In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup (SIPGWW) meeting. The objectives were ...to review areas of agreement among the most-recently published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the groups that have published North American guidelines for antimicrobial prophylaxis, as well as authors from several specialty colleges. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of SIPGWW include that infusion of the first antimicrobial dose should begin within 60 min before surgical incision and that prophylactic antimicrobials should be discontinued within 24 h after the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis, including specific suggestions regarding antimicrobial selection.
In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup meeting. The objectives were to review ...areas of agreement among the published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the published North American guidelines for antimicrobial prophylaxis and several specialty colleges. The workgroup reviewed currently published guidelines for antimicrobial prophylaxis. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of the workgroup include that infusion of the first antimicrobial dose should begin within 60 minutes before surgical incision and that prophylactic antimicrobial agents should be discontinued within 24 hours of the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis including specific suggestions regarding antimicrobial selection.
Background. Volunteer challenge studies have provided detailed data on viral shedding from the respiratory tract before and through the course of experimental influenza virus infection. There are no ...comparable quantitative data to our knowledge on naturally acquired infections. Methods. In a community-based study in Hong Kong in 2008, we followed up initially healthy individuals to quantify trends in viral shedding on the basis of cultures and reverse-transcription polymerase chain reaction (RT-PCR) through the course of illness associated with seasonal influenza A and B virus infection. Results. Trends in symptom scores more closely matched changes in molecular viral loads measured with RT-PCR for influenza A than for influenza B. For influenza A virus infections, the replicating viral loads determined with cultures decreased to undetectable levels earlier after illness onset than did molecular viral loads. Most viral shedding occurred during the first 2–3 days after illness onset, and we estimated that 1%–8% of infectiousness occurs prior to illness onset. Only 14% of infections with detectable shedding at RT-PCR were asymptomatic, and viral shedding was low in these cases. Conclusions. Our results suggest that “silent spreaders” (ie, individuals who are infectious while asymptomatic or presymptomatic) may be less important in the spread of influenza epidemics than previously thought.
Background. Large clinical trials have demonstrated the therapeutic efficacy of oseltamivir against influenza. We assessed the indirect effectiveness of oseltamivir in reducing secondary household ...transmission in an incident cohort of influenza index patients and their household members. Methods. We recruited index outpatients whose rapid test results were positive for influenza from February through September 2007 and January through September 2008. Household contacts were followed up for 7–10 days during 3–4 home visits to monitor symptoms. Nose and throat swabs were collected and tested for influenza by reverse-transcription polymerase chain reaction or viral culture. Results. We followed up 384 index patients and their household contacts. Index patients who took oseltamivir within 24 h of symptom onset halved the time to symptom alleviation (adjusted acceleration factor, 0.56; 95% confidence interval CI, 0.42–0.76). Oseltamivir treatment was not associated with statistically significant reduction in the duration of viral shedding. Household contacts of index patients who had taken oseltamivir within 24 h of onset had a nonstatistically significant lower risk of developing laboratory-confirmed infection (adjusted odds ratio, 0.54; 95% CI, 0.11–2.57) and a marginally statistically significant lower risk of clinical illness (adjusted odds ratio, 0.52; 95% CI, 0.25–1.08) compared with contacts of index patients who did not take oseltamivir. Conclusions. Oseltamivir treatment is effective in reducing the duration of symptoms, but evidence of household reduction in transmission of influenza virus was inconclusive.
There are sparse data on whether non-pharmaceutical interventions can reduce the spread of influenza. We implemented a study of the feasibility and efficacy of face masks and hand hygiene to reduce ...influenza transmission among Hong Kong household members.
We conducted a cluster randomized controlled trial of households (composed of at least 3 members) where an index subject presented with influenza-like-illness of <48 hours duration. After influenza was confirmed in an index case by the QuickVue Influenza A+B rapid test, the household of the index subject was randomized to 1) control or 2) surgical face masks or 3) hand hygiene. Households were visited within 36 hours, and 3, 6 and 9 days later. Nose and throat swabs were collected from index subjects and all household contacts at each home visit and tested by viral culture. The primary outcome measure was laboratory culture confirmed influenza in a household contact; the secondary outcome was clinically diagnosed influenza (by self-reported symptoms). We randomized 198 households and completed follow up home visits in 128; the index cases in 122 of those households had laboratory-confirmed influenza. There were 21 household contacts with laboratory confirmed influenza corresponding to a secondary attack ratio of 6%. Clinical secondary attack ratios varied from 5% to 18% depending on case definitions. The laboratory-based or clinical secondary attack ratios did not significantly differ across the intervention arms. Adherence to interventions was variable.
The secondary attack ratios were lower than anticipated, and lower than reported in other countries, perhaps due to differing patterns of susceptibility, lack of significant antigenic drift in circulating influenza virus strains recently, and/or issues related to the symptomatic recruitment design. Lessons learnt from this pilot have informed changes for the main study in 2008.
ClinicalTrials.gov NCT00425893 HKClinicalTrials.com HKCTR-365.
Few data are available about the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission.
To investigate whether hand hygiene and use of facemasks prevents ...household transmission of influenza.
Cluster randomized, controlled trial. Randomization was computer generated; allocation was concealed from treating physicians and clinics and implemented by study nurses at the time of the initial household visit. Participants and personnel administering the interventions were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00425893)
Households in Hong Kong.
407 people presenting to outpatient clinics with influenza-like illness who were positive for influenza A or B virus by rapid testing (index patients) and 794 household members (contacts) in 259 households.
Lifestyle education (control) (134 households), hand hygiene (136 households), or surgical facemasks plus hand hygiene (137 households) for all household members.
Influenza virus infection in contacts, as confirmed by reverse-transcription polymerase chain reaction (RT-PCR) or diagnosed clinically after 7 days.
Sixty (8%) contacts in the 259 households had RT-PCR-confirmed influenza virus infection in the 7 days after intervention. Hand hygiene with or without facemasks seemed to reduce influenza transmission, but the differences compared with the control group were not significant. In 154 households in which interventions were implemented within 36 hours of symptom onset in the index patient, transmission of RT-PCR-confirmed infection seemed reduced, an effect attributable to fewer infections among participants using facemasks plus hand hygiene (adjusted odds ratio, 0.33 95% CI, 0.13 to 0.87). Adherence to interventions varied.
The delay from index patient symptom onset to intervention and variable adherence may have mitigated intervention effectiveness.
Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of index patient symptom onset. These findings suggest that nonpharmaceutical interventions are important for mitigation of pandemic and interpandemic influenza.
Centers for Disease Control and Prevention.
Coronary artery disease is the leading cause of death among women over 65 years of age in the United States.
1
In 1992 it accounted for more than 45 percent of all deaths in women, which is more than ...the proportion due to all forms of cancer combined.
2
Case fatality rates after hospitalization for acute myocardial infarction decreased for both women and men from 1987 through 1994.
3
However, several studies have found that women receive less aggressive in-hospital therapy for acute myocardial infarction than do men,
4
–
15
even though studies have reported that the beneficial effects of thrombolytic agents, aspirin, beta-blockers, . . .
It is recommended that blood cultures be performed on all patients admitted to the hospital with pneumonia. Questions regarding the cost-effectiveness of this practice have emerged. We used data on ...13,043 Medicare patients hospitalized with pneumonia to determine predictors of bacteremia. Predictors included recent antibiotic treatment, liver disease, and three vital-sign and three laboratory abnormalities. Patients were stratified into three groups on the basis of the likelihood of bacteremia. We then created a decision support tool that recommends performing no blood cultures on patients with low likelihood of bacteremia, one blood culture on patients with moderate likelihood of bacteremia, and two blood cultures on patients with higher likelihood of bacteremia. This tool was then applied to a validation cohort of 12,771 patients with pneumonia. Use of the decision support tool would result in 38% fewer blood cultures being performed when compared with the standard practice of performing two blood cultures for each patient and identified 88 to 89% of patients with bacteremia. A simplified tool performed similarly overall but was less sensitive than was the first tool among pneumonia severity index Class V patients. These tools may allow clinicians to target patients with pneumonia in whom blood cultures are most likely to yield a pathogen.
The questions of whether the use of antibiotics that are active against atypical organisms is beneficial in the treatment of community-acquired pneumonia and of the potential mechanisms of any ...beneficial effects remain unresolved. Proposed mechanisms include activity against atypical organisms vs the immunomodulatory effects of these antibiotics. The study of outcomes of a large cohort of patients with bacteremic pneumonia provides a unique opportunity to address these questions by excluding patients with primary atypical infection.
We reviewed data from the charts of 2,209 Medicare patients who were admitted to hospitals across the United States from either home or a nursing facility with bacteremic pneumonia between 1998 and 2001. Patients were stratified according to the type of antibiotic treatment. Multivariate modeling was performed to assess the relationship between the class of antibiotic used and several outcome variables.
The initial use of any antibiotic active against atypical organisms was independently associated with a decreased risk of 30-day mortality (odds ratio OR, 0.76; 95% confidence interval CI, 0.59 to 0.98; p = 0.03) and hospital admission within 30 days of discharge (OR, 0.67; 95% CI, 0.51 to 0.89; p = 0.02). Further analysis revealed that the benefits of atypical treatment were associated with the use of macrolides, but not the use of fluoroquinolones or tetracyclines, with macrolides conferring lower risks of in-hospital mortality (OR, 0.59; 95% CI, 0.40 to 0.88; p = 0.01), 30-day mortality (OR, 0.61; 95% CI, 0.43 to 0.87; p = 0.007), and hospital readmission within 30 days of discharge (OR, 0.59; 95% CI, 0.42 to 0.85; p = 0.004).
Initial antibiotic treatment including a macrolide agent is associated with improved outcomes in Medicare patients hospitalized with bacteremic pneumonia. These results have implications regarding the mechanism by which the use of a macrolide for treatment of pneumonia is associated with improved outcomes.
CONTEXT Despite condition-specific and managed care–specific reports,
no systematic program has been developed for monitoring the quality of medical
care provided to Medicare beneficiaries. OBJECTIVE ...To create a monitoring system for a range of measures of clinical performance
that supports quality improvement and provides repeated, reliable estimates
at the national and state levels for fee-for-service (FFS) Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS National study of repeated, cross-sectional observational data collected
in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample
of beneficiaries with a particular condition. Data were collected using medical
record abstraction for inpatient care, analysis of Medicare claims for some
ambulatory services, and surveys for immunization rates. Separate samples
were drawn for each topic for each state. MAIN OUTCOME MEASURES Beneficiary patients' receipt of 24 process-of-care measures related
to primary prevention, secondary prevention, or treatment of 6 medical conditions
(acute myocardial infarction, breast cancer, diabetes mellitus, heart failure,
pneumonia, and stroke) for which there is strong scientific evidence and professional
consensus that the process of care either directly improves outcomes or is
a necessary step in a chain of care that does so. RESULTS Across all states for all measures, the percentage of patients receiving
appropriate care in the median state ranged from a high of 95% (avoidance
of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients
with pneumonia screened for pneumococcal immunization status before discharge).
The median performance on an indicator is 69% (patients discharged with heart
failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic
patients having an eye examination in the last 2 years). Some states (particularly
less populous states and those in the Northeast) consistently ranked high
in relative performance while others (particularly more populous states and
those in the Southeast) consistently ranked low. CONCLUSIONS It is possible to assemble information on a diverse set of clinical
performance measures that represent performance on the range of services in
a health insurance program. These findings indicate substantial opportunities
to improve the care delivered to Medicare beneficiaries and urgently invite
a partnership among practitioners, hospitals, health plans, and purchasers
to achieve that improvement.
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