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Antimicrobial use: risk driver of multidrug resistant microorganisms in healthcare settings.

Curr Opin Infect Dis. 2009 Aug;22(4):352-8

Authors: Tacconelli E

PURPOSE OF REVIEW: This review explores recent evidence on the association between antibiotics usage and resistance. RECENT FINDINGS: A meta-analysis showed that the risk of acquiring methicillin-resistant Staphylococcus aureus was increased by 1.8-fold in patients who had taken antibiotics. Such risk was almost three-times greater after using quinolones or glycopeptides. Significant heterogeneity between studies was mainly related to study designs. A Cochrane systematic review suggested that, although the quality of the evidence was poor, interventions to improve hospital antibiotic prescribing were associated with a reduction in the incidence of antimicrobial resistant pathogens. Against this evidence, mupirocin-resistant S. aureus and linezolid-resistant vancomycin-resistant enterococci (VRE) were detected in institutions where these drugs were not widely used. Studies assessing the impact of vancomycin prescribing restriction on VRE rates were heterogeneous and the effectiveness of such interventions remains poorly defined. Important confounders of studies, other than study design, are the lack of analysis of secular trends of infections, colonization pressure in the ward and duration of follow up. SUMMARY: Available evidence, although not always of high quality, suggests that a link between antibiotics usage at individual and institutional levels and resistant bacteria does exist. Benchmark guidelines for empiric therapy in hospitalized patients, taking into consideration not only patients’ needs but also ecological costs of resistance, should be rapidly developed.

PMID: 19461514 [PubMed - indexed for MEDLINE]

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Care bundles: the holy grail of infectious risk management in hospital?

Curr Opin Infect Dis. 2009 Aug;22(4):364-9

Authors: Marwick C, Davey P

PURPOSE OF REVIEW: A care bundle is set of four or five processes that each individually improve patient outcome and that should be performed together for every patient every time. We describe how bundles should be designed, implemented and evaluated with measurement designed for quality improvement rather than research or judgement. RECENT FINDINGS: A systematic review concluded that the relative risk reduction associated with the introduction of a sepsis bundle exceeded 25%, and absolute risk reduction exceeded 9% in all studies. The number needed to treat to save one life in each study population ranged from three to 11. Bundles for the prevention of infections have focused on ventilator-associated pneumonia and catheter-associated bloodstream infections in the ICU. The most persuasive evidence of effectiveness comes from multicentre studies, but results from single ICUs provide valuable insights into how bundle implementation fits within a broader quality improvement strategy. SUMMARY: Care bundles can be a powerful driver for improving the reliability of delivery of evidence-based care and patient outcomes. It remains to be seen whether the success that has been achieved in acute admissions and ICUs can be reproduced in general wards.

PMID: 19506477 [PubMed - indexed for MEDLINE]

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Sodium bicarbonate for the prevention of contrast-induced nephropathy: a meta-analysis of 17 randomized trials.

Int Urol Nephrol. 2009;41(3):617-27

Authors: Kanbay M, Covic A, Coca SG, Turgut F, Akcay A, Parikh CR

BACKGROUND: Contrast-induced nephropathy (CIN) is a common cause of acute kidney injury. Several preventive therapies for this injury have been tested; however, there is still no consensus on the optimal protocol. METHODS: We performed a systematic search of the National Library of Medicine and the Cochrane Library databases from January 1985 to November 2008 to identify randomized controlled studies examining sodium bicarbonate as a preventive measure for CIN in humans. We also reviewed conference abstracts from cardiology nephrology and radiology meetings from 2004 to 2008. A change in serum creatinine levels defined by an absolute (>or=0.5 mg/dl) or percentage (>or=25%) increase in the serum creatinine level is defined as CIN. The primary outcome measure was the incidence of CIN, and the secondary outcome measures were: change in serum creatinine from baseline, requirement for renal replacement therapy and death. RESULTS: Seventeen randomized controlled trials have investigated the role of sodium bicarbonate for prophylaxis of CIN. The overall incidence of CIN was 11.3%. Using the results from all 17 studies that compared bicarbonate versus saline, the pooled relative risk of developing CIN was 0.54 (95% CI, 0.36-0.83) in the intervention arm, indicating a significant benefit from sodium bicarbonate. The pooled relative risk of CIN was 0.57 (95% CI, 0.35-0.95) when we analyzed for the studies that compared the effects sodium bicarbonate to NAC on development of CIN. There was no difference in the rates of requirement for renal replacement therapy and death. CONCLUSIONS: The use of sodium bicarbonate appears to reduce the incidence of CIN when compared to other preventive strategies for CIN without a significant difference in the requirement of renal replacement therapy and mortality. There are study heterogeneity and publication biases. Further adequately powered randomized controlled studies are needed to determine whether sodium bicarbonate will reduce the clinically meaningful outcomes (e.g., need for dialysis or death) and optimal hydration strategy in high-risk patients.

PMID: 19396567 [PubMed - indexed for MEDLINE]

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Effects of shift length on quality of patient care and health provider outcomes: systematic review.

Qual Saf Health Care. 2009 Jun;18(3):181-8

Authors: Estabrooks CA, Cummings GG, Olivo SA, Squires JE, Giblin C, Simpson N

BACKGROUND: Healthcare providers work increasingly under a variety of shift work systems to cover the continuous care required by patients. However, the effects of shift work on patient and provider outcomes in healthcare settings has not been systematically evaluated. OBJECTIVE: To identify and analyse the available evidence on the effect of shift length (8-h vs 12-h shifts) on quality of patient care and healthcare provider outcomes. METHODS: Systematic searching of eight online databases, key governmental/organisational websites and academic journals with ancestry search of relevant articles (limited to articles published in English and Spanish). RESULTS: Of 562 articles that were retrieved from 20 446 titles identified through database and manual searches, 27 satisfied the inclusion criteria, of which 15 were rejected because of low methodological quality. The 12 final studies included cross-sectional/survey (7), before-after (3) and prospective cohort (2) designs. The main primary outcomes evaluated were: (1) quality of patient care and (2) healthcare provider outcomes. The results were equivocal. With respect to the effect of shift length on quality of patient care, two studies found that errors and near errors were associated with working longer shifts, and another study reported decreased patient complications and length of stay with longer shifts. Specific healthcare provider outcomes such as health complaints, well-being, drug and alcohol consumption, stress and job satisfaction were mostly evaluated by single studies and therefore there was insufficient evidence from which to draw conclusions. CONCLUSIONS: Methodological quality of the studies generally was low and results equivocal with insufficient evidence to determine the effects of shift length on quality of patient care and healthcare provider outcomes. Clearly, robust well-designed studies are needed to examine the effect of shift length on patient and healthcare provider outcomes.

PMID: 19467999 [PubMed - indexed for MEDLINE]

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Advances in antibacterial therapy against emerging bacterial pathogens.

Semin Hematol. 2009 Jul;46(3):198-211

Authors: Pournaras S, Iosifidis E, Roilides E

During the last decade, both gram-positive and gram-negative bacteria that are resistant to most or all available antibacterial classes have become increasingly prevalent nosocomial pathogens, particularly among immunocompromised patients and those hospitalized in intensive care units. Among gram-positive bacteria, increasing concerns are posed for health care- and community-associated methicillin-resistant Staphylococcus aureus (MRSA), S aureus with reduced susceptibility to vancomycin, and vancomycin-resistant enterococci (VRE). A spectrum of newer antibacterial agents has been developed for the treatment of multi-resistant gram-positive bacteria, such as linezolid, tigecycline, daptomycin, and novel glycopeptides. Gram-negative bacteria have also developed multidrug resistance (MDR), which in the Enterobacteriacae is commonly due to the production of extended-spectrum beta-lactamases and carbapenemases of VIM, IMP, or KPC types. Currently, non-fermenting bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii are commonly resistant to all available antibiotics, including the newer agents. Colistin retains activity against most P aeruginosa and A baumannii, but its clinical use remains questionable, while newer carbapenems and tigecycline have limited additional advantages. Rational use of newer antibacterial agents coupled with enhanced infection control measures may be able to sufficiently control MDR organisms as to allow hematological patients to recover from serious infectious complications.

PMID: 19549574 [PubMed - indexed for MEDLINE]

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Neutropenic fever syndromes in patients undergoing cytotoxic therapy for acute leukemia and myelodysplastic syndromes.

Semin Hematol. 2009 Jul;46(3):259-68

Authors: Bow EJ

Fever represents the major surrogate of infection in neutropenic cancer patients. A number of neutropenic fever syndromes have been recognized, the causes and significance of which will vary depending upon the clinical context. First neutropenic fever syndromes are typically of bacterial origin, the character of which may be influenced by whether antibacterial chemoprophylaxis has been administered. Persistent neutropenic fevers are documented during the empirical systemic antibacterial therapy for the first neutropenic fever, the cause of which is likely outside the spectrum of activity of the initial therapy. Recrudescent neutropenic fevers, defined by the appearance of a new fever after defervescence of the first fever, are often a function of invasive fungal infection or gram-positive infections outside the spectrum of the initial empirical antibacterial regimen. The myeloid reconstitution syndrome occurs in parallel with neutrophil recovery from aplasia and may not necessarily represent new infection. Recognition of these patterns can help the clinician make better clinical judgments and management plans.

PMID: 19549578 [PubMed - indexed for MEDLINE]

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Myelodysplastic syndromes.

Am J Clin Pathol. 2009 Aug;132(2):290-305

Authors: Orazi A, Czader MB

Session 4 of the 2007 Workshop of the Society for Hematopathology/European Association for Haematopathology was devoted to myelodysplastic syndromes (MDSs). Submitted cases highlighted important issues and difficulties in relation to the diagnosis and classification of MDS. Much of the discussion focused on the correlation, or lack of it, between morphologic examination and other diagnostic techniques, cytogenetics in particular. The cases included examples of isolated del(5q) chromosomal abnormality, including the “classical” 5q- syndrome and other myeloid neoplasms. Other cytogenetic abnormalities in MDSs and the role of cytogenetics in diagnosing MDSs were addressed. Particularly challenging is the correct identification of fibrotic subtypes of MDSs and their separation from subsets of acute myeloid leukemia with myelofibrosis such as acute panmyelosis with myelofibrosis. The association and eventual relation of MDSs (hypoplastic in particular) with aplastic anemia, paroxysmal nocturnal hemoglobinuria, and other nonneoplastic disorders were illustrated. Novel cytogenetic and molecular genetic approaches are likely to revolutionize the classification of MDSs. However, it is unlikely that these new techniques will be capable, on their own, of adequately stratifying patients for treatment purposes. At least for the foreseeable future, the diagnosis of MDS requires integration of morphologic, immunophenotypic, and genetic features in the light of patient history and clinical manifestations.

PMID: 19605823 [PubMed - indexed for MEDLINE]

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The impact of selecting a high hemoglobin target level on health-related quality of life for patients with chronic kidney disease: a systematic review and meta-analysis.

Arch Intern Med. 2009 Jun 22;169(12):1104-12

Authors: Clement FM, Klarenbach S, Tonelli M, Johnson JA, Manns BJ

BACKGROUND: Treatment of anemia in chronic kidney disease (CKD) with erythropoietin-stimulating agents (ESAs) is commonplace. The optimal hemoglobin treatment target has not been established. A clearer understanding of the health-related quality of life (HQOL) impact of hemoglobin target levels is needed. We systematically reviewed the randomized controlled trial (RCT) data on HQOL for patients treated with low to intermediate (9.0-12.0 g/dL) and high hemoglobin target levels (>12.0 g/dL) and performed a meta-analysis of all available 36-item short-form (SF-36) RCT data. METHODS: We conducted a search to identify all RCTs of ESA therapy in patients with anemia associated with CKD (1966-December 2006). Inclusion criteria were (1) 30 or more participants, (2) anemic adults with CKD, (3) epoetin (alfa and beta) or darbepoetin used, (4) a control arm, and (5) reported HQOL using a validated measure. All available SF-36 data underwent meta-analysis using the weighted mean difference. RESULTS: Of 231 full texts screened, 11 eligible studies were identified. The SF-36 was used in 9 trials. Reporting of these data was generally incomplete. Data from each domain of the SF-36 were summarized. Statistically significant changes were noted in the physical function (weighted mean difference [WMD], 2.9; 95% confidence interval [CI], 1.3 to 4.5), general health (WMD, 2.7; 95% CI, 1.3 to 4.2), social function (WMD, 1.3; 95% CI, -0.8 to 3.4), and mental health (WMD, 0.4; 95% CI, 0.1 to 0.8) domains. None of the changes would be considered clinically significant. CONCLUSIONS: Our study suggests that targeting hemoglobin levels in excess of 12.0 g/dL leads to small and not clinically meaningful improvements in HQOL. This, in addition to significant safety concerns, suggests that targeting treatment to hemoglobin levels that are in the range of 9.0 to 12.0 g/dL is preferred.

PMID: 19546410 [PubMed - indexed for MEDLINE]

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Management of primary sclerosing cholangitis.

Minerva Gastroenterol Dietol. 2009 Jun;55(2):163-72

Authors: Björnsson E

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease with fibrosis surrounding the intrahepatic and/or the extrahepatic bile ducts. PSC is characterized by progressive periductal obliterating fibrosis and bile duct strictures. In individual cases, PSC can have favorable prognosis but in most cases it is a progressive disorder which leads to liver related morbidity, mortality and the need for liver transplantation. In previous early cohorts median survival free of transplantation was 12 years whereas more recent studies indicated a median transplantation free survival of 18 years. More recently, patients with small-duct PSC, who have biochemical and histological features similar to other PSC patients but with a normal cholangiography have been shown to have a better prognosis than classic large-duct PSC. PSC is complicated by cholangiocarcinoma (CCA) which develops in 10-30% of PSC patients depending on the length of follow-up. The diagnosis of an early CCA in the setting of PSC is a major challenge and no consensus on screening strategies exists. No curative therapy for PSC is available at the current time except liver transplantation. The etiopathogenesis of PSC is unknown but the underlying pathophysiology of PSC is beyond the scope of this paper.

PMID: 19305376 [PubMed - indexed for MEDLINE]

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Warm and fuzzy hospitalists.

Hosp Health Netw. 2009 Jul;83(7):42-3, 1

Authors: Greene J

Hospital leaders see these in-house specialists as the key to improving patient satisfaction. In turn, hospitalists are finding that sometimes the simplest ideas work the best.

PMID: 19708614 [PubMed - in process]

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Exposure to low-dose ionizing radiation from medical imaging procedures.

N Engl J Med. 2009 Aug 27;361(9):849-57

Authors: Fazel R, Krumholz HM, Wang Y, Ross JS, Chen J, Ting HH, Shah ND, Nasir K, Einstein AJ, Nallamothu BK

BACKGROUND: The growing use of imaging procedures in the United States has raised concerns about exposure to low-dose ionizing radiation in the general population. METHODS: We identified 952,420 nonelderly adults (between 18 and 64 years of age) in five health care markets across the United States between January 1, 2005, and December 31, 2007. Utilization data were used to estimate cumulative effective doses of radiation from imaging procedures and to calculate population-based rates of exposure, with annual effective doses defined as low (< or = 3 mSv), moderate (> 3 to 20 mSv), high (> 20 to 50 mSv), or very high (> 50 mSv). RESULTS: During the study period, 655,613 enrollees (68.8%) underwent at least one imaging procedure associated with radiation exposure. The mean (+/-SD) cumulative effective dose from imaging procedures was 2.4+/-6.0 mSv per enrollee per year; however, a wide distribution was noted, with a median effective dose of 0.1 mSv per enrollee per year (interquartile range, 0.0 to 1.7). Overall, moderate effective doses of radiation were incurred in 193.8 enrollees per 1000 per year, whereas high and very high doses were incurred in 18.6 and 1.9 enrollees per 1000 per year, respectively. In general, cumulative effective doses of radiation from imaging procedures increased with advancing age and were higher in women than in men. Computed tomographic and nuclear imaging accounted for 75.4% of the cumulative effective dose, with 81.8% of the total administered in outpatient settings. CONCLUSIONS: Imaging procedures are an important source of exposure to ionizing radiation in the United States and can result in high cumulative effective doses of radiation.

PMID: 19710483 [PubMed - in process]

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Early diagnosis of myocardial infarction with sensitive cardiac troponin assays.

N Engl J Med. 2009 Aug 27;361(9):858-67

Authors: Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S, Biedert S, Schaub N, Buerge C, Potocki M, Noveanu M, Breidthardt T, Twerenbold R, Winkler K, Bingisser R, Mueller C

BACKGROUND: The rapid and reliable diagnosis of acute myocardial infarction is a major unmet clinical need. METHODS: We conducted a multicenter study to examine the diagnostic accuracy of new, sensitive cardiac troponin assays performed on blood samples obtained in the emergency department from 718 consecutive patients who presented with symptoms suggestive of acute myocardial infarction. Cardiac troponin levels were determined in a blinded fashion with the use of four sensitive assays (Abbott-Architect Troponin I, Roche High-Sensitive Troponin T, Roche Troponin I, and Siemens Troponin I Ultra) and a standard assay (Roche Troponin T). The final diagnosis was adjudicated by two independent cardiologists. RESULTS: Acute myocardial infarction was the adjudicated final diagnosis in 123 patients (17%). The diagnostic accuracy of measurements obtained at presentation, as quantified by the area under the receiver-operating-characteristic curve (AUC), was significantly higher with the four sensitive cardiac troponin assays than with the standard assay (AUC for Abbott-Architect Troponin I, 0.96; 95% confidence interval [CI], 0.94 to 0.98; for Roche High-Sensitive Troponin T, 0.96; 95% CI, 0.94 to 0.98; for Roche Troponin I, 0.95; 95% CI, 0.92 to 0.97; and for Siemens Troponin I Ultra, 0.96; 95% CI, 0.94 to 0.98; vs. AUC for the standard assay, 0.90; 95% CI, 0.86 to 0.94). Among patients who presented within 3 hours after the onset of chest pain, the AUCs were 0.93 (95% CI, 0.88 to 0.99), 0.92 (95% CI, 0.87 to 0.97), 0.92 (95% CI, 0.86 to 0.99), and 0.94 (95% CI, 0.90 to 0.98) for the sensitive assays, respectively, and 0.76 (95% CI, 0.64 to 0.88) for the standard assay. We did not assess the effect of the sensitive troponin assays on clinical management. CONCLUSIONS: The diagnostic performance of sensitive cardiac troponin assays is excellent, and these assays can substantially improve the early diagnosis of acute myocardial infarction, particularly in patients with a recent onset of chest pain. (ClinicalTrials.gov number, NCT00470587.)

PMID: 19710484 [PubMed - in process]

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Sensitive troponin I assay in early diagnosis of acute myocardial infarction.

N Engl J Med. 2009 Aug 27;361(9):868-77

Authors: Keller T, Zeller T, Peetz D, Tzikas S, Roth A, Czyz E, Bickel C, Baldus S, Warnholtz A, Fröhlich M, Sinning CR, Eleftheriadis MS, Wild PS, Schnabel RB, Lubos E, Jachmann N, Genth-Zotz S, Post F, Nicaud V, Tiret L, Lackner KJ, Münzel TF, Blankenberg S

BACKGROUND: Cardiac troponin testing is central to the diagnosis of acute myocardial infarction. We evaluated a sensitive troponin I assay for the early diagnosis and risk stratification of myocardial infarction. METHODS: In a multicenter study, we determined levels of troponin I as assessed by a sensitive assay, troponin T, and traditional myocardial necrosis markers in 1818 consecutive patients with suspected acute myocardial infarction, on admission and 3 hours and 6 hours after admission. RESULTS: For samples obtained on admission, the diagnostic accuracy was highest with the sensitive troponin I assay (area under the receiver-operating-characteristic curve [AUC], 0.96), as compared with the troponin T assay (AUC, 0.85) and traditional myocardial necrosis markers. With the use of the sensitive troponin I assay (cutoff value, 0.04 ng per milliliter) on admission, the clinical sensitivity was 90.7%, and the specificity was 90.2%. The diagnostic accuracy was virtually identical in baseline and serial samples, regardless of the time of chest-pain onset. In patients presenting within 3 hours after chest-pain onset, a single sensitive troponin I assay had a negative predictive value of 84.1% and a positive predictive value of 86.7%; these findings predicted a 30% rise in the troponin I level within 6 hours. A troponin I level of more than 0.04 ng per milliliter was independently associated with an increased risk of an adverse outcome at 30 days (hazard ratio, 1.96; 95% confidence interval, 1.27 to 3.05; P=0.003). CONCLUSIONS: The use of a sensitive assay for troponin I improves early diagnosis of acute myocardial infarction and risk stratification, regardless of the time of chest-pain onset.

PMID: 19710485 [PubMed - in process]

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Proton pump inhibitors for gastroduodenal damage related to nonsteroidal anti-inflammatory drugs or aspirin: twelve important questions for clinical practice.

Clin Gastroenterol Hepatol. 2009 Jul;7(7):725-35

Authors: Arora G, Singh G, Triadafilopoulos G

Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin are among the most commonly used medications worldwide. Their use is associated with significant gastroduodenal adverse effects, including dyspepsia, bleeding, ulcer formation, and perforation. Given their long-term use by millions of patients, there is a substantial impact at the population level of these complications. In this evidence-based review, we have endeavored to answer 12 commonly encountered questions in clinical practice that deal with the following: extent of the problem of NSAID/aspirin-induced gastroduodenal damage and its impact on public health; role of proton pump inhibitors (PPIs) in the primary prevention, healing, and secondary prevention of NSAID/aspirin-induced gastroduodenal ulceration as assessed by using endoscopic end points; role of PPIs in the prevention of adverse clinical outcomes related to NSAID/aspirin use; whether PPIs are effective in NSAID-induced dyspepsia; comparison of PPI co-therapy with selective cyclooxygenase-2 inhibitors for risk reduction of adverse clinical outcomes; role of PPIs in preventing rebleeding from aspirin +/- clopidogrel therapy in high-risk patients; identifying high-risk patients who can benefit from PPI co-therapy; the role of other gastroprotective agents for prevention of NSAID/aspirin-induced gastroduodenal damage; and the cost-effectiveness of and limitations to the use of PPIs for prevention of gastroduodenal damage related to the use of NSAIDs or aspirin. We then summarized our recommendations on the use of PPIs for the clinical management of patients using NSAIDs or aspirin.

PMID: 19306941 [PubMed - indexed for MEDLINE]

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Cryptosporidium and cryptosporidiosis.

Adv Parasitol. 2005;59:77-158

Authors: Thompson RC, Olson ME, Zhu G, Enomoto S, Abrahamsen MS, Hijjawi NS

Cryptosporidium is one of the most common enteric protozoan parasites of vertebrates with a wide host range that includes humans and domestic animals. It is a significant cause of diarrhoeal disease and an ubiquitous contaminant of water which serves as an excellent vehicle for transmission. A better understanding of the development and life cycle of Cryptosporidium, and new insights into its phylogenetic relationships, have illustrated the need to re-evaluate many aspects of the biology of Cryptosporidium. This has been reinforced by information obtained from the recent successful Cryptosporidium genome sequencing project, which has emphasised the uniqueness of this organism in terms of its parasite life style and evolutionary biology. This chapter provides an up to date review of the biology, biochemistry and host parasite relationships of Cryptosporidium.

PMID: 16182865 [PubMed - indexed for MEDLINE]

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