Archive for May 8, 2015

Nosocomial bacteriuria in elderly inpatients may be leading to considerable antibiotic overuse: an audit of current management practice in a secondary level care hospital in New Zealand.

Infect Drug Resist. 2014 Nov 13;7:301-8.

Blakiston M1, Zaman S1.

1Department of Medicine, MidCentral District Health Board, Palmerston North, New Zealand.

Abstract

BACKGROUND:

Bacteriuria in the form of symptomatic urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) is common in the elderly. There is no clinical benefit obtained by treating elderly individuals with ASB. However, its high prevalence leads to the overdiagnosis of UTI and unnecessary antibiotic use, which can result in adverse events, including Clostridium difficile diarrhea and reinfection with antibiotic-resistant organisms.

METHODS:

This was a retrospective audit that assessed the management of nosocomial bacteriuria in elderly patients admitted to the over-65 years rehabilitation unit of a secondary level care hospital in New Zealand. Identified bacteriuria episodes had the timing of sample collection relative to admission, microbial etiology, antibiotic susceptibility profile, inflammatory marker level, and treatment determined. Episodes were classified into six different clinical groups based on the presence or absence of signs and symptoms, urinary catheter status, and systemic inflammatory response. The proportion of bacteriuria episodes by clinical grouping and the level of treatment by clinical group were determined, followed by assessment of the amount of overtreatment in terms of the number of unnecessary antibiotic courses and unnecessary antibiotic treatment days.

RESULTS:

Significant bacteriuria was identified in 30% of patients, with 35% of urine samples collected in the immediate postadmission period. Fifty-four percent of the bacteriuria episodes were ASB or catheter-associated ASB (CA-ASB) without an inflammatory response, 24% were ASB or CA-ASB with raised inflammatory markers, and 22% were UTI or CA-UTI. The most common cause of bacteriuria was Escherichia coli, although the etiology was diverse, especially after prolonged hospitalization or in catheterized patients. A large proportion of organisms were resistant to one or more of the commonly used oral antibiotics. Treatment of ASB and CA-ASB accounted for 43% of all antibiotic courses received. Furthermore, treatment of ASB and CA-ASB combined with unnecessarily prolonged treatment days for clinically relevant infections accounted for 55% of all antibiotic treatment days received.

CONCLUSION:

The results suggest that inappropriate urine screening was occurring and that 43% of antibiotic courses and 55% of all antibiotic treatment days were unnecessary. Current practice is amenable to improvement by performing urine culture only when clinically indicated, focusing on clinical signs and symptoms to diagnose clinically significant UTI rather than a positive culture, and using, where possible, the ecologically least damaging antibiotic for the shortest duration required.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235501/pdf/idr-7-301.pdf

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May 8, 2015 at 1:18 pm

Duration of Colonization With Methicillin-Resistant Staphylococcus aureus: A Question With Many Answers

Clin Infect Dis. (2015) 60 (10): 1497-1499

Editorial Commentary

Michael S. Calderwood

Emergency room visits and hospital admissions for skin and soft tissue infections (SSTIs) have been increasing [1, 2], with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) cultured from the site of infection [3]. By recent estimates, approximately 7% of patients in US hospitals are colonized with MRSA [4]. This includes an increase in colonization with community-acquired strains commonly associated with SSTIs [5, 6].

According to the Society for Healthcare Epidemiology of America, the duration of colonization remains an unresolved issue [7]. Data have shown that individuals remain at increased risk of MRSA infection and death until they are no longer colonized [8]. However, there is a wide range of estimates for the median time to clearance, ranging from 7 to 9 months [9–11] to well beyond a year [12–14]. Thus, many US hospitals recommend waiting 6 months or more prior to screening for clearance of MRSA colonization [15].

In this issue of Clinical Infectious Diseases, the study by Cluzet et al adds to the debate on the duration of MRSA colonization, looking at clearance following diagnosis of an SSTI with a positive MRSA culture [16]. In this longitudinal sampling study, MRSA surveillance cultures were collected from nares, axilla, and groin every 2 weeks for up to 6 months on both index cases and their household members. The first finding of interest was a median duration of MRSA …

PDF

http://cid.oxfordjournals.org/content/60/10/1497.full.pdf+html

May 8, 2015 at 1:13 pm

Systemic Inflammatory Response Syndrome Criteria in Definifng Severe Sepsis

New England Journal of Medicine, April 23, 2015  V.327 N.17 P.1629-1638

Kaukonen K, Bailey M, Pilcher D et al

From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (K.-M.K., M.B., D.P., D.J.C., R.B.), the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (D.P.), and the Department of Intensive Care, Alfred Hospital (D.P.), Melbourne, VIC, and the Intensive Care Unit, Austin Health, Heidelberg, VIC (R.B.) — all in Australia; and the Neurosurgical Unit, Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Central Hospital, Helsinki (K.-M.K.).

Address reprint requests to Dr. Bellomo at the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 6, the Alfred Centre, 99 Commercial Rd., Melbourne, VIC 3004, Australia, or at rinaldo.bellomo@austin.org.au .

BACKGROUND

The consensus definition of severe sepsis requires suspected or proven infection, organ failure, and signs that meet two or more criteria for the systemic inflammatory response syndrome (SIRS). We aimed to test the sensitivity, face validity, and construct validity of this approach.

METHODS

We studied data from patients from 172 intensive care units in Australia and New Zealand from 2000 through 2013. We identified patients with infection and organ failure and categorized them according to whether they had signs meeting two or more SIRS criteria (SIRS-positive severe sepsis) or less than two SIRS criteria (SIRS-negative severe sepsis). We compared their characteristics and outcomes and assessed them for the presence of a step increase in the risk of death at a threshold of two SIRS criteria.

RESULTS

Of 1,171,797 patients, a total of 109,663 had infection and organ failure. Among these, 96,385 patients (87.9%) had SIRS-positive severe sepsis and 13,278 (12.1%) had SIRS-negative severe sepsis. Over a period of 14 years, these groups had similar characteristics and changes in mortality (SIRS-positive group: from 36.1% [829 of 2296 patients] to 18.3% [2037 of 11,119], P<0.001; SIRS-negative group: from 27.7%

[100 of 361] to 9.3% [122 of 1315], P<0.001). Moreover, this pattern remained similar after adjustment for baseline characteristics (odds ratio in the SIRS-positive group, 0.96; 95% confidence interval [CI], 0.96 to 0.97; odds ratio in the SIRSnegative group, 0.96; 95% CI, 0.94 to 0.98; P=0.12 for between-group difference). In the adjusted analysis, mortality increased linearly with each additional SIRS criterion (odds ratio for each additional criterion, 1.13; 95% CI, 1.11 to 1.15; P<0.001) without any transitional increase in risk at a threshold of two SIRS criteria.

CONCLUSIONS

The need for two or more SIRS criteria to define severe sepsis excluded one in eight otherwise similar patients with infection, organ failure, and substantial mortality and failed to define a transition point in the risk of death. (Funded by the Australian and New Zealand Intensive Care Research Centre.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1415236

 

May 8, 2015 at 1:09 pm


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