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Biomedical subjects

L E Nicolle

Publications and source records attributed to L E Nicolle.

At least 19 recordsLinked to original sources
PubMed2001

An outbreak of methicillin resistant Staphylococcus aureus on a burn unit: potential role of contaminated hydrotherapy equipment.

OBJECTIVE: To report a multi-institution outbreak caused by a single strain of methicillin-resistant Staphylococcus aureus (MRSA). OUTBREAK: Between September 19 and November 20, 1996 an index case and five secondary cases of nosocomial MRSA occurred on a 26 bed adult plastic surgery/burn unit (PSBU) at a tertiary care teaching hospital. Between November 11 and December 23, 1996, six additional cases were identified at a community hospital. One of the community hospital cases was transferred from the PSBU. All strains were identical by pulsed-field gel electrophoresis. MRSA may have contributed to skin graft breakdown in one case, and delayed wound healing in others. Patients required 2 to 226 isolation days. CONTROL MEASURES: A hand held shower and stretcher for showering in the hydrotherapy room of the PSBU were culture positive for the outbreak strain, and the presumed means of transmission. Replacement of stretcher showering with bedside sterile burn wound compresses terminated the outbreak. The PSBU was closed to new admissions and transfers out for 11 days during the investigation. Seven of 12 patients had effective decolonization therapy. CONCLUSION: Environmental contamination is a potential source of nosocomial MRSA transmission on a burn unit. Notification among institutions and community care providers of shared patients infected or colonized with an antimicrobial resistant microorganism is necessary.

Adult↗
PubMed2001

Urinary tract infection in adults: research priorities and strategies.

Waning interest in urinary tract infection (UTI) research has limited clinical advances during the past two decades. Although care has improved for some specific UTI syndromes, there is limited evidence for most of the decisions made each day in the management of these infections. Additional clinical research is necessary to improve UTI prevention and care strategies.

Adult↗
PubMed2001

Development of minimum criteria for the initiation of antibiotics in residents of long-term-care facilities: results of a consensus conference.

Establishing a clinical diagnosis of infection in residents of long-term-care facilities (LTCFs) is difficult. As a result, deciding when to initiate antibiotics can be particularly challenging. This article describes the establishment of minimum criteria for the initiation of antibiotics in residents of LTCFs. Experts in this area were invited to participate in a consensus conference. Using a modified delphi approach, a questionnaire and selected relevant articles were sent to participants who were asked to rank individual signs and symptoms with respect to their relative importance. Using the results of the weighting by participants, a modification of the nominal group process was used to achieve consensus. Criteria for initiating antibiotics for skin and soft-tissue infections, respiratory infections, urinary infections, and fever where the focus of infection is unknown were developed.

Aged↗
PubMed2001

Urinary tract infections in long-term-care facilities.

Urinary tract infection (UTI) is the most common bacterial infection occurring in residents of long-term-care facilities. It is a frequent reason for antimicrobial administration, but antimicrobial use for treating UTIs is often inappropriate. Achieving optimal management of UTI in this population is problematic because of the very high prevalence of bacteriuria, evidence that the treatment of asymptomatic bacteriuria is not beneficial, and the clinical and microbiological imprecision in diagnosing symptomatic UTI. This position paper has been developed, using available evidence, to assist facilities and healthcare professionals in managing this common problem.

Age Distribution↗
PubMed2001

The chronic indwelling catheter and urinary infection in long-term-care facility residents.

From 5% to 10% of residents of long-term-care facilities have urinary drainage managed with chronic indwelling catheters. These residents are always bacteriuric, usually with a complex microbiological flora of two to five organisms and a biofilm on the catheter that may contribute to obstruction. Residents with chronic indwelling catheters have increased morbidity from urinary infection compared to bacteriuric residents without chronic catheters. The most effective means to prevent infection is limitation of chronic indwelling catheter use. While appropriate catheter care and infection control precautions are recommended in managing these patients, the impact of these practices on the occurrence of urinary infection or prevention of symptomatic episodes has not been evaluated. Symptomatic infection can likely be prevented by attention to catheter care, including early recognition and replacement of obstructed catheters and prevention of catheter trauma. Appropriate use of prophylactic antimicrobial therapy prior to invasive genitourinary procedures is also necessary. Asymptomatic bacteriuria should not be treated. When symptomatic episodes occur, patients should be evaluated clinically and microbiologically and treated with appropriate antimicrobial therapy. Further technological advances in catheter material and urine drainage will be needed to have a substantial impact on the frequency of urinary infection with chronic catheter use.

Bacteriuria↗
PubMed2001

A practical guide to antimicrobial management of complicated urinary tract infection.

Complicated urinary tract infection occurs in the setting of a functionally or structurally abnormal genitourinary tract. Many different abnormalities may lead to a designation of complicated urinary tract infection, and these abnormalities will have different influences on the frequency of infection and likelihood of relapse or reinfection. The microbiology of complicated urinary tract infection is characterised by a greater variety of organisms and increased likelihood of antimicrobial resistance compared with acute uncomplicated urinary tract infection. Appropriate management requires a urine specimen for culture prior to institution of antimicrobial therapy, and ensuring that the underlying abnormality is fully characterised to determine whether it can be corrected. A wide variety of antimicrobial agents are effective for treatment, and are usually given for 7 to 14 days. If the underlying abnormality can be corrected, subsequent infections may be prevented. However, if the underlying abnormality cannot be corrected a high recurrence rate of infection, approaching 50% by 4 to 6 weeks, is expected. Further study of complicated urinary tract infection is necessary, including determination of when asymptomatic bacteriuria warrants treatment, and exploration of nonantimicrobial approaches to management.

Anti-Infective Agents↗
PubMed2000

Urinary tract infection in long-term-care facility residents.

Urinary tract infection is the most frequent bacterial infection in residents of long-term-care facilities. Most infections are asymptomatic, with a remarkable prevalence of asymptomatic bacteriuria of 15%-50% among all residents. The major reasons for this high prevalence are chronic comorbid illnesses with neurogenic bladder and interventions to manage incontinence. Prospective, randomized, comparative trials of therapy and no therapy for asymptomatic bacteriuria among nursing home residents have repeatedly documented that antimicrobial treatment had no benefits. However, there is substantial diagnostic uncertainty in determining whether an individual with a positive urine culture has symptomatic or asymptomatic infection when there is clinical deterioration and there are no localized findings. In the noncatheterized resident, urinary infection is an infrequent source of fever but may not be definitively excluded. The use of antimicrobials for treatment of urinary infection is part of the larger concern about appropriate antimicrobial use in long-term-care facilities and the impacts of the selective pressure of antimicrobials on colonization and infection with resistant organisms.

Aged↗
PubMed2000

Infection control in long-term care facilities.

Infections are common in long-term care facilities. The most frequent endemic infections are urinary infection, respiratory infection, and skin and soft tissue infections. Outbreaks also occur frequently, and some facilities have a high prevalence of colonization of residents with antimicrobial-resistant organisms. Our understanding of infections and the development of infection-control programs for long-term care facilities have progressed greatly over the past 15 years. Whereas the occurrence of infections has been described and specific guidelines for infection-control programs in long-term care facilities have been developed, there is still limited evaluation of the effectiveness of programs or specific interventions to support prioritization of infection-control resources. In addition, the spectrum of patients and care delivered in long-term care facilities continues to evolve. Increasingly, chronic care patients, including those requiring chronic respirator therapy, dialysis, or percutaneous feeding tubes, are cared for in these facilities. Our understanding of prevention of infection in these patients remains limited. Important questions include what interventions may prevent endemic infections, what are the most effective means to identify outbreaks early, and what interventions may minimize the prevalence of antimicrobial-resistant organisms. Programs to optimize antimicrobial use need to be developed. Thus, although progress in understanding and practice has been made, important questions remain.

Aged↗
PubMed2000

Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee.

There is intense antimicrobial use in long-term-care facilities (LTCFs), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and the virtual absence of relevant clinical trials. This position paper recommends approaches to management of common infections in LTCF patients and proposes minimal standards for an antimicrobial review program. In developing these recommendations, the position paper acknowledges the unique aspects of provision of care in the LTCF.

Aged↗
PubMed2000

Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection.

PURPOSE: We determined whether routine replacement of a chronic indwelling catheter before instituting antimicrobial therapy leads to an improved bacteriological or clinical outcome when treating symptomatic urinary tract infection in elderly nursing home residents. MATERIALS AND METHODS: We performed a prospective randomized open clinical trial at 2 long-term care facilities. Patients were randomized to indwelling catheter replacement before initiating antimicrobial therapy or no replacement. Urine and blood cultures were done before antimicrobial therapy began. Clinical and microbiological outcomes were assessed after 3 days of therapy, and 7 and 28 days after therapy was complete. RESULTS: Enrolled in our study were 21 male and 33 female nursing home residents with a mean age of 72.6 years, a chronic indwelling catheter and a clinical diagnosis of urinary tract infection. A total of 27 cases were randomized to either catheter replacement and no replacement before antimicrobial therapy. Polymicrobial bacteriuria significantly decreased 3 days after therapy was initiated, and 7 and 28 days after it was discontinued in 24 versus 8 (p = 0.002), 18 versus 9 (p = 0.01) and 13 versus 5 (p = 0.02) patients with and without catheter replacement, respectively. Catheter replacement was also associated with a shorter time to afebrile status, improved clinical status 72 hours after the initiation of therapy in 25 versus 11 patients (p <0.001) and a lower rate of symptomatic clinical relapse 28 days after therapy in 3 versus 11 (p = 0.015). CONCLUSIONS: Clinical and bacteriological outcomes are improved when long-term indwelling catheters are replaced before initiating antimicrobial therapy for symptomatic urinary tract infection.

Aged↗
PubMed2000

Pivmecillinam in the treatment of urinary tract infections.

The efficacy of pivmecillinam for empirical treatment of acute uncomplicated urinary tract infection (UTI) was initially reported in clinical trials published in the 1970s and 1980s. Bacteriological cure rates observed in these trials were consistently >85%, and studies of different dosing regimens suggested that a 3 day course was appropriate. Comparative studies reported that pivmecillinam was equivalent to other antimicrobial agents in terms of clinical and bacteriological outcomes. These studies also documented that pivmecillinam was effective for treatment of Staphylococcus saprophyticus infections, was acceptable for use in pregnancy and was well tolerated. Subsequent widespread use of pivmecillinam in Scandinavian countries has led to a body of clinical experience which confirms the efficacy and safety of this antimicrobial agent in the treatment of acute cystitis. Recently, two large, prospective, randomized, double-blind, multi-centre clinical trials have been completed to assist in defining the role of this antimicrobial agent in the treatment of acute cystitis. A comparison of 3 day courses of pivmecillinam or norfloxacin, both at 400 mg bd, showed higher bacteriological cure rates with norfloxacin but generally similar clinical outcomes. A second, dose-ranging study found that pivmecillinam, given bd for 7 days, led to superior bacteriological and clinical outcomes at short-term follow-up than the 3 day regimen. Pooling bacteriological outcomes from the two studies showed similar outcomes with 7 days of pivmecillinam 200 mg bd or 3 days of norfloxacin 400 mg bd. The shorter, 3 day, course achieved similar short-term clinical outcomes to 7 days of pivmecillinam and 3 days of norfloxacin in women aged < or =50 years. These recent studies confirm earlier reports and clinical experience that pivmecillinam is effective and well tolerated for the treatment of acute cystitis in women.

Amdinocillin Pivoxil↗
PubMed1999

Candidemia at selected Canadian sites: results from the Fungal Disease Registry, 1992-1994. Fungal Disease Registry of the Canadian Infectious Disease Society.

BACKGROUND: Candida species are important bloodstream pathogens that are being isolated with increasing frequency. Despite the availability of effective antifungal therapy, the mortality rate associated with Candida infection remains high. With the objective of describing the epidemiology of candidemia, the Canadian Infectious Disease Society conducted a study of candidemia in Canada. METHODS: Fourteen medical centres across Canada identified all patients with candidemia from March 1992 to February 1994 through blood culture surveillance for Candida spp. Patient-related data for invasive fungal infection were compiled retrospectively by chart review using a standardized data-recording form developed for the Fungal Disease Registry of the Canadian Infectious Disease Society. Cases of Candidemia were studied in relation to underlying medical conditions, predisposing factors, concurrent infection, antimicrobial agents, antifungal treatment and deaths. RESULTS: In total, 415 cases of candidemia were identified, 48 (11.6%) in children and 367 (88.4%) in adults. The causative pathogens were C. albicans in 286 cases (68.9%), C. parapsilosis in 43 (10.4%), C. glabrata in 34 (8.2%), C. tropicalis in 27 (6.5%) and other Candida species in 18 (4.3%); polymicrobial candidemia occurred in 7 cases (1.7%). The overall mortality rate was 46%, and the rate of deaths clinically related to candidemia was 19%. However, only 13 (27%) of the children died. A univariate analysis indicated that significant risk factors for death were age greater than 60 years, therapy for concomitant bacterial infection, stay in an intensive care unit, concurrent malignant disease, cytotoxic chemotherapy and granulocytopenia, although only age and stay in an intensive care unit emerged as significant risk factors in the multivariate analysis. After adjustment for other predictors of death, only infection with C. parapsilosis was associated with a lower mortality rate than infection with C. albicans. Treatment was given in 352 (84.8%) of cases. Amphotericin B was the preferred agent in 244 cases (69.3% of those treated); fluconazole was used in 101 cases (28.7%) and ketoconazole in 5 cases (1.4%). INTERPRETATION: Candidemia in Canada is caused predominantly by C. albicans. The mortality rate associated with candidemia is high, but it varies with the species of Candida and is lower in children than in adults. Age greater than 60 years and stay in an intensive care unit were the most significant risk factors for overall mortality.

Adult↗
PubMed1999

Asymptomatic bacteriuria in spinal cord patients and the elderly.

The prevalence and incidence of symptomatic and asymptomatic bacteriuria will remain high for many years to come. Antimicrobial agents are necessary to treat symptomatic UTI because no natural methods have been shown to be effective. Treatment of ABU is not appropriate. There is growing resistance to antibiotics, biocides, and antiseptics and, simultaneously, a decreasing rate of introduction of new antibacterial agents; thus the problem of resistance is magnified and potentially complicates the management of patients with SCI and elderly persons. New options of managing health and of preventing ABU and UTI and the complications arising from these diseases must be investigated vigorously and urgently. In particular, further study of the role of bacterial biofilms, the normal microflora, the influence of diet and hygiene, and the importance of the host immune response in the process of urinary tract colonization and infection is relevant and necessary.

Aged↗