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R R Muder

Publications and source records attributed to R R Muder.

At least 19 recordsLinked to original sources
PubMed2001

Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality in long-term care facilities. Prior studies of pneumonia have failed to identify risk factors potentially amenable to intervention. Our objectives were to (1) identify modifiable risk factors for the occurrence of pneumonia and (2) determine the long-term impact of pneumonia on survival. METHODS: We performed a case-control study among residents of a Veterans Affairs long-term care facility. Case patients included all patients developing pneumonia from 2 days to 1 year after admission. Control subjects were matched for admission date, level of nursing care, and dependence in activities of daily living. Patients were followed up for 2 years or until death or discharge from the facility. RESULTS: We identified 104 case-control pairs. Risk factors significantly associated with pneumonia included witnessed aspiration (odds ratio, 13.9; 95% confidence interval, 1.7-111.0; P =.01), sedative medication (odds ratio, 2.6; 95% confidence interval, 1.2-5.4; P =.01), and comorbidity score (odds ratio, 1.2; 95% confidence interval, 1.0-1.4; P =.05). Mortality due to pneumonia was 23% at 14 days. Patients with pneumonia had a significantly higher mortality than did controls at 1 year (75% vs 40%; P<.001); survival curves converged at 2 years. In a Cox proportional hazards regression model, an episode of pneumonia was independently associated with mortality during follow-up (odds ratio, 2.6; 95% confidence interval, 1.7-3.9; P<.001). CONCLUSIONS: Among long-term care patients closely matched for age, level of dependency, and duration of institutionalization, an episode of pneumonia is associated with significant excess mortality that persists for up to 2 years. Two identified risk factors, large-volume aspiration and receipt of sedating medication, are potentially amenable to intervention.

Activities of Daily Living↗
PubMed2001

Determinants of vancomycin resistance and mortality rates in enterococcal bacteremia. a prospective multicenter study.

BACKGROUND: Enterococcus species are major nosocomial pathogens and are exhibiting vancomycin resistance with increasing frequency. Previous studies have not resolved whether vancomycin resistance is an independent risk factor for death in patients with invasive disease due to Enterococcus species or whether antibiotic therapy alters the outcome of enterococcal bacteremia. OBJECTIVE: To determine whether vancomycin resistance is an independent predictor of death in patients with enterococcal bacteremia and whether appropriate antimicrobial therapy influences outcome. DESIGN: Prospective observational study. SETTING: Four academic medical centers and a community hospital. PATIENTS: All patients with enterococcal bacteremia. MEASUREMENTS: Demographic characteristics; underlying disease; Acute Physiology and Chronic Health Evaluation (APACHE) II scores; antibiotic therapy, immunosuppression, and procedures before onset; and antibiotic therapy during the ensuing 6 weeks. The major end point was 14-day survival. RESULTS: Of 398 episodes, 60% were caused by E. faecalis and 37% were caused by E. faecium. Thirty-seven percent of isolates exhibited resistance or intermediate susceptibility to vancomycin. Twenty-two percent of E. faecium isolates showed reduced susceptibility to quinupristin-dalfopristin. Previous vancomycin use (odds ratio [OR], 5.82 [95% CI, 3.20 to 10.58]; P < 0.001), previous corticosteroid use (OR, 2.43 [CI, 1.22 to 4.86]; P = 0.01), and total APACHE II score (OR, 1.06 per unit change [CI, 1.02 to 1.10 per unit change]; P = 0.003) were associated with vancomycin-resistant enterococcal bacteremia. The mortality rate was 19% at 14 days. Hematologic malignancy (OR, 3.83 [CI, 1.56 to 9.39]; P = 0.003), vancomycin resistance (OR, 2.10 [CI, 1.14 to 3.88]; P = 0.02), and APACHE II score (OR, 1.10 per unit change [CI, 1.05 to 1.14 per unit change]; P < 0.001) were associated with 14-day mortality. Among patients with monomicrobial enterococcal bacteremia, receipt of effective antimicrobial therapy within 48 hours independently predicted survival (OR for death, 0.21 [CI, 0.06 to 0.80]; P = 0.02). CONCLUSIONS: Vancomycin resistance is an independent predictor of death from enterococcal bacteremia. Early, effective antimicrobial therapy is associated with a significant improvement in survival.

APACHE↗
PubMed2001

Control of an outbreak of infection due to extended-spectrum beta-lactamase--producing Escherichia coli in a liver transplantation unit.

We report an outbreak of infection due to genotypically identical extended-spectrum beta-lactamase--producing Escherichia coli among patients in a liver transplantation unit. Control of the outbreak was achieved by a combination of contact isolation, feedback on hand hygiene, and gut decontamination with an orally administered fluoroquinolone. These interventions led to abrupt curtailment of the outbreak.

Disease Outbreaks↗
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↗
PubMed2000

Approach to the problem of pneumonia in long-term care facilities.

The incidence of pneumonia among patients in long-term care facilities is approximately 1/1000 patient-days. Evidence indicates that the majority can be managed without transfer to a hospital. Immunization with pneumococcal and influenza vaccines is appropriate for all residents.

Aged↗
PubMed2000

Legionnaires' disease in a newly constructed long-term care facility.

OBJECTIVES: To determine whether a newly-constructed long-term care facility would become colonized with Legionella and whether Legionnaires' disease would occur in residents of this new facility. DESIGN: Prospective environmental surveillance of the hospital's water distribution system for the presence of Legionella pneumophila during construction. Utilization of diagnostic tests for Legionnaires' disease in cases of nosocomial pneumonia. SETTING: The Pittsburgh VA Health Care System, Aspinwall Division, a two-building 400-bed complex. PARTICIPANTS: Six patients who acquired Legionnaires' disease while in the facility. INTERVENTION: Installation of copper-silver ionization systems. MEASUREMENTS: Isolation of L. pneumophila from potable water and the occurrence of Legionnaires' disease. RESULTS: L. pneumophila serogroup 1 was recovered from the water distribution system within 1 month of operation; 74% (61/82) of distal sites were positive during construction. In the first 2 years of occupancy, six cases of legionellosis were diagnosed. Both clinical isolates of L. pneumophila were identical to environmental isolates by pulsed field gel electrophoresis (PFGE). Copper-silver ionization systems were installed to control Legionella in the water system. CONCLUSIONS: We conclude that long-term care residents are at risk for acquiring nosocomial Legionnaires' disease in the presence of a colonized water system, even in a newly constructed building.

Aged↗
PubMed1999

Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections.

Because of high incidence of catheter-related urinary tract infections (UTIs) in our Veterans Affairs medical center, we began providing nursing staff with unit-specific UTI rates. In our preintervention period, the first quarter of 1995, 38 infections occurred in 1186 catheter-patient-days or 32/1000 catheter-patient-days (95% CI, 22.9-43.7). Thereafter, nursing staff members were provided with a quarterly report with catheter-related UTI rates depicted graphically by unit. In the 18 months after this intervention, the mean UTI rate decreased to 17.4/1000 catheter-patient-days (95% CI, 14.6-20.6, P =.002). We estimated a cost savings of $403,000. We conclude that unit-specific feedback of nosocomial UTI rates to nursing staff is a highly effective method of reducing infection rates and reducing costs associated with nosocomial UTI.

Cross Infection↗
PubMed1999

Methicillin-resistant Staphylococcus aureus in the community: a hospital-based study.

To determine the proportion of methicillin-resistant Staphylococcus aureus (MRSA) among patients presenting for hospitalization and to assess risk factors for MRSA carriage, we conducted a study for 13 months at five Pittsburgh-area hospitals. Of 504 S aureus identified, 125 (25%) were MRSA. Independent risk factors for MRSA included organ transplantation, employment in a healthcare facility, pressure sores, tube feeding, and hospitalization within the preceding year.

Carrier State↗
PubMed1998

Pneumonia in residents of long-term care facilities: epidemiology, etiology, management, and prevention.

Pneumonia is a leading cause of morbidity and mortality among patients in long-term care facilities; the median reported incidence is 1 per 1,000 patient-days. Risk factors include functional dependency, chronic pulmonary disease, and conditions causing aspiration. The frequency of etiologic agents varies widely among reports; for example; Streptococcus pneumoniae ranges from 0% to 39% of cases, and gram negative bacilli ranges from 0% to 51% of reported cases. Viral respiratory infections, particularly influenza and respiratory syncytial virus, typically occur in outbreaks. Mortality varies from 5% to 40%; functional status is the major determinant of survival. Many patients receive inadequate initial evaluations, and as many as 40% receive no physician visit during the episode. Although transfer to an acute care facility occurs in 9% to 51% of cases, most transferred patients could be managed in the nursing home with minimal additional support. Appropriate evaluation includes examination by a practitioner, recording of vital signs, chest radiograph, and examination of an adequate sputum sample, if available. Patients without contraindications to oral therapy or severe abnormalities of vital signs (pulse > 120 beats per minute, respirations >30 per minute, systolic blood pressure < 90) may initially receive oral therapy. Appropriate oral agents include amoxicillin/clavulanate, second generation cephalosporins, quinolones active against S pneumoniae, or trimethoprim/sulfamethoxazole. Appropriate parenteral agents include beta-lactam/beta-lactamase inhibitor combinations, second or third generation cephalosporins, or quinolones. Pneumococcal and influenza vaccines should be administered to all residents. Future studies should focus on identifying risk factors for pneumonia that are amenable to intervention and to identifying highly effective, preferably oral, antimicrobial regimens in randomized trials.

Cross Infection↗
PubMed1998

Infection and colonization with vancomycin-resistant Enterococcus faecium in an acute care Veterans Affairs Medical Center: a 2-year survey.

BACKGROUND: After our first known patient with vancomycin-resistant enterococci (VRE) infection was admitted in 1993, we observed a gradual increase in infections and colonization caused by this organism. Thus we initiated a prospective study to quantitate the incidence of VRE infection versus colonization, to identify risk factors for VRE, and to define the natural history of VRE colonization among our patients. METHODS: Stool/rectal cultures were performed for patients admitted to the intensive care units at the time of admission and weekly thereafter. Patients found to be carrying VRE were followed with cultures every 2 weeks, and this protocol was continued after transfer to the medical-surgical wards. A surveillance form was initiated on each VRE patient and included demographics, underlying diseases, and risk factors. Environmental cultures in the intensive care units were randomly performed. Patients with positive cultures were isolated. RESULTS: During a 27-month period, 210 patients were found to be colonized or infected with VRE. Ages ranged from 35 to 97 years; the mean age was 65 years. Fourteen percent (29 of 210) of the patients were VRE positive on admission. Nosocomial colonization or infection occurred at an average of 28 days after admission. Seventeen percent (25 of 216) of patients cleared VRE during their hospital stay; 19% (40 of 210) developed 47 infections. One third of infections involved the urinary tract. Liver transplantation, chemotherapy, and total parenteral nutrition were each associated with infection. CONCLUSION: Routine measures as advocated by the Centers for Disease Control and Prevention were not effective in controlling VRE in our patient population.

Adult↗
PubMed1998

Risk of infection due to central venous catheters: effect of site of placement and catheter type.

OBJECTIVE: To determine the influence of catheter site and type (single- vs triple-lumen) on infection rates associated with central venous catheterization. DESIGN: Prospective observational study of all nontunneled central venous catheters over a 28-month period. Data collected included patient characteristics, insertion site, catheter type, and receipt of parenteral nutrition. End points were clinical infection (bacteremia or site infection) and catheter contamination (clinical infection or colonization with >15 colonies on semiquantitative culture). SETTING: Medical-surgical wards of Veterans' Affairs hospital. RESULTS: Three hundred catheters were inserted into 204 patients. Seventy percent were inserted into upper-body sites, and 30% were inserted into the femoral vein. Forty-five percent were triple-lumen catheters. Bacteremia occurred in 2.7% of catheter insertions; insertion-site infections developed in 1.3%, and catheter colonization developed in 12%. Catheter contamination was associated with emergent insertion (odds ratio [OR], 6.2; 95% confidence interval [CI95], 1.1-36.7; P=.04) by logistic regression and with femoral location (hazard, 4.2; CI95, 2.0-8.8; P=.0001) and history of transplantation (hazard, 2.8; CI95, 1.1-6.7; P=.024) by Cox regression. Clinical infection was not associated with any of the risk factors evaluated, although there was a trend for association with femoral location by Cox regression (hazard, 4.7; CI95, 0.82-26; P=.08). We did not identify an association between infection and use of triple-lumen catheters or parenteral nutrition. CONCLUSION: Our data support an association between intravenous catheter contamination and insertion at a femoral site.

Adult↗
PubMed1998

Vancomycin-resistant Enterococcus faecium in a long-term care facility.

OBJECTIVE: To describe the epidemiology and natural history of colonization with vancomycin-resistant Enterococcus faecium (VREF) in a long-term care facility. DESIGN: All patients in whom VREF was isolated were followed prospectively, with rectal swab cultures at 2-week intervals, until discharge, death, or clearance of VREF. Clearance was defined as two consecutive negative cultures. In addition, three prevalence surveys were conducted of all patients in residence on one 34-bed intermediate care ward. SETTING: A 400-bed, long-term care Veterans Affairs facility. PARTICIPANTS: Thirty-six patients colonized with VREF. RESULTS: Vancomycin-resistant Enterococcus faecium was identified in 24 of the 36 patients at the time of transfer from an acute care facility. Seventeen patients had concomitant methicillin-resistant Staphylococcus aureus, and seven patients had a recent history of Clostridium difficile-associated diarrhea. VREF in these patients persisted for a median of 67 days after identification. Treatment of VREF colonization with antimicrobials was associated with prolongation of colonization. Serial surveillance of the 34-bed ward found stable rates of colonization, with only three documented instances of VREF acquisition. During 2.5 years of surveillance for infection, a single case of bacteremia occurred in a patient in whom colonization with VREF could not be demonstrated by rectal swab culture. No infections occurred in patients colonized with VREF. CONCLUSIONS: Long-term care patients have protracted carriage of VREF. Most will improve over time; however, receipt of antimicrobial therapy is associated with prolongation of VREF carriage. The risk of VREF infection is low in this population. When there are appropriate contact precautions, patient to patient transmission occurs at a low rate. These observations can be used to design a practical infection control strategy for long-term care facilities.

Adult↗
PubMed1998

Controlling Legionella in hospital water systems: experience with the superheat-and-flush method and copper-silver ionization.

OBJECTIVE: To evaluate the effect of copper-silver ionization on Legionella colonization and nosocomial legionnaires' disease and to compare the efficacy of metal ions versus the superheat-and-flush method of disinfection. DESIGN: Prospective determination over a 36-month period of copper and silver ion concentrations in the recirculating hot-water system, Legionella colonization of the hospital water distribution system, and cases of nosocomial legionnaires' disease. Retrospective comparison of results with the previous 13 years, during which the superheat-and-flush method was used. SETTING: The Pittsburgh Veterans' Affairs Health Care System (University Drive Division) acute-care hospital. INTERVENTION: Three copper-silver ionization systems were installed on the hot-water distribution system in November 1994. RESULTS: The average number of cases of legionnaires' disease per year and the percentage of distal sites positive for Legionella pneumophila for the superheat-and-flush method versus the copper-silver ionization method was six cases with 15% positivity versus two cases with 4% positivity, respectively. The reduction in Legionella colonization after copper-silver ionization was significant (P<.05) compared to the superheat and flush. Mean copper and silver ion concentrations (mg/L) were 0.29 and 0.054 from hot-water tanks, and 0.17 and 0.04 from distal outlets, respectively. CONCLUSIONS: We conclude that a properly maintained and monitored copper-silver ionization system was more effective than the superheat-and-flush method for reducing the recovery of Legionella from the hospital water distribution system.

Copper↗
PubMed1997

Multiply antibiotic-resistant gram-negative bacilli in a long-term-care facility: a case-control study of patient risk factors and prior antibiotic use.

OBJECTIVE: To determine the relation between prior exposure to specific antimicrobials and acquisition of gram-negative bacilli resistant to multiple beta-lactam and aminoglycoside antibiotics among long-term-care patients. DESIGN: Case-control study. Cases were patients from whom multiply resistant Enterobacteriaceae or Pseudomonas aeruginosa were isolated; controls were patients from whom nonresistant bacteria of the same species were isolated. Prospectively defined risk factors included underlying illness, activity level, presence of decubitus ulcers, presence of indwelling devices, and prior exposure to specific antimicrobial agents. Resistant and control isolates of P aeruginosa were compared using pulsed-field gel electrophoresis (PFGE) of genomic DNA after digestion with XbaI. SETTING: 390-bed long-term Veterans' Affairs facility. RESULTS: We identified 35 patients with multiply resistant Enterobacteriaceae and 24 patients with multiply resistant P aeruginosa. Of the resistant Enterobacteriaceae, 87% of isolates were resistant to piperacillin, 55% to ceftazidime, and 90% to gentamicin. Acquisition of multiply resistant Enterobacteriaceae was associated with presence of decubitus ulcers (odds ratio [OR], 12.2; 95% confidence interval [CI95], 3.3-44.2; P = .0002) and prior receipt of ampicillin (OR, 13.7; CI95, 2.2-84; P = .005). Of resistant isolates of P aeruginosa, 88% were resistant to piperacillin, 25% to ceftazidime, 42% to imipenem, and 67% to ciprofloxacin. Isolation of a multiply resistant P aeruginosa was associated with total days of antimicrobial exposure (OR, 1.07; CI95, 1.01-1.12; P = .011) and not with prior receipt of any individual agent. Eleven multiply resistant isolates shared a common PFGE pattern. CONCLUSIONS: In our long-term-care facility, acquisition of multiply resistant Enterobacteriaceae was associated with the presence of decubitus ulcers and prior exposure to ampicillin. Acquisition of resistant P aeruginosa was associated with total antibiotic exposure. Molecular typing of P aeruginosa isolates implicated patient-to-patient transmission of a limited number of resistant strains.

Aged↗