IMPORTANCE: Estimates from claims-based analyses suggest that the incidence of sepsis is increasing and mortality rates from sepsis are decreasing. However, estimates from claims data may lack ...clinical fidelity and can be affected by changing diagnosis and coding practices over time. OBJECTIVE: To estimate the US national incidence of sepsis and trends using detailed clinical data from the electronic health record (EHR) systems of diverse hospitals. DESIGN, SETTING, AND POPULATION: Retrospective cohort study of adult patients admitted to 409 academic, community, and federal hospitals from 2009-2014. EXPOSURES: Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction, adapting Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria for objective and consistent EHR-based surveillance. MAIN OUTCOMES AND MEASURES: Sepsis incidence, outcomes, and trends from 2009-2014 were calculated using regression models and compared with claims-based estimates using International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding criteria were validated against Sepsis-3 criteria using medical record reviews. RESULTS: A total of 173 690 sepsis cases (mean age, 66.5 SD, 15.5 y; 77 660 42.4% women) were identified using clinical criteria among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to hospice. From 2009-2014, sepsis incidence using clinical criteria was stable (+0.6% relative change/y 95% CI, −2.3% to 3.5%, P = .67) whereas incidence per claims increased (+10.3%/y 95% CI, 7.2% to 13.3%, P < .001). In-hospital mortality using clinical criteria declined (−3.3%/y 95% CI, −5.6% to −1.0%, P = .004), but there was no significant change in the combined outcome of death or discharge to hospice (−1.3%/y 95% CI, −3.2% to 0.6%, P = .19). In contrast, mortality using claims declined significantly (−7.0%/y 95% CI, −8.8% to −5.2%, P < .001), as did death or discharge to hospice (−4.5%/y 95% CI, −6.1% to −2.8%, P < .001). Clinical criteria were more sensitive in identifying sepsis than claims (69.7% 95% CI, 52.9% to 92.0% vs 32.3% 95% CI, 24.4% to 43.0%, P < .001), with comparable positive predictive value (70.4% 95% CI, 64.0% to 76.8% vs 75.2% 95% CI, 69.8% to 80.6%, P = .23). CONCLUSIONS AND RELEVANCE: In clinical data from 409 hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast to claims-based analyses, neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009-2014. The findings also suggest that EHR-based clinical data provide more objective estimates than claims-based data for sepsis surveillance.
Background. An antimicrobial stewardship program (ASP) is one of the core elements needed to optimize antimicrobial use. Although collaboration at the national level to address the importance of ASPs ...and antimicrobial resistance has occurred in the Asia Pacific region, hospital-level ASP implementation in this region has not been comprehensively evaluated. Methods. We conducted a systematic review and meta-analysis to assess the efficacy of ASPs in inpatient settings in the Asia Pacific region from January 2005 through March 2016. The impact of ASPs on various outcomes, including patient clinical outcomes, antimicrobial prescription outcomes, microbiological outcomes, and expenditure were assessed. Results. Forty-six studies were included for a systematic review and meta-analysis. The pooled risk ratio for mortality from ASP before-after trials and 2-group comparative studies were 1.03 (95% confidence interval CI, .88–1.19) and 0.69 (95% CI, .56–.86), respectively. The pooled effect size for change in overall antimicrobial and carbapenem consumption (% difference) was −9.74% (95% CI, −18.93% to −.99%) and −10.56% (95% CI, −19.99% to −3.03%), respectively. Trends toward decreases in the incidence of multidrug-resistant organisms and antimicrobial expenditure (range, 9.7%–58.1% reduction in cost in the intervention period/arm) were also observed. Conclusions. ASPs in inpatient settings in the Asia Pacific region appear to be safe and effective to reduce antimicrobial consumption and improve outcomes. However, given the significant variations in assessing the efficacy of ASPs, high-quality studies using standardized surveillance methodology for antimicrobial consumption and similar metrics for outcome measurement are needed to further promote antimicrobial stewardship in this region.
In this cluster-randomized study at ICUs in six hospitals, chlorhexidine-impregnated washcloths were associated with significantly lower rates of bloodstream infections and acquisition of ...multidrug-resistant organisms than were nonantimicrobial washcloths.
Multidrug-resistant organisms (MDROs), including methicillin-resistant
Staphylococcus aureus
(MRSA) and vancomycin-resistant enterococcus (VRE), have become endemic in many acute care and long-term care facilities.
1
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5
Infections with these organisms are often difficult to treat, owing to a dwindling armamentarium of active antimicrobial agents. The Centers for Disease Control and Prevention (CDC) has promulgated a variety of strategies, including hand hygiene and the use of isolation precautions, to limit the spread of these organisms among patients, but these strategies require consistent adherence to practices by large numbers of health care personnel during frequent patient encounters and can be difficult to sustain.
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In . . .
Cyclosporins are natural or synthetic undecapeptides with a wide range of actual and potential pharmaceutical applications. Several members of the cyclosporin compound family have remarkably high ...passive membrane permeabilities that are not well-described by simple structural metrics. Here we review experimental studies of cyclosporin structure and permeability, including cyclosporin–metal complexes. We also discuss models for the conformation-dependent permeability of cyclosporins and similar compounds. Finally, we identify current knowledge gaps in the literature and provide recommendations regarding future avenues of exploration.
Abstract Background Staphylococcus aureus bacteremia results in substantial mortality. Infectious diseases specialist consultation can improve adherence to evidence-based management of S. aureus ...bacteremia, but its effect on mortality is unclear. Methods A 2-year prospective cohort study of patients with S. aureus bacteremia was performed at a large tertiary care hospital. Patients who died within 2 days of diagnosis were excluded. Independent risk factors for 28-day mortality were determined. Results Among 341 patients with S. aureus bacteremia, 189 (55%) were male, 196 (58%) were Caucasian, 185 (54%) had methicillin-resistant S. aureus , 108 (32%) had nosocomial bacteremia, and 231 (68%) had a central venous catheter at the time of diagnosis. The median age was 56 years (range 22-95 years). A total of 111 patients (33%) had an infectious diseases consultation. Fifty-four patients (16%) died within 28 days after diagnosis. Factors associated with mortality were intensive care unit admission 48 hours or less after the first positive blood culture (adjusted hazard ratio, 4.65; 95% confidence interval CI, 2.65-8.18), cirrhosis (adjusted hazard ratio, 4.44; 95% CI, 2.40-8.20), and advanced age (adjusted hazard ratio, 1.27 per every 10 years of age; 95% CI, 1.08-1.50). Infectious diseases consultation was associated with a 56% reduction in 28-day mortality (adjusted hazard ratio, 0.44; 95% CI, 0.22-0.89). Conclusion Only one third of patients with S. aureus bacteremia in this cohort had an infectious diseases specialist consultation. Infectious diseases consultation was independently associated with a reduction in 28-day mortality. Routine infectious diseases consultation should be considered for patients with S. aureus bacteremia, especially those with greater severity of illness or multiple comorbidities.
These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these ...infections or may be at risk for them.
With noncommunicable diseases (NCDs) now constituting the majority of global mortality, there is a growing need for low-cost, noninvasive methods to diagnose and treat this class of diseases, ...especially in resource-limited settings. Molecular biomarkers combined with low-cost point-of-care assays constitute a potential solution for diagnosing NCDs, but the dearth of naturally occurring, predictive markers limits this approach. Here, we describe the design of exogenous agents that serve as synthetic biomarkers for NCDs by producing urinary signals that can be quantified by a companion paper test. These synthetic biomarkers are composed of nanoparticles conjugated to ligand-encoded reporters via protease-sensitive peptide substrates. Upon delivery, the nanoparticles passively target diseased sites, such as solid tumors or blood clots, where up-regulated proteases cleave the peptide substrates and release reporters that are cleared into urine. The reporters are engineered for detection by sandwich immunoassays, and we demonstrate their quantification directly from unmodified urine; furthermore, capture antibody specificity allows the probes to be multiplexed in vivo and quantified simultaneously by ELISA or paper lateral flow assay (LFA). We tailor synthetic biomarkers specific to colorectal cancer, a representative solid tumor, and thrombosis, a common cardiovascular disorder, and demonstrate urinary detection of these diseases in mouse models by paper diagnostic. Together, the LFA and injectable synthetic biomarkers, which could be tailored for multiple diseases, form a generalized diagnostic platform for NCDs that can be applied in almost any setting without expensive equipment or trained medical personnel.
Abstract
The opioid epidemic has increased hospital admissions for serious infections related to opioid abuse. Our findings demonstrate that addiction medicine consultation is associated with ...increased treatment for opioid use disorder (OUD), greater likelihood of completing antimicrobial therapy, and reduced readmission rates among patients with OUD and serious infections requiring hospitalization.
Black Hairy Tongue Hamad, Yasir; Warren, David K
The New England journal of medicine,
09/2018, Letnik:
379, Številka:
10
Journal Article
Recenzirano
A 55-year-old woman started treatment with meropenem and minocycline for a polymicrobial infection. Within 1 week, she had tongue discoloration that was consistent with black hairy tongue.
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