Posts filed under ‘Bacterias’

Decolonization in Prevention of Health Care-Associated Infections.

Clin Microbiol Rev. April 2016 V.29 N.2 P.201-22.

Septimus EJ1, Schweizer ML2.

Author information

1 Hospital Corporation of America, Nashville, Tennessee, USA Texas A&M Health Science Center, College of Medicine, Houston, Texas, USA Edward.septimus@hcahealthcare.com.

2 University of Iowa Carver College of Medicine, Iowa City, Iowa, USA Iowa City VA Health Care System, Iowa City, Iowa, USA University of Iowa College of Public Health, Iowa City, Iowa, USA.

Abstract

Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection.

Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs).

This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant.

Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin.

Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin.

Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy.

Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida.

Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time.

There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms.

The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.

PDF

http://cmr.asm.org/content/29/2/201.full.pdf+html

May 12, 2017 at 7:45 am

Early, Goal-Directed Therapy for Septic Shock — A Patient-Level Meta-Analysis

N Engl J Med  Mar 21, 2017

The PRISM Investigators*

BACKGROUND

After a single-center trial and observational studies suggesting that early, goal-directed therapy (EGDT) reduced mortality from septic shock, three multicenter trials (ProCESS, ARISE, and ProMISe) showed no benefit. This meta-analysis of individual patient data from the three recent trials was designed prospectively to improve statistical power and explore heterogeneity of treatment effect of EGDT.

METHODS

We harmonized entry criteria, intervention protocols, outcomes, resource-use measures, and data collection across the trials and specified all analyses before unblinding. After completion of the trials, we pooled data, excluding the protocol-based standard-therapy group from the ProCESS trial, and resolved residual differences. The primary outcome was 90-day mortality. Secondary outcomes included 1-year survival, organ support, and hospitalization costs. We tested for treatment-by-subgroup interactions for 16 patient characteristics and 6 care-delivery characteristics.

RESULTS

We studied 3723 patients at 138 hospitals in seven countries. Mortality at 90 days was similar for EGDT (462 of 1852 patients [24.9%]) and usual care (475 of 1871 patients [25.4%]); the adjusted odds ratio was 0.97 (95% confidence interval, 0.82 to 1.14; P=0.68). EGDT was associated with greater mean (±SD) use of intensive care (5.3±7.1 vs. 4.9±7.0 days, P=0.04) and cardiovascular support (1.9±3.7 vs. 1.6±2.9 days, P=0.01) than was usual care; other outcomes did not differ significantly, although average costs were higher with EGDT. Subgroup analyses showed no benefit from EGDT for patients with worse shock (higher serum lactate level, combined hypotension and hyperlactatemia, or higher predicted risk of death) or for hospitals with a lower propensity to use vasopressors or fluids during usual resuscitation.

CONCLUSIONS

In this meta-analysis of individual patient data, EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics. (Funded by the National Institute of General Medical Sciences and others; PRISM ClinicalTrials.gov number, NCT02030158.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1701380

May 11, 2017 at 11:13 am

Eradication of methicillin-resistant Staphylococcus aureus carriage: a systematic review.

Clin Infect Dis. Apr 1, 2009 V.48 N.7 P.922-30.

Ammerlaan HS1, Kluytmans JA, Wertheim HF, Nouwen JL, Bonten MJ.

Author information

1 Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands. H.Ammerlaan@umcutrecht.nl

Abstract

A systematic review was performed to determine the effectiveness of different approaches for eradicating methicillin-resistant Staphylococcus aureus carriage. Twenty-three clinical trials were selected that evaluated oral antibiotics (7 trials), topically applied antibiotics (12 trials), or both (4 trials). Because of clinical heterogeneity, quantitative analysis of all studies was deemed to be inappropriate, and exploratory subgroup analyses were performed for studies with similar study populations, methods, and targeted bacteria. The estimated pooled relative risk of treatment failure 1 week after short-term nasal mupirocin treatment, compared with placebo, was 0.10 (range, 0.07-0.14). There was low heterogeneity between study outcomes, and effects were similar for patients and healthy subjects, as well as in studies that included only methicillin-susceptible S. aureus carriers or both methicillin-susceptible S. aureus and methicillin-resistant S. aureus carriers. The development of drug resistance during treatment was reported in 1% and 9% of patients receiving mupirocin and oral antibiotics, respectively. Short-term nasal application of mupirocin is the most effective treatment for eradicating methicillin-resistant S. aureus carriage, with an estimated success of rate of 90% 1 week after treatment and approximately 60% after a longer follow-up period.

PDF

https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/cid/48/7/10.1086/597291/2/48-7-922.pdf?Expires=1494547126&Signature=C-3w0qidaoRa7nD1JLkVurTsGPMZt6nFPH~~ukmz~Wrdd2rLVyc4nFgZ5uT0RDQSwfwFtWB2QPZw8l7HjcKFHWaiSy8qEDU3uZM28k~O4MHJYjd~B86s2~s8-xP9j04r6TKdnJ2lsY3VZLXEb22vNGmERggjk4B2h7DUCAJGXBBba-7AixeOYEbLumFS8-5SmkCgBSKsKsa8UWzqmXJWZrQDlgMLMzqAUURfPITtO9AoiLUzDH~bVNd5zCozVmfpbxf3nAVk4cZVekXwNiAH3SYHOKfVd3YomfEzd5~tBxRwwqnxDp8kvCJtB1oFv9HNMf3Jy1GdMCnjNuyVrA1cQg__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q

May 10, 2017 at 7:11 pm

“Utilización de penicilina benzatínica como tratamiento para la prevención de sífilis congénita en el primer nivel de atención de la salud.” 36 pags

Organización Panamericana de la Salud

Ministerio de Salud de la Provincia de Buenos Aires – Argentina

Dirección Provincial de Programas Sanitarios

Dirección HIV/SIDA/ITS

Este documento fue escrito por Mariana Ceriotto (Médica especialista en Infectología y Salud Pública. Diplomada en Gestión Pública. Experta en prevención, diagnóstico y tratamiento de las infecciones perinatales).

La revisión técnica fue realizada por: Marcelo Vila (Asesor Subregional para el Cono Sur- Unidad de VIH, hepatitis, TBC e ITS- OPS/OMS); Adriana Duran (Directora de Programas Sanitarios- Ministerio de Salud de la Provincia de Buenos Aires) y Mónica Moyano (Directora de VIH-ITS y Hepatitis virales- Ministerio de Salud de la Provincia de Buenos Aires).

Avalan este documento:

  • Asociación Argentina de Alergia e Inmunología Clínica (AAAeIC)
  • Sociedad Argentina de Infectología (SADI)
  • Sociedad de Ginecología Y Obstetricia de la Provincia de Buenos Aires (SOGBA)
  • Dirección de SIDA y ETS- Ministerio de Salud de la Nación

Esta publicación contó con apoyo financiero de la OPS/OMS.

Contenido

  1. La persistencia del problema de la sífilis congénita como problema de salud pública en Argentina y la región de las Américas
  2. El tratamiento de la embarazada con diagnóstico de sífilis
  3. Alergia a beta-lactámicos
  4. Uso de penicilina benzatínica en el primer nivel de atención
  5. Recomendaciones
  6. Cuestionario para la evaluación de los factores de riesgo
  7. Evaluación de los factores de riesgo de alergia a penicilina
  8. Protocolo de diagnóstico y tratamiento inicial de reacciones anafilácticas
  9. Referencias bibliográficas

 

PDF

http://www.paho.org/arg/images/gallery/PenicilinaFinal.pdf

May 10, 2017 at 7:59 am

Corticosteroids in treating CAP – has the time really come.

Clinical Microbiology and Infection May 2017 V.23 N.5

Blot, A. Salmon-Rousseau, P. Chavanet, L. Piroth*

Departement d’Infectiologie, Centre Hospitalier Universitaire, Dijon, France

Whether corticosteroids should be used in the treatment of severe community-acquired pneumonia (CAP) is still a matter of debate.

This question is all the more relevant as pneumonia remains a leading cause of death worldwide.

Severe CAP is associated with an increase in pulmonary and circulatory cytokines, which may be associated with treatment failure, especially in bacteraemic pneumococcal pneumonia.

Thus corticosteroids, which suppress inflammatory reactions and prevent the migration of inflammatory cells to tissues, may be of particular interest in the treatment of such severe pneumonias …

PDF

http://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)30388-3/pdf

May 9, 2017 at 8:25 am

Real-Time Electronic Tracking of Diarrheal Episodes and Laxative Therapy Enables Verification of Clostridium difficile Clinical Testing Criteria and Reduction of Clostridium difficile Infection Rates

Journal of Clinical Microbiology May 2017 V.55 N.5 P.1276-1284

Cynthia Y. Truong, Saurabh Gombar, Richard Wilson, Gopalakrishnan Sundararajan, Natasa Tekic, Marisa Holubar, John Shepard, Alexandra Madison, Lucy Tompkins, Neil Shah, Stan Deresinski, Lee F. Schroeder, and Niaz Banaei

aDepartment of Pathology, Stanford University School of Medicine, Stanford, California, USA

bDigital Solutions, Stanford Health Care, Stanford, California, USA

cDivision of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA

dInfection Control and Prevention, Stanford Health Care, Stanford, California, USA

eStanford Antimicrobial Safety and Sustainability, Stanford Health Care, Stanford, California, USA

fDepartment of Pathology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA

gClinical Microbiology Laboratory, Stanford Health Care, Stanford, California, USA

Health care-onset health care facility-associated Clostridium difficile infection (HO-CDI) is overdiagnosed for several reasons, including the high prevalence of C. difficile colonization and the inability of hospitals to limit testing to patients with clinically significant diarrhea. We conducted a quasiexperimental study from 22 June 2015 to 30 June 2016 on consecutive inpatients with C. difficile test orders at an academic hospital. Real-time electronic patient data tracking was used by the laboratory to enforce testing criteria (defined as the presence of diarrhea [≥3 unformed stools in 24 h] and absence of laxative intake in the prior 48 h). Outcome measures included C. difficile test utilization, HO-CDI incidence, oral vancomycin utilization, and clinical complications. During the intervention, 7.1% (164) and 9.1% (211) of 2,321 C. difficile test orders were canceled due to absence of diarrhea and receipt of laxative therapy, respectively. C. difficile test utilization decreased upon implementation from an average of 208.8 tests to 143.0 tests per 10,000 patient-days (P < 0.001). HO-CDI incidence rate decreased from an average of 13.0 cases to 9.7 cases per 10,000 patient-days (P = 0.008). Oral vancomycin days of therapy decreased from an average of 13.8 days to 9.4 days per 1,000 patient-days (P = 0.009). Clinical complication rates were not significantly different in patients with 375 canceled orders compared with 869 episodes with diarrhea but negative C. difficile results. Real-time electronic clinical data tracking is an effective tool for verification of C. difficile clinical testing criteria and safe reduction of inflated HO-CDI rates.

PDF

http://jcm.asm.org/content/55/5/1276.full.pdf+html

May 9, 2017 at 8:23 am

Commentaries – Strategies for Optimizing the Diagnostic Predictive Value of Clostridium difficile Molecular Diagnostics

Journal of Clinical Microbiology May 2017 V.55 N.5 P.1244-1248

Larry K. Kociolek

Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA

Because nucleic acid amplification tests (NAATs) do not distinguish Clostridium difficile infection (CDI) and asymptomatic C. difficile carriage, the diagnostic predictive value of NAATs is limited when used in patients with a low probability of CDI. In this issue of the Journal of Clinical Microbiology, Truong et al. (J. Clin. Microbiol., 55:1276–1284, 2017, https://doi.org/10.1128/JCM.02319-16) report significant reductions in hospital-onset CDI and oral vancomycin utilization at their institution following implementation of a novel intervention that leveraged their clinical bioinformatics resources to prevent C. difficile testing of stools from patients without clinically significant diarrhea and in patients with recent laxative use….

PDF

http://jcm.asm.org/content/55/5/1244.full.pdf+html

May 9, 2017 at 8:22 am

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