Don't eat the spinach--controlling foodborne infectious disease.
Explore the source record for details and available documents.
Agriculture↗
Biomedical subjects
Dennis G Maki
Publications and source records attributed to Dennis G Maki.
Device-associated nosocomial infections in 55 intensive care units of 8 developing countries.
BACKGROUND: Health care-associated infections from invasive medical devices in the intensive care unit (ICU) are a major threat to patient safety. Most published studies of ICU-acquired infections have come from industrialized western countries. In a Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance (NNIS) System report, the U.S. pooled mean rates of central venous catheter (CVC)-related bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections were 4.0 per 1000 CVC days, 5.4 per 1000 mechanical ventilator days, and 3.9 per Foley catheter days, respectively. OBJECTIVE: To ascertain the incidence of device-associated infections in the ICUs of developing countries. DESIGN: Multicenter, prospective cohort surveillance of device-associated infection by using the CDC NNIS System definitions. SETTING: 55 ICUs of 46 hospitals in Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey that are members of the International Nosocomial Infection Control Consortium (INICC). MEASUREMENTS: Rates of device-associated infection per 100 patients and per 1000 device days. RESULTS: During 2002-2005, 21,069 patients who were hospitalized in ICUs for an aggregate 137,740 days acquired 3095 device-associated infections for an overall rate of 14.7% or 22.5 infections per 1000 ICU days. Ventilator-associated pneumonia posed the greatest risk (41% of all device-associated infections or 24.1 cases [range, 10.0 to 52.7 cases] per 1000 ventilator days), followed by CVC-related bloodstream infections (30% of all device-associated infections or 12.5 cases [range, 7.8 to 18.5 cases] per 1000 catheter days) and catheter-associated urinary tract infections (29% of all device-associated infections or 8.9 cases [range, 1.7 to 12.8 cases] per 1000 catheter days). Notably, 84% of Staphylococcus aureus infections were caused by methicillin-resistant strains, 51% of Enterobacteriaceae isolates were resistant to ceftriaxone, and 59% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones. The crude mortality rate for patients with device-associated infections ranged from 35.2% (for CVC-associated bloodstream infection) to 44.9% (for ventilator-associated pneumonia). LIMITATIONS: These initial data are not adequate to represent any entire country, and likely variations in the efficiency of surveillance and institutional resources may have affected the rates that were detected. CONCLUSIONS: Device-associated infections in the ICUs of these developing countries pose greater threats to patient safety than in U.S. ICUs. Active infection control programs that perform surveillance of infection and implement guidelines for prevention can improve patient safety and must become a priority in every country.
Catheterization, Central Venous↗
Use of vancomycin-containing lock or flush solutions for prevention of bloodstream infection associated with central venous access devices: a meta-analysis of prospective, randomized trials.
BACKGROUND: Prolonged exposure to central venous access devices carries significant risk of device-associated bloodstream infection (BSI), which is associated with morbidity, added health care costs, and attributable mortality. We aimed to determine the efficacy of vancomycin-heparin lock or flush solution in preventing BSI in patients being treated with long-term central venous intravascular devices (IVDs). METHODS: We collected data from January 1966 to January 2006 from multiple computerized databases and compiled reference lists of identified articles. We identified prospective, randomized controlled trials comparing a vancomycin-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term central venous IVDs. Using a standardized form, we abstracted data regarding study quality, patient characteristics, and incidence of BSI. RESULTS: Seven randomized, controlled trials involving a total of 463 patients being treated with IVDs met the inclusion criteria; 5 studies were conducted among patients with cancer, 1 among a critically ill neonatal population, and 1 among patients with cancer or who required parenteral nutrition. We could not detect publication bias. The summary risk ratio with a vancomycin heparin-lock solution for IVD-associated BSI was 0.49 (95% confidence interval [CI], 0.26-0.95; P = .03). Results of the test for heterogeneity were statistically significant; however, when a single study was removed from the analysis, heterogeneity was no longer present. Use of vancomycin as a true lock solution--instilling it for a defined period, rather than simply flushing it directly through the device--conferred a much greater benefit, with a risk ratio of 0.34 (95% CI, 0.12-0.98; P = .04). The 2 studies that performed prospective surveillance cultures to identify colonization or infection by vancomycin-resistant organisms did not find an increased risk. CONCLUSIONS: Use of a vancomycin lock solution in high-risk patient populations being treated with long-term central IVDs reduces the risk of BSI. The use of an anti-infective lock solution warrants consideration for patients who require central access but who are at high risk of BSI, such as patients with malignancy or low-birthweight neonates.
Adult↗
Disinfection of needleless catheter connectors and access ports with alcohol may not prevent microbial entry: the promise of a novel antiseptic-barrier cap.
BACKGROUND: Needleless valve connectors for vascular catheters are widely used throughout the United States because they reduce the risk of biohazardous injuries from needlesticks and exposure to bloodborne pathogens, such as human immunodeficiency virus and hepatitis C virus. Patients with long-term central venous catheters are at significant risk of acquiring catheter-related bloodstream infections caused by microbes that gain access through the connection between the administration set and the catheter or an injection port. Most healthcare practitioners wipe the membranous septum of the needleless connector or the injection port with 70% alcohol before accessing it. We report a simulation study of the efficacy of conventional alcohol disinfection before access, compared with that of a novel antiseptic-barrier cap that, when threaded onto a needleless luer-activated valved connector, allows a chlorhexidine-impregnated sponge to come into continuous contact with the membranous surface; after removal of the cap, there is no need to disinfect the surface with alcohol before accessing it. METHODS: One hundred five commercial, needleless luer-activated valved connectors, each accessible by a blunt male-connector luer-lock attachment, were purchased from 3 manufacturers and were tested. The membranous septum of each test device was first heavily contaminated with approximately 10(5) colony-forming units of Enterococcus faecalis and then was allowed to dry for 24 hours. Fifteen of the contaminated devices were not disinfected (positive controls), 30 were conventionally disinfected with a commercial 70% alcohol pledget, and 60 had the antiseptic cap threaded onto the connector and then removed after 10 minutes. The test connectors were then accessed with a sterile syringe containing nutrient broth media, which was injected, captured on the downstream side of the intraluminal fluid pathway, and cultured quantitatively. RESULTS: All 15 control connectors (100%) showed massive transmission of microorganisms across the membranous septum (4,500-10,000 colony-forming units). Of the 30 connectors accessed after conventional disinfection with 70% alcohol, 20 (67%) showed transmission of microorganisms (442-25,000 colony-forming units). In contrast, of the 60 connectors cultured after application of the novel antiseptic cap, only 1 (1.6%) showed any transmission of microorganisms (P < .001). CONCLUSIONS: The findings of this study show that, if the membranous septum of a needleless luer-activated connector is heavily contaminated, conventional disinfection with 70% alcohol does not reliably prevent entry of microorganisms. In contrast, the antiseptic-barrier cap provided a high level of protection, even in the presence of very heavy contamination. This novel technology deserves to be studied in a clinical trial.
Bacteriological Techniques↗
Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit.
BACKGROUND: We report the effectiveness of preemptive enhanced barrier precautions in containing a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a university hospital burn unit and further controlling endemic nosocomial MRSA infection in the unit during the succeeding 27 months. METHODS: During a 6-month period, 12 patients in a 7-bed burn unit were found to be colonized (7) or infected (5) by MRSA. An epidemiologic study was undertaken. RESULTS: Seven of the 10 strains of MRSA from patients that were available for DNA typing were clonally identical. Early in the outbreak, a health care worker was found to be a concordant nasal carrier and was successfully decolonized with nasal mupirocin. However, despite stringent compliance with isolation of MRSA-positive patients (targeted precautions), new cases of MRSA colonization or infection continued to occur. The outbreak was rapidly terminated after implementing preemptive barrier precautions with all patients in the unit: a new, clean gown and gloves for any physical contact with the patient or their environment. Although 25% of all nosocomial S aureus isolates in our hospital are resistant to methicillin, the incidence of endemic MRSA colonization and infection in the burn unit has remained very low since implementing barrier precautions unit wide (baseline rate, 2.2 [95% CI: 1.0-4.2] cases per 1000 patient-days; outbreak rate, 7.2 [95% CI: 4.4-11.0] cases per 1000 patient-days; post-outbreak termination endemic rate, 1.1 (95% CI: 0.4-2.3) cases per 1000 patient-days). The rate ratio comparing the outbreak and the baseline period was 3.20 (95% CI: 1.40-7.95, P = .002); the rate ratio comparing the post-outbreak period with the baseline period was 0.48 (95% CI: 0.14-1.53, P = .10), and it has not been necessary to screen personnel for MRSA carriage to prevent nosocomial MRSA infections in this highly vulnerable population. CONCLUSION: Preemptive barrier precautions were highly effective in controlling the outbreak and, most notably, have also been highly effective in maintaining a very low incidence of nosocomial MRSA infection endemically in the succeeding 27 months of follow-up. Use of clean gloves, with or without a gown, bears consideration for all high-risk hospitalized patients to prevent cross transmission of all multiresistant nosocomial pathogens.
Burn Units↗
The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies.
OBJECTIVE: To better understand the absolute and relative risks of bloodstream Infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults In which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI. METHODS: English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremla [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream Infection AND the specific type of intravascular device (e.g., central venous port). Mean rates of IVD-related BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days. RESULTS: Point incidence rates of IVD-related BSI were lowest with peripheral Intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the Intensive care unit. Surgically implanted long-term central venous devices--cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)--appear to have high rates of Infection when risk Is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodlalysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI. CONCLUSIONS: Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies In which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs In use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related Infection have focused on short-term noncuffed CVCs used in Intensive care units, Infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.
Catheterization↗
Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: a randomized, controlled trial.
BACKGROUND: Central venous catheter-related infections are a significant medical problem. Improved preventive measures are needed. OBJECTIVE: To ascertain 1) effectiveness of a second-generation antiseptic-coated catheter in the prevention of microbial colonization and infection; 2) safety and tolerability of this device; 3) microbiology of infected catheters; and 4) propensity for the development of antiseptic resistance. DESIGN: Multicenter, randomized, double-blind, controlled trial. SETTING: 9 university-affiliated medical centers. PATIENTS: 780 patients in intensive care units who required central venous catheterization. INTERVENTION: Patients received either a standard catheter or a catheter coated with chlorhexidine and silver sulfadiazine. MEASUREMENTS: The authors assessed catheter colonization and catheter-related infection, characterized microbes by molecular typing, and determined their susceptibility to antiseptics. Patient tolerance of the catheter was monitored. RESULTS: Patients with the 2 types of catheters had similar demographic features, clinical interventions, laboratory values, and risk factors for infection. Antiseptic catheters were less likely to be colonized at the time of removal compared with control catheters (13.3 vs. 24.1 colonized catheters per 1000 catheter-days; P < 0.01). The center-stratified Cox regression hazard ratio for colonization controlling for sampling design and potentially confounding variables was 0.45 (95% CI, 0.25 to 0.78). The rate of definitive catheter-related bloodstream infection was 1.24 per 1000 catheter-days (CI, 0.26 to 3.62 per 1000 catheter-days) for the control group versus 0.42 per 1000 catheter-days (CI, 0.01 to 2.34 per 1000 catheter-days) for the antiseptic catheter group (P = 0.6). Coagulase-negative staphylococci and other gram-positive organisms were the most frequent microbes to colonize catheters. Noninfectious adverse events were similar in both groups. Antiseptic susceptibility was similar for microbes recovered from either group. LIMITATIONS: The antiseptic catheter was not compared with an antibiotic-coated catheter, and no conclusion can be made regarding its effect on bloodstream infection. CONCLUSIONS: The second-generation chlorhexidine-silver sulfadiazine catheter is well tolerated. Antiseptic coating appears to reduce microbial colonization of the catheter compared with an uncoated catheter.
Aged↗
Are antimicrobial-impregnated catheters effective? When does repetition reach the point of exhaustion?
Explore the source record for details and available documents.
Anti-Bacterial Agents↗
A vancomycin-heparin lock solution for prevention of nosocomial bloodstream infection in critically ill neonates with peripherally inserted central venous catheters: a prospective, randomized trial.
OBJECTIVE: Critically ill neonates are at high risk for vascular catheter-related bloodstream infection (CRBSI), most often caused by coagulase-negative staphylococci. Most CRBSIs with long-term devices derive from intraluminal contaminants. The objective of this study was to ascertain the safety and the efficacy of a vancomycin-heparin lock solution for prevention of CRBSI. METHODS: A prospective, randomized double-blind trial was conducted during 2000-2001 at a community hospital level III NICU. Very low birth weight and other critically ill neonates with a newly placed peripherally inserted central venous catheter were randomized to have the catheter locked 2 or 3 times daily for 20 or 60 minutes with heparinized normal saline (n = 43) or heparinized saline that contained vancomycin 25 microg/mL (n = 42). The origin of each nosocomial bloodstream infection (BSI) was studied by culturing skin, catheter hubs, and implanted catheter segments and blood cultures, demonstrating concordance by restriction-fragment DNA subtyping. Surveillance axillary and rectal cultures were performed to detect colonization by vancomycin-resistant organisms. The main outcome measures were (1) CRBSIs and (2) colonization or infection by vancomycin-resistant Gram-positive bacteria. RESULTS: Two (5%) of 42 infants in the vancomycin-lock group developed a CRBSI as compared with 13 (30%) of 43 in the control group (2.3 vs 17.8 per 1000 catheter days; relative risk: 0.13; 95% confidence interval: 0.01-0.57). No vancomycin-resistant enterococci or staphylococci were recovered from any cultures. Vancomycin could not be detected in the blood of infants who did not receive systemic vancomycin therapy. Twenty-six neonates (8 vancomycin-lock group, 18 control group) had at the end of a catheter-lock period asymptomatic hypoglycemia that resolved promptly when glucose-containing intravenous fluids were restarted. CONCLUSIONS: Prophylactic use of a vancomycin-heparin lock solution markedly reduced the incidence of CRBSI in high-risk neonates with long-term central catheters and did not promote vancomycin resistance but was associated with asymptomatic hypoglycemia. The use of an anti-infective lock solution for prevention of CRBSI with long-term intravascular devices has achieved proof of principle and warrants selective application in clinical practice.
Anti-Bacterial Agents↗
Meta-analysis: methods for diagnosing intravascular device-related bloodstream infection.
BACKGROUND: No consensus exists on the best methods for diagnosis of intravascular device (IVD)-related bloodstream infection. PURPOSE: To identify the most accurate methods for diagnosis of IVD-related bloodstream infection. DATA SOURCES: 51 English-language studies published from 1966 to 31 July 2004. STUDY SELECTION: Studies of diagnostic tests for IVD-related bloodstream infection that described a reference standard and provided sufficient data to calculate sensitivity and specificity. DATA EXTRACTION: Study quality, diagnostic tests examined, patient characteristics, prevalence, sensitivity, and specificity. DATA SYNTHESIS: Pooled sensitivity and specificity were calculated for 8 diagnostic methods. Summary measures of accuracy were Q* (the upper leftmost point on the summary receiver-operating characteristic curve) and mean D (a log odds ratio). Subgroup analyses were used to assess heterogeneity. Overall, the most accurate test was paired quantitative blood culture (Q* = 0.94 [95% CI, 0.88 to 1.0]), followed by IVD-drawn quantitative [corrected] blood culture (Q* = 0.89 [CI, 0.79 to 0.99]) and the acridine orange leukocyte cytospin test (Q* = 0.89 [CI, 0.79 to 0.91]). The most accurate catheter segment culture test was quantitative culture (Q* = 0.87 [CI, 0.81 to 0.93]), followed by semi-quantitative culture (Q* = 0.84 [CI, 0.80 to 0.88]). Significant heterogeneity in pooled sensitivity and specificity was observed across all test categories. LIMITATIONS: The limited number of studies of some of the diagnostic methods precludes precise estimates of accuracy. CONCLUSIONS: Paired quantitative blood culture is the most accurate test for diagnosis of IVD-related bloodstream infection. However, most other methods studied showed acceptable sensitivity and specificity (both >0.75) and negative predictive value (>99%). The positive predictive value of all tests increased greatly with high pretest clinical probability. Catheters should not be cultured routinely but rather only if IVD-related bloodstream infection is suspected clinically.
Catheterization, Central Venous↗
The effects of prolonged ethanol exposure on the mechanical properties of polyurethane and silicone catheters used for intravascular access.
BACKGROUND: Products containing alcohol are commonly used with intravascular devices at insertion, to remove lipids from occluded intravascular devices used during parenteral nutrition, and increasingly for the prevention and treatment of intravascular device-related bloodstream infection. The effects of alcohol on the integrity of intravascular devices remain unknown. METHODS: Two types of widely used commercial peripherally inserted central catheters, one made of polyetherurethane and one made of silicone, were exposed to a 70% ethanol lock solution for up to 10 weeks. Mechanical testing was performed to identify force-at-break, stress, strain, modulus of elasticity, modulus of toughness, and wall area of ethanol-exposed and control catheters. RESULTS: No significant differences between exposed and unexposed catheters were identified for any of the mechanical parameters tested except for a marginal reduction in the modulus of elasticity for both polyetherurethane and silicone catheters and minor increases in the wall area of polyetherurethane catheters. CONCLUSIONS: These data indicate that exposure to a 70% ethanol lock solution does not appreciably alter the integrity of selected commercial polyetherurethane and silicone catheters. Given the greatly expanded use of alcoholic solutions with intravascular devices of all types, we believe that manufacturers would be well advised to subject their catheters and other intravascular devices to formal testing of the type employed in this study.
Catheterization↗
Severe community-acquired pneumonia as a cause of severe sepsis: data from the PROWESS study.
OBJECTIVE: To investigate community-acquired pneumonia (CAP) as a cause of severe sepsis in the PROWESS (Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis) trial and to evaluate the effect of drotrecogin alfa (activated) (DrotAA) in this subgroup. DESIGN: Retrospective analysis of the severe CAP subgroup in the PROWESS trial. SETTING: Tertiary care institutions in 11 countries. INTERVENTIONS: DrotAA (n = 850), 24 microg.kg.hr for 96 hrs, or placebo (n = 840). PARTICIPANTS: The 1,690 patients with severe sepsis enrolled in the PROWESS trial. MEASUREMENTS AND MAIN RESULTS: Patients were classified as having CAP if lung was the primary site of infection and if they were enrolled directly from home (private residence) with </=4 days in the hospital before receipt of study drug in the PROWESS trial. Survival at 28 days, hospital discharge, and 90 days was compared in DrotAA and placebo groups in the CAP subgroup of PROWESS and CAP subgroups based on disease severity. Of the 1,690 PROWESS patients, 35.6% (DrotAA, n = 324; placebo, n = 278) were classified as severe CAP. Of these severe CAP patients, 26.1% had Streptococcus pneumoniae infections. Within CAP, 79.1% were enrolled by the end of the second calendar day in the hospital, and approximately 90% of CAP patients were at high risk of death according to the Pneumonia Severity Index category. Based on their dependence on vasopressors, 59% of CAP patients were judged at high risk of death. Biomarkers of coagulation and inflammation were markedly abnormal in severe CAP patients. In severe CAP patients treated with DrotAA, a relative risk reduction in mortality of 28% was observed at 28 days, with a relative risk reduction in mortality of 14% observed at 90 days from the start of study drug infusion. The survival benefit was most pronounced in severe CAP patients with S. pneumoniae and in severe CAP patients at high risk of death as indicated by Acute Physiology and Chronic Health Evaluation II score of >/=25, Pneumonia Severity Index score of >/=4, or CURB-65 (confusion, urea, respiratory rate, blood pressure, age) score of >/=3. CONCLUSIONS: CAP associated with a high Pneumonia Severity Index score, bacteremia, or an intense coagulation and inflammatory response requiring intensive care unit care were indicators of a high risk of death from severe sepsis. In patients with severe sepsis resulting from CAP, a readily identifiable disease, DrotAA, improved survival compared with placebo.
APACHE↗
Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients.
BACKGROUND: Peripherally inserted central venous catheters (PICCs) are now widely used for intermediate and long-term access in current-day health care, especially in the inpatient setting, where they are increasingly supplanting conventional central venous catheters (CVCs) placed percutaneously into the internal jugular, subclavian, or femoral veins. Data on the risk of PICC-related bloodstream infection (BSI) with PICCs used in hospitalized patients are limited. STUDY OBJECTIVES: To determine the risk of PICC-related BSI in hospitalized patients. STUDY DESIGN: Prospective cohort study using data from two randomized trials assessing the efficacy of chlorhexidine-impregnated sponge dressing and chlorhexidine for cutaneous antisepsis. METHODS: PICCs inserted into the antecubital vein in two randomized trials during from 1998 to 2000 were prospectively studied; most patients were in an ICU. PICC-related BSI was confirmed in each case by demonstrating concordance between isolates colonizing the PICC at the time of removal and from blood cultures by restriction-fragment DNA subtyping. RESULTS: Overall, 115 patients had 251 PICCs placed. Mean duration of catheterization was 11.3 days (total, 2,832 PICC-days); 42% of the patients were in an ICU at some time, 62% had urinary catheters, and 49% had received mechanical ventilation. Six PICC-related BSIs were identified (2.4%), four with coagulase-negative staphylococcus, one with Staphylococcus aureus, and one with Klebsiella pneumoniae, a rate of 2.1 per 1,000 catheter-days. CONCLUSION: This prospective study shows that PICCs used in high-risk hospitalized patients are associated with a rate of catheter-related BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (2 to 5 per 1,000 catheter-days), much higher than with PICCs used exclusively in the outpatient setting (approximately 0.4 per 1,000 catheter-days), and higher than with cuffed and tunneled Hickman-like CVCs (approximately 1 per 1,000 catheter-days). A randomized trial of PICCs and conventional CVCs in hospitalized patients requiring central access is needed. Our data raise the question of whether the growing trend in many hospital hematology and oncology services to switch from use of cuffed and tunneled CVCs to PICCs is justified, particularly since PICCs are more vulnerable to thrombosis and dislodgment, and are less useful for drawing blood specimens. Moreover, PICCs are not advisable in patients with renal failure and impending need for dialysis, in whom preservation of upper-extremity veins is needed for fistula or graft implantation.
Bacteremia↗
Avian H5N1 influenza--are we inching closer to a global pandemic?
Explore the source record for details and available documents.
Disease Outbreaks↗
The pathogenesis of ventilator-associated pneumonia: its relevance to developing effective strategies for prevention.
Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit and is associated with major morbidity and attributable mortality. Strategies to prevent VAP are likely to be successful only if based upon a sound understanding of pathogenesis and epidemiology. The major route for acquiring endemic VAP is oropharyngeal colonization by the endogenous flora or by pathogens acquired exogenously from the intensive care unit environment, especially the hands or apparel of health-care workers, contaminated respiratory equipment, hospital water, or air. The stomach represents a potential site of secondary colonization and reservoir of nosocomial Gram-negative bacilli. Endotracheal-tube biofilm formation may play a contributory role in sustaining tracheal colonization and also have an important role in late-onset VAP caused by resistant organisms. Aspiration of microbe-laden oropharyngeal, gastric, or tracheal secretions around the cuffed endotracheal tube into the normally sterile lower respiratory tract results in most cases of endemic VAP. In contrast, epidemic VAP is most often caused by contamination of respiratory therapy equipment, bronchoscopes, medical aerosols, water (eg, Legionella) or air (eg, Aspergillus or the severe acute respiratory syndrome virus). Strategies to eradicate oropharyngeal and/or intestinal microbial colonization, such as with chlorhexidine oral care, prophylactic aerosolization of antimicrobials, selective aerodigestive mucosal antimicrobial decontamination, or the use of sucralfate rather than H(2) antagonists for stress ulcer prophylaxis, and measures to prevent aspiration, such as semirecumbent positioning or continuous subglottic suctioning, have all been shown to reduce the risk of VAP. Measures to prevent epidemic VAP include rigorous disinfection of respiratory equipment and bronchoscopes, and infection-control measures to prevent contamination of medical aerosols. Hospital water should be Legionella-free, and high-risk patients, especially those with prolonged granulocytopenia or organ transplants, should be cared for in hospital units with high-efficiency-particulate-arrestor (HEPA) filtered air. Routine surveillance of VAP, to track endemic VAPs and facilitate early detection of outbreaks, is mandatory.
Anti-Bacterial Agents↗
The role of the intensive care unit environment in the pathogenesis and prevention of ventilator-associated pneumonia.
Ventilator-associated pneumonia is preceded by lower-respiratory-tract colonization by pathogenic microorganisms that derive from endogenous or exogenous sources. Most ventilator-associated pneumonias are the result of exogenous nosocomial colonization, especially, pneumonias caused by resistant bacteria, such as methicillin-resistant Staphylococcus aureus and multi-resistant Acinetobacter baumannii and Pseudomonas aeruginosa, or by Legionella species or filamentous fungi, such as Aspergillus. Exogenous colonization originates from a very wide variety of animate and inanimate sources in the intensive care unit environment. As a result, a strategic approach that combines measures to prevent cross-colonization with those that focus on oral hygiene and prevention of microaspiration of colonized oropharyngeal secretions should bring the greatest reduction in the risk of ventilator-associated pneumonia. This review examines strategies to prevent transmission of environmental pathogens to the vulnerable mechanically-ventilated patient.
Cross Infection↗
Infected bilomas in liver transplant recipients: clinical features, optimal management, and risk factors for mortality.
BACKGROUND: Infected hepatic fluid collections (bilomas) are a major infectious complication of liver transplantation. Limited data exist on management and outcome of biloma. METHODS: We report a cohort study of 57 liver transplant recipients with posttransplantation bilomas undertaken to identify the clinical features of biloma, management strategies, and outcome. RESULTS: Fever (44%) and abdominal pain (40%) were the most common presenting symptoms, but one-third of patients were asymptomatic; 79% had elevated hepatic enzyme levels. Patients without hepatic artery thrombosis (HAT) had the highest rates of resolution with percutaneous drainage and anti-infective therapy (64%). Retransplantation was necessary in 64% of patients with HAT and biloma. Independent predictors of resolution with nonsurgical therapy were absence of HAT (odds ratio [OR] 7.69; P=.01) and absence of Candida (OR, 9.09; P=.02) or enterococcal infection (OR, 7.69; P=.03). Patients with bilomas had significantly greater mortality (Cox proportional hazard ratio [HR], 2.38; P=.008, by log rank test) and graft loss (HR, 4.31; P<.0001). Predictors of mortality by multivariable analysis included renal insufficiency (OR, 12.51; P=.02) or infection with Candida species (OR, 4.93; P=.03) or gram-negative bacilli (OR, 9.12; P=.01). CONCLUSION: Posttransplantation biloma should be suspected in patients with fever or abdominal pain or abnormalities of hepatic enzymes, and it can be confirmed by computerized tomography and radiographically guided aspiration. Bilomas are most likely to be successfully treated nonsurgically in patients without HAT and without Candida or enterococcus infection.
Candida↗