3, p = 0.0008, 95% CI 1.64-277), however, 10% of patients with disseminated cryptococcosis had CRAG titres <1:16. CONCLUSION: Our data support routine CRAG testing in hospitalized HIV-infected patients with CD4 counts ≤200/µl, and/or pneumocystis pneumonia.