Nosocomial infections in elderly patients in the United States, 1986-1990. National Nosocomial Infections Surveillance System

Mirror proteorhodopsins

Proteorhodopsins (PRs), bacterial light-driven outward proton pumps comprise the first discovered and largest family of rhodopsins, they play a significant role in life on the Earth. A big remaining mystery was that up-to-date there was no described bacterial rhodopsins pumping protons at acidic pH despite the fact that bacteria live in different pH environment. Here we describe conceptually new bacterial rhodopsins which are operating as outward proton pumps at acidic pH. A comprehensive function-structure study of a representative of a new clade of proton pumping rhodopsins which we name "mirror proteorhodopsins", from Sphingomonas paucimobilis (SpaR) shows cavity/gate architecture of the proton translocation pathway rather resembling channelrhodopsins than the known rhodopsin proton pumps. Another unique property of mirror proteorhodopsins is that proton pumping is inhibited by a millimolar concentration of zinc. We also show that mirror proteorhodopsins are extensively represented in opportunistic multidrug resistant human pathogens, plant growth-promoting and zinc solubilizing bacteria. They may be of optogenetic interest.

Health Care-Associated Infections in Older Adults: Epidemiology and Prevention

Health care-associated infections (HAIs) are a global public health threat, which disproportionately impact older adults. Host factors including aging-related changes, comorbidities, and geriatric syndromes, such as dementia and frailty, predispose older individuals to infection. The HAI risks from medical interventions such as device use, antibiotic use, and lapses in infection control follow older adults as they transfer among a network of interrelated acute and long-term care facilities. Long-term care facilities are caring for patients with increasingly complex needs, and the home-like communal environment of long-term care facilities creates distinct infection prevention challenges.

Perioperative glycemic status is linked to postoperative complications in non-intensive care unit patients with type-2 diabetes: a retrospective study

BACKGROUND

Perioperative hyperglycemia is a risk factor for postoperative complications in the general population. However, it has not been clarified whether perioperative hyperglycemia increases postoperative complications in patients with type-2 diabetes mellitus (T2D). Therefore, we aimed to analyze the relationship between perioperative glycemic status and postoperative complications in non-intensive care unit (non-ICU) hospitalized patients with T2D.

MATERIALS AND METHODS

Medical records of 1217 patients with T2D who were admitted to the non-ICU in our hospital were analyzed retrospectively. Relationships between clinical characteristics including perioperative glycemic status and postoperative complications were assessed using univariate and multivariate analyses. Perioperative glycemic status was evaluated by calculating the mean, standard deviation (SD), and coefficient of variation (CV) of blood glucose (BG) measurements in preoperative and postoperative periods for three contiguous days before and after surgery, respectively. Postoperative complications were defined as infections, delayed wound healing, postoperative bleeding, and/or thrombosis.

RESULTS

Postoperative complications occurred in 139 patients (11.4%). These patients showed a lower BG immediately before surgery (P = 0.04) and a higher mean postoperative BG (P = 0.009) than those without postoperative complications. There were no differences in the other perioperative BG parameters including BG variability and the frequency of hypoglycemia. The multivariate analysis showed that BG immediately before surgery (adjusted odds ratio (95% confidence interval [CI]), 0.91 (0.85-0.98), P = 0.01) and mean postoperative BG (1.11 (1.05-1.18), P < 0.001) were independently associated with postoperative complications.

CONCLUSION

Perioperative glycemic status, that is, a low BG immediately before surgery and a high mean postoperative BG, are associated with the increased incidence of postoperative complications in non-ICU patients with T2D.

Primary Care Variation in Rates of Unplanned Hospitalizations, Functional Ability, and Quality of Life of Older People

PURPOSE

To investigate variability in older people's outcomes according to general practitioner (GP) and practice characteristics in New Zealand and the Netherlands.

METHODS

We used data from 2 primary care-based, cluster-randomized, controlled trials to separately fit mixed models of unplanned admission rates, functional ability, and quality of life (QOL) and examine variation according to GP- and practice-level characteristics after adjusting for participant-level characteristics. For the New Zealand sample (n = 3,755 aged 75+ years in 60 practices), we modeled 36-month unplanned admission rates, Nottingham Extended Activities of Daily Living (NEADL) scale, and QOL domain ratings from the brief version of the World Health Organization Quality of Life assessment tool. For the Netherlands sample (n = 3,141 aged 75+ years in 59 practices), we modeled 12-month unplanned admission rates, Groningen Activity Restriction Scale scores, and EuroQOL 5 dimensions (EQ-5D) summary index.

RESULTS

None of the GP or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample, but we found greater rates of admission in larger practices (incidence rate ratio [IRR], 1.45; 95% CI, 1.15-1.81) and practices staffed with a practice nurse (IRR, 1.74; 95% CI, 1.20-2.52) in the Netherlands sample. In both samples, differences were consistently small where there were significant associations with function (range, -0.26 to 0.19 NEADL points in the New Zealand sample; no associations in the Netherlands sample) and QOL (range, -1.64 to 0.97 QOL points in New Zealand; -0.01 EQ-5D points in the Netherlands).

CONCLUSIONS

In the absence of substantial differences in older people's function and QOL, it remains unclear whether intriguing GP- or practice-related variations in admission rates represent low- or high-quality practice.

Estrogen deficiency - a central paradigm in age-related impaired healing?

Wound healing is a dynamic biological process achieved through four sequential, overlapping phases; hemostasis, inflammation, tissue proliferation and remodeling. For effective wound healing, all four phases must occur in the appropriate order and time frame. It is well accepted that the wound healing process becomes disrupted in the elderly, increasing the propensity of non-healing wound states that can lead to substantial patient morbidity and an enormous financial burden on healthcare systems. Estrogen deprivation in the elderly has been identified as the key driver of age-related delayed wound healing in both genders, with topical and systemic estrogen replacement reversing the detrimental effects of aging on wound repair. Evidence suggests estrogen deprivation may contribute to the development of chronic wound healing states in the elderly but research in this area is somewhat limited, warranting further investigations. Moreover, although the beneficial effects of estrogen on cutaneous healing have been widely explored, the development of estrogen-based treatments to enhance wound repair in the elderly have yet to be widely exploited. This review explores the critical role of estrogen in reversing age-related impaired healing and evaluates the prospect of developing more focused novel therapeutic strategies that enhance wound repair in the elderly via activation of specific estrogen signaling pathways in regenerating tissues, whilst leaving non-target tissues largely unaffected.

Strategies for improving antimicrobial properties of stainless steel

In this review, strategies for improving the antimicrobial properties of stainless steel (SS) are presented. The main focus given is to present current strategies for surface modification of SS, which alter surface characteristics in terms of surface chemistry, topography and wettability/surface charge, without influencing the bulk attributes of the material. As SS exhibits excellent mechanical properties and satisfactory biocompatibility, it is one of the most frequently used materials in medical applications. It is widely used as a material for fabricating orthopedic prosthesis, cardiovascular stents/valves and recently also for three dimensional (3D) printing of custom made implants. Despite its good mechanical properties, SS lacks desired biofunctionality, which makes it prone to bacterial adhesion and biofilm formation. Due to increased resistance of bacteria to antibiotics, it is imperative to achieve antibacterial properties of implants. Thus, many different approaches were proposed and are discussed herein. Emphasis is given on novel approaches based on treatment with highly reactive plasma, which may alter SS topography, chemistry and wettability under appropriate treatment conditions. This review aims to present and critically discuss different approaches and propose novel possibilities for surface modification of SS by using highly reactive gaseous plasma in order to obtain a desired biological response.

Continuous Peritoneal Dialysis-Associated Peritonitis of Nosocomial Origin

Objective

To describe our experience with nosocomial continuous peritoneal dialysis (CPD)-associated peritonitis focusing on the incidence, possible risk factors, spectrum of organisms, and outcome.

Design

Retrospective review of the medical records of our CPD patients admitted to an acute-care hospital between November, 1993 and December, 1994.

Setting

University-associated acute-care hospitals in New Haven, Connecticut.

Patients

One hundred and eighty-eight patients maintained on CPD therapy and admitted to an acute-care hospital.

Results

Nineteen patients (5%) developing nosocomial peritonitis (NP) were identified from the 408 admissions occurring during the study period. Patients developing NP were older than the hospitalized CPD patients not developing NP(65.5± 14.6vs58.4± 14.7years, p<0.05). Comorbid diseases including diabetes, peripheral vascular disease, gastrointestinal disease, cardiovascular disease, and human immunodeficiency virus seropositivity were not more common in the patients developing NP. Patients developing NP were hospitalized significantly longer than the CPD patients not developing NP (39.5 ± 46.5 days vs 12.7 ± 12.4 days, p < 0.001). The mean serum albumin was lower in the NP patients than in the CPD patients not developing NP (2.35 ± 0.52 g/dL vs 3.02 ± 0.60 g/dL, p < 0.001). Antecedent antibiotic use and performance of invasive procedures were noted in 89% and 68% of the patients developing NP, respectively. Staphylococcal species, enterococcal species, and gram-negative organisms accounted for 26%, 21 %, and 53% of the episodes of NP, respectively. Furthermore, two strains of Enterococcus resistant to vancomycin were cultured. Eight patients developing NP expired, 8 patients continued CPD therapy, 2 patients transferred to hemodialysis, and one patient recovered renal function.

Conclusion

We conclude that NP is uncommon. Increased age, increased length of hospital stay, and hypoalbuminemia may predispose patients to the development of NP. Further studies with case controls should help to clarify whether antecedent antibiotics or prior performance of invasive procedures predispose patients to the development of nosocomial peritonitis. The spectrum of organisms accounting for NP is different than the spectrum of organisms causing community-acquired CPD-associated peritonitis. Some of these organisms may be resistant to standard antibiotic therapies. Patients developing NP do poorly, with 42% expiring while being treated for NP.

Combined Plasma Elevation of CRP, Intestinal-Type Fatty Acid-Binding Protein (I-FABP), and sCD14 Identify Older Patients at High Risk for Health Care-Associated Infections

Background

We hypothesized that low-grade inflammation was driven by microbial translocation and associated with an increased risk of health care-associated infections (HAIs).

Methods

We included 121 patients aged 75 years or over in this prospective cohort study. High-sensitivity C-reactive protein (hs-CRP), I-FABP, and sCD14-as markers for low-grade inflammation, intestinal epithelial barrier integrity, and monocyte activation, respectively-were measured at admission.

Results

HAIs occurred during hospitalization in 62 (51%) patients. Elevated hs-CRP (≥6.02 mg/L, ie, the median) was associated with a significantly higher HAI risk when I-FABP was in the highest quartile (odds ratio [OR], 4; 95% confidence interval [95% CI], 1.39-11.49; p = .010). In patients with hs-CRP elevation and highest-quartile I-FABP, sCD14 elevation (≥0.65 µg/mL, ie, the median) was associated with an 11-fold higher HAI risk (OR, 10.8; 95% CI, 2.28-51.1; p = .003). Multivariate analyses adjusted for invasive procedures and comorbidities did not change the associations linking the three markers to the HAI risk.

Conclusion

Increased levels of hs-CRP, I-FABP, and sCD14 may reflect loss of intestinal epithelial barrier integrity with microbial translocation leading to monocyte activation and low-grade inflammation. In our cohort, these markers identified patients at high risk for HAIs.

Risk Factors and Prevention Strategies of Nosocomial Infection in Geriatric Patients

Introduction

To investigate the risk factors of nosocomial infections (NIs) in geriatric department and the effectiveness of the proposed prevention strategy.

Methodology

We studied 3370 cases of elderly patients who were hospitalized more than 48 hours from January 2015 to December 2017 in the Geriatrics Department of Zhongda Hospital, Southeast University. In order to reduce the infection rate, nutritional risk screening (NRS 2002) was used to evaluate the nutritional status of the patients; enteral nutritional suspension (TPF-FOS) was provided to the patients who were assessed to be necessary.

Results

Before prevention strategy was taken, the nosocomial infection rate was 3.3% (80 among 2413 patients) in our department. The most frequent NIs were pneumonia (60 cases) followed by urinary tract infection (30 cases). It is worth noting that the elderly patients are often associated with multiple infections: in our study, 15 patients have pneumonia and UTI at the same time. After prevention strategy was taken, the nosocomial infection rate reduced to 1.15% (11 among 957 patients) in our department.

Conclusions

NIs are common in elderly patients. The improvement of the nutritional status of patients is effective in reducing the risks of NIs.

Proton-pump inhibitors elevate infection rate in cardiothoracic surgery patients by influencing PMN function in vitro and in vivo

Proton-pump inhibitors (PPI) as pantoprazole are highly effective acid suppressive agents that belong to the world's most sold medication. However, they are pronounced to have immunosuppressive aspects. In our study, a negative influence of PPI on functions of polymorphonuclear cells in vitro like phagocytosis, oxidative burst, chemotaxis, and killing activity was shown, whereas formation of neutrophil extracellular traps (NET)osis remained unaffected. Pantoprazole stimulation additionally reduced the production of the proinflammatory cytokine IL-1β in whole blood assay as well as the production of IL-2 and IFN-γ after whole blood stimulation with phytohaemagglutinin. Moreover, IFN-γ feedback mechanisms and signaling by STAT-1 was impaired by PPI. Cardiac surgery is accompanied by developing systemic inflammatory response syndrome with immunosuppressive aspects. We exhibited reduced oxidative burst analyzing cardiac surgery patients' samples receiving or not receiving PPI. Furthermore, a higher rate of infections in patients receiving permanent PPI medication in retrospective analysis was uncovered. Patients undergoing cardiac surgery with cardiopulmonary bypass and regular PPI medication developed significant more infections retrospectively indicating a clinical impact of the immunosuppressive influence of PPI.

Effectiveness of Multifaceted Hospitalwide Quality Improvement Programs Featuring an Intervention to Remove Unnecessary Urinary Catheters at a Tertiary Care Center in Thailand

Objective.

To evaluate the efficacy of a multifaceted hospitalwide quality improvement program that featured an intervention to remind physicians to remove unnecessary urinary catheters.

Methods.

A hospitalwide preintervention-postintervention study was conducted over 2 years (July 1, 2004, through June 30, 2006). The intervention consisted of nurse-generated daily reminders that were used by an intervention team to remind physicians to remove unnecessary urinary catheters, beginning 3 days after insertion. Clinical, microbiological, pharmaceutical, and cost data were collected.

Results.

A total of 2,412 patients were enrolled in the study. No differences were found in the demographic and/or clinical characteristics of patients between the preintervention and postintervention periods. After the intervention, reductions were found in the rate of inappropriate urinary catheterization (mean rate, preintervention vs postintervention, 20.4% vs 11% [P = .04]), the rate of catheter-associated urinary tract infection (CA-UTI) (mean rate, 21.5 vs 5.2 infections per 1,000 catheter-days [P <.001]), the duration of urinary catheterization (mean, 11 vs 3 days [P < .001]), and the total length of hospitalization (mean, 16 vs 5 days [P < .001]). A linear relationship was seen between the monthly average duration of catheterization and the rate of CA-UTI (r = 0.89; P < .001). The intervention had the greatest impact on the rate of CA-UTI in the intensive care units (mean rate, preintervention vs postintervention, 23.4 vs 3.5 infections per 1,000 catheter-days [P = .01]). The monthly hospital costs for antibiotics to treat CA-UTI were reduced by 63% (mean, $3,739 vs $1,378 [P < .001]), and the hospitalization cost for each patient during the intervention was reduced by 58% (mean, $366 vs $154 [P < .001]).

Conclusions.

This study suggests that a multifaceted intervention to remind physicians to remove unnecessary urinary catheters can significantly reduced the duration of urinary catheterization and the CA-UTI rate in a hospital in a developing country.

Epidemiologic Study of Nosocomial Urinary Tract Infections in Saudi Military Hospitals

A case-control study of patients with and without confirmed UTI was performed to identify risk factors for nosocomial UTI. Duration of hospitalization, unit of admission, history of diabetes mellitus or debilitating diseases, and duration and number of urinary catheters were independently associated with increased risk of nosocomial UTIs.

Nosocomial infections in patients admitted in intensive care unit of a tertiary health center, India

Background:

Patients in Intensive Care Units (ICUs) are a significant subgroup of all hospitalized patients, accounting for about a quarter of all hospital infections.

Aim:

The aim was to study, the current status of nosocomial infection, rate of infection and distribution of infection among patients admitted in Medical Intensive Care Unit (MICU) of a District Hospital.

Subjects and Methods:

Data were collected retrospectively from 130 patient's records presented with symptoms of nosocomial infection in MICU of a Tertiary Health Center, Tumkur from August 2012 to May 2013. Descriptive statistics using percentage was calculated.

Results:

Incidence of nosocomial infections in MICU patients was 17.7% (23/130). Of which 34.8% (8/130) was urinary tract infection (UTI) being the most frequent; followed by pneumonia 21.7% (5/130), 17.4% (4/130) surgical site infection, 13.0% (3/130) gastroenteritis, 13.0% (3/130) blood stream infection and meningitis. The nosocomial infection was seen more in the 40-60 year of age. The male were more prone to nosocomial infections than the female.

Conclusion:

The most frequent nosocomial infections (urinary, respiratory, and surgical site) were common in geriatric patients in the MICU setting and are associated with the use of invasive device. Large-scale studies are needed to be carried out in Indian population to plan long-term strategies for prevention and management of nosocomial infections.

Innate immunesenescence: underlying mechanisms and clinical relevance

A well-established feature of physiological ageing is altered immune function, a phenomenon termed immunesenescence. Thought to be responsible in part for the increased incidence and severity of infection reported by older adults, as well as the age-related decline in vaccine efficacy and autoimmunity, immunesenescence affects both the innate and adaptive arms of the immune system. Whilst much is known regarding the impact of age on adaptive immunity, innate immunity has received far less attention from immune gerontologists. However, over the last decade it has become increasingly apparent that this non-specific arm of the immune response undergoes considerable functional and phenotypical alterations with age. Here, we provide a detailed overview of innate immunesenescence and its underlying molecular mechanisms, and highlight those studies whose results indicate that changes in innate immunity with age have a significant impact upon the health and well-being of older adults.

Prevention of surgical site infections

In the current era of pay-for-performance standards, the incidence of surgical site infections is increasingly becoming an institutional marker of quality assurance. Surgical site infections lead to increased morbidity and mortality in the surgical population and contribute to an already rising healthcare cost. As a result, the surgical community goes to great lengths to prevent this costly and occasionally lethal complication. Many practices are evidence based, however, many are not. In this article, the most commonly used preventive strategies in practice today and the evidence behind each are reviewed. In addition, an overview of the epidemiology, pathophysiology and microbiology of surgical site infections will be provided.

Addressing bioterrorism concerns: options for investigating the mechanism of action of Staphylococcus aureus enterotoxin B

Staphylococcal enterotoxin B (SEB) is of concern to military and civilian populations as a bioterrorism threat agent. It is a highly potent toxin produced by Staphylococcus aureus and is stable in storage and under aerosolisation; it is able to produce prolonged highly incapacitating illness at very low-inhaled doses and death at elevated doses. Concerns regarding SEB are compounded by the lack of effective medical countermeasures for mass treatment of affected populations. This article considers the mechanism of action of SEB, the availability of appropriate experimental models for evaluating the efficacy of candidate medical countermeasures with particular reference to the need to realistically model SEB responses in man and the availability of candidate countermeasures (with an emphasis on commercial off-the-shelf options). The proposed in vitro approaches would be in keeping with Dstl’s commitment to reduction, refinement and replacement of animal models in biomedical research, particularly in relation to identifying valid alternatives to the use of nonhuman primates in experimental studies.

Post-discharge surveillance of wound infections by telephone calls method in a Sudanese Teaching Hospital

Surveillance of wound infections has been shown to be a powerful preventive tool, and feedback to the clinical staff reduces wound infection rates. The main objectives of this study were to identify the applicability of telephone calls as a method of post-discharge wound infection surveillance, and to identify patients and procedures characteristics associated with loss for follow-up after hospital discharge.

MATERIALS AND METHODS

This was a prospective cohort study conducted in Khartoum Teaching Hospital, Sudan. Patients, aged >18 years admitted for elective clean and clean-contaminated surgery during March 1st to 31st October 2010 were recruited. 1-month surveillance of wound infections was conducted with telephone interviews.

RESULTS

Overall 3656 patients were operated on. Of them 1769 (48.4%) were eligible {mean age 37.8+14 years; females, n=1472 (83.3%)}. The performed surgical interventions were 1814. Of these 1277 (70.4%) were clean-contaminated and 537 (29.6%) were clean. Patients who successfully completed the follow-up were 1387 (78.4%), while 368 (20.8%) were lost, and 14 (0.8%) died. The percentage of male patients (85.3%) who successfully completed the follow-up was significantly higher than females (77.8%); (P=0.002). Wound infection was detected in 15 (0.8%) cases during hospital stay and 110 (6.2%) others after hospital discharge.

CONCLUSIONS

The majority of wound infections in the current study appeared in post-discharge period; this emphasis the need for establishment of surveillance program in the hospital. Surveillance of wound infections using telephone calls is applicable in this setting and can be used as an alternative method to clinic-based diagnosis of wound infections.

Appropriate use of indwelling urethra catheters in hospitalized patients: results of a multicentre prevalence study

BACKGROUND

Although indwelling urethra catheterization is a medical intervention with well-defined risks, studies show that approximately 14-38% of the indwelling urethra catheters (IUCs) are placed without a specific medical indication. In this paper we describe the prevalence of IUCs, including their inappropriate use in the Netherlands. We also determine factors associated with inappropriate use of IUCs in hospitalized patients.

METHODS

In 28 Dutch hospitals, prevalence surveys were performed biannually in 2009 and 2010 within the PREZIES-network. All patients admitted to a participating hospital and who had an IUC in place at the day of the survey were included. Pre-determined criteria were used to categorize the indication for catheterization as appropriate or inappropriate.

RESULTS

A total of 14,252 patients was included and 3020 (21.2%) of them had an IUC (range hospitals 13.4-27.3). Initial catheter placement was inappropriate in 5.2% of patients and 7.5% patients had an inappropriate indication at the day of the survey. In multivariate analyses inappropriate catheter use at the time of placement was associated with female sex, older age, admission on a non-intensive care ward, and not having had surgery. Inappropriate catheter use at the time of survey showed comparable associated factors.

CONCLUSIONS

Although lower than in many other countries, inappropriate use of IUC is present in Dutch hospitals. To reduce the inappropriate use of IUCs, recommended components of care (bundle for UTI), including daily revision and registration of the indication for catheterization, should be introduced for all patients with an IUC. Additionally, an education and awareness campaign about appropriate indications for IUC should be available.

Immune risk phenotype is associated with nosocomial lung infections in elderly in-patients

BACKGROUND

Nosocomial infections are extremely common in the elderly and may be related to ageing of the immune system. The Immune Risk Phenotype (IRP), which predicts shorter survival in elderly patients, has not been evaluated as a possible risk factor for nosocomial infection. Our aim was to assess the prevalence of nosocomial infections in elderly in-patients and to investigate potential relationships between nosocomial infections and the immunophenotype, including IRP parameters.

RESULTS

We included 252 consecutive in-patients aged 70 years or over (mean age, 85 ± 6.2 years), between 2006 and 2008. Among them, 97 experienced nosocomial infections, yielding a prevalence rate of 38.5% (95% confidence interval, 32.5-44.5). The main infection sites were the respiratory tract (21%) and urinary tract (17.1%) When we compared immunological parameters including cell counts determined by flow cytometry in the groups with and without nosocomial infections, we found that the group with nosocomial infections had significantly lower values for the CD4/CD8 ratio and naive CD8 and CD4 T-cell counts and higher counts of memory CD8 T-cells with a significant increase in CD28-negative CD8-T cells. Neither cytomegalovirus status (positive in 193/246 patients) nor presence of the IRP was associated with nosocomial infections. However, nosocomial pneumonia was significantly more common among IRP-positive patients than IRP-negative patients (17/60 versus 28/180; p = 0.036).

CONCLUSION

Immunological parameters that are easy to determine in everyday practice and known to be associated with immune system ageing and shorter survival in the elderly are also associated with an elevated risk of nosocomial pneumonia in the relatively short term.

Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are important causes of morbidity and mortality, with mortality rates approaching 62%. HAP and VAP are the second most common cause of nosocomial infection overall, but are the most common cause documented in the intensive care unit setting. In addition, HAP and VAP produce the highest mortality associated with nosocomial infection. As a result, evidence-based guidelines were prepared detailing the epidemiology, microbial etiology, risk factors and clinical manifestations of HAP and VAP. Furthermore, an approach based on the available data, expert opinion and current practice for the provision of care within the Canadian health care system was used to determine risk stratification schemas to enable appropriate diagnosis, antimicrobial management and nonantimicrobial management of HAP and VAP. Finally, prevention and risk-reduction strategies to reduce the risk of acquiring these infections were collated. Future initiatives to enhance more rapid diagnosis and to effect better treatment for resistant pathogens are necessary to reduce morbidity and improve survival.

Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women

BACKGROUND

Urinary tract infections (UTI) are common in elderly patients. Authors of non systematic literature reviews often recommend longer treatment durations (7 to 14 days) for older women, but the evidence for such recommendations is unclear.

OBJECTIVES

To determine the optimal duration of antibiotic treatment for uncomplicated symptomatic lower UTI in elderly women.

SEARCH STRATEGY

We contacted known investigators and pharmaceutical companies, screened reference lists of identified articles, reviews and books, and searched MEDLINE, EMBASE, CINAHL, Healthstar, Popline, Gerolit, Bioethics Line, The Cochrane Library, Dissertation Abstracts International and Index to Scientific & Technical Proceedings without language restriction. Date of most recent search: 7 May 2008.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing different treatment durations of oral antibiotics for uncomplicated symptomatic lower UTIs in elderly women were included. Whenever possible we obtained outcome data for older women included in studies with a broader age range. We excluded patients with fever, flank pain or complicating factors; studies with treatment durations longer than 14 days and prevention studies.

DATA COLLECTION AND ANALYSIS

The two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and results expressed as risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Fifteen studies (1644 elderly women) were included. Three studies compared single dose with short-course treatment (3 to 6 days), six compared single dose with long-course treatment (7 to 14 days) and six compared short- with long-course treatment. Methodological quality of all studies was low except for a more recent geriatric study. There was a significant difference for persistent UTI between single dose and short-course treatment (RR 2.01, 95% CI 1.05 to 3.84) and single versus long-course treatment (RR 1.93, 1.01 to 3.70 95% CI), in the short-term (< 2 weeks post-treatment) but not at long-term follow-up or on clinical outcomes. Patients preferred single dose treatment (RR 0.73, 95% CI 0.60 to 0.88) to long-course treatments, but this was based on one study comparing different antibiotics. Short versus longer treatments showed no significant difference in efficacy. Rate of adverse drug reactions increased significantly with longer treatment durations in only one study.

AUTHORS' CONCLUSIONS

Short-course treatment (3 to 6 days) could be sufficient for treating uncomplicated UTIs in elderly women, although more studies on specific commonly prescribed antibiotics are needed.

Differentiation of C2D macrophage cells after adoptive transfer

C2D macrophage cells protect immunocompromised mice from experimentally induced pneumonias after intraperitoneal (i.p.) adoptive transfer. These macrophage cells are immature and display minimal activity in vitro. Therefore, we wanted to understand how adoptive transfer affected these cells. We believe that the in vivo environment affects the phenotypic and functional characteristics of macrophages that help maintain the physiological integrity of the host. To test this hypothesis, we characterized the trafficking patterns and cellular changes of the established macrophage C2D cell line after adoptive transfer. We examined phenotypic changes of the C2D macrophage cells in vivo with and without stimulation with gamma interferon (IFN-gamma). After in vivo i.p. adoptive transfer, C2D macrophage cells trafficked to the lungs, spleen, lymph nodes, and bone marrow of recipient mice. The cells were detected for as long as 2 months, and the cells expressed increased levels of CD11b, c-fms, and F4/80 on their surface, becoming more differentiated macrophages compared to cells maintained in vitro. Upon in vivo stimulation with IFN-gamma, c-fms levels decreased while Gr-1 levels increased compared to in vivo, unstimulated, phosphate-buffered saline-injected controls. These responses were independent of the genetic backgrounds of the recipient mice. These data support the hypothesis and indicate that C2D macrophage cells respond to in vivo signals that are absent during in vitro culture.

European and Asian guidelines on management and prevention of catheter-associated urinary tract infections

We surveyed the extensive literature regarding the development, therapy and prevention of catheter-associated urinary tract infections (UTIs). We systematically searched for meta-analyses of randomised controlled trials available in Medline giving preference to the Cochrane Central Register of Controlled Trials and also considered other relevant publications, rating them on the basis of their quality. The studies' recommendations, rated according to a modification of the US Department of Health and Human Services (1992), give a close-to-evidence-based guideline for all medical disciplines, with special emphasis on urology where catheter care is an important issue. The survey found that the urinary tract is the commonest source of nosocomial infection, particularly when the bladder is catheterised (IIa). Most catheter-associated UTIs are derived from the patient's own colonic flora (IIb) and the catheter predisposes to UTI in several ways. The most important risk factor for the development of catheter-associated bacteriuria is the duration of catheterisation (IIa). Most episodes of short-term catheter-associated bacteriuria are asymptomatic and are caused by a single organism (IIa). Further organisms tend to be acquired by patients catheterised for more than 30 days. The clinician should be aware of two priorities: the catheter system should remain closed and the duration of catheterisation should be minimal (A). While the catheter is in place, systemic antimicrobial treatment of asymptomatic catheter-associated bacteriuria is not recommended (A), except for some special cases. Routine urine culture in an asymptomatic catheterised patient is also not recommended (C) because treatment is in general not necessary. Antibiotic treatment is recommended only for symptomatic infection (B). Long-term antibiotic suppressive therapy is not effective (A). Antibiotic irrigation of the catheter and bladder is of no advantage (A). Routine urine cultures are not recommended if the catheter is draining properly (C). A minority of patients can be managed with the use of the non-return (flip) valve catheter, avoiding the closed drainage bag. Such patients may exchange the convenience of on-demand drainage with an increased risk of infection. Patients with urethral catheters in place for 10 years or more should be screened annually for bladder cancer (C). Clinicians should always consider alternatives to indwelling urethral catheters that are less prone to causing symptomatic infection. In appropriate patients, suprapubic catheters, condom drainage systems and intermittent catheterisation are each preferable to indwelling urethral catheterisation (B).

Initial inappropriate urinary catheters use in a tertiary-care center: incidence, risk factors, and outcomes

OBJECTIVES

To evaluate the epidemiology and outcomes for initiation of inappropriate urinary catheterization (IUC) among hospitalized patients.

SETTING

A 450-bed, tertiary-care hospital.

PATIENTS

All patients admitted to the hospital from September 1, 2003 to June 12, 2004 with urinary catheter (UC). An independent observer reviewed the patient's chart, interviewed the patient and nursing staff, and assessed the need for the UC daily until the catheter was removed or the patient was discharged.

RESULTS

One hundred thirty-one (15%) of 895 patients had initiation of IUC. The median age was 61 (range, 15-92). Medicine (0.52 catheter utilization ratio), surgery (0.24 catheter utilization ratio) and the ICUs (0.32) had the most UC use. Main reasons for initial IUC included no clear indication (28%), inappropriate urine output monitoring (26%), and urinary incontinence (18%). Admission to the medical ICU (adjusted odds ratio [aOR]=2.3; P<0.001), nonambulatory functional status (aOR=2.1; P<0.001), and female sex (aOR=1.9; P=0.001) were independently associated with IUC. Catheter-associated urinary tract infections (CA-UTI) occurred in 129 patients (14%). Patients with IUC had a longer duration of catheterization (12 vs. 3 days; P<0.01) were more likely to develop CA-UTI (82% vs. 8%; P=0.001) and had prolonged hospital length of stay (median, 15 vs. 5 days; P<0.001). The mean monthly cost of antibiotics for treatment of CA-UTI was $3480 (range, $1874-$5584).

CONCLUSION

UC were inappropriately used more commonly among female, nonambulatory, and medical ICU patients. Careful attention to this aspect of medical care may reduce the incidence CA-UTI with subsequent decreases in length of stay, cost of hospitalization, and cost for treatment of CA-UTI.

Nine-year downward trends in surgical site infection rate in southeast France (1995–2003)

The aim of this study was to estimate temporal trends in the incidence of surgical site infection (SSI) using a large SSI surveillance network in southeast France from 1995 to 2003. Data were analysed from 187 surgical wards that had participated in the network for at least two years. The change in SSI rate over time was modelled using a hierarchical logistic regression model with patients clustered within surgical wards. Of the 200 207 patients selected, 3786 (1.9%) had an SSI. The nine-year trend in SSI rate estimated by an odds ratio of 0.95 (95% confidence interval 0.93-0.97) was interpreted as a 5% decrease in SSI rate per year. This decrease was constant over the study period and was observed for almost all of the different types of surgical operations (orthopaedic, gastrointestinal, urology, etc). Overall SSI rates were reduced by 45% over a period of nine years. This trend was maintained even when taking into account the heterogeneity of the surgical wards and the diversity of patient demographics over time. From this, the 5% decrease per year can be reasonably interpreted as a result of preventive measures taken by surgical wards to reduce SSIs.

Skin and Soft Tissue Infections in Older Adults

Skin and soft tissue infections (SSTIs) are a common cause of morbidity in older patients. Because of changes in skin consistency, immunosenescence, and the presence of underlying skin conditions and comorbid conditions, elderly persons are at high risk for SSTIs. Specific community- and hospital-associated SSTIs are reviewed in this article with particular emphasis on the epidemiology, prevention, risk factors, and treatment of SSTIs in older patients.

The Relationship of Indwelling Urinary Catheters to Death, Length of Hospital Stay, Functional Decline, and Nursing Home Admission in Hospitalized Older Medical Patients

OBJECTIVES

To determine the association between indwelling urinary catheterization without a specific medical indication and adverse outcomes.

DESIGN

Prospective cohort.

SETTING

General medical inpatient services at a teaching hospital.

PARTICIPANTS

Five hundred thirty-five patients aged 70 and older admitted without a specific medical indication for urinary catheterization.

INTERVENTION

Indwelling urinary catheterization within 48 hours of admission.

MEASUREMENTS

Death, length of hospital stay, decline in ability to perform activities of daily living (ADLs), and new admission to a nursing home.

RESULTS

Indwelling urinary catheters were placed in 76 of the 535 (14%) patients without a specific medical indication. Catheterized patients were more likely to die in the hospital (6.6% vs 1.5% of those not catheterized, P=.006) and within 90 days of hospital discharge (25% vs 10.5%, P<.001); the greater risk of death with catheterization persisted in a propensity-matched analysis (hazard ratio (HR)=2.42, 95% confidence interval (CI)=1.04-5.65). Catheterized patients also had longer lengths of hospital stay (median, 6 days vs 4 days; P=.001); this association persisted in a propensity-matched analysis (HR=1.46, 95% CI=1.03-2.08). Catheterization was not associated (P>.05) with decline in ADL function or with admission to a nursing home.

CONCLUSION

In this cohort of older patients, urinary catheterization without a specific medical indication was associated with greater risk of death and longer hospital stay.

Construção e validação de indicadores de avaliação de práticas de controle e prevenção de infecção do trato urinário associada a cateter

OBJETIVO: contribuir com uma nova modalidade de avaliação de qualidade de práticas de controle de infecção hospitalar do trato urinário associada a cateterismo. MÉTODOS: estudo de desenvolvimento metodológico, consistindo de elaboração cientificamente fundamentada e validade de conteúdo de três indicadores de avaliação. A validade de conteúdo foi realizada por especialistas e referiu-se ao julgamento dos indicadores em quatro etapas: manual operacional; atributos de conjunto; atributos de componentes; relevância dos seus componentes. RESULTADOS: dois indicadores foram validados ao obterem consenso favorável mínimo e ajustados conforme as sugestões apresentadas. O terceiro, mesmo sendo julgado relevante, não obteve consenso mínimo em duas etapas e não foi validado. CONCLUSÃO: o método de validação utilizado mostrou-se eficaz, permitindo concluir que a importância de uma dada prática não é condição suficiente para sua avaliação, se sua construção não for validada, a fim de ser aplicada de maneira objetiva e inequívoca.

Ventilator associated pneumonia and infection control

Ventilator associated pneumonia (VAP) is the leading cause of morbidity and mortality in intensive care units. The incidence of VAP varies from 7% to 70% in different studies and the mortality rates are 20-75% according to the study population. Aspiration of colonized pathogenic microorganisms on the oropharynx and gastrointestinal tract is the main route for the development of VAP. On the other hand, the major risk factor for VAP is intubation and the duration of mechanical ventilation. Diagnosis remains difficult, and studies showed the importance of early initiation of appropriate antibiotic for prognosis. VAP causes extra length of stay in hospital and intensive care units and increases hospital cost. Consequently, infection control policies are more rational and will save money.

Methicillin-resistant Staphylococcus aureus in elderly care facilities

Among multidrug-resistant bacteria, methicillin-resistant Staphylococcus aureus (MRSA) is of immediate concern, given its potential for pathogenicity and widespread presence in geriatric hospitals. Epidemiological surveys indicate that rates of MRSA cross-transmission are increasing in elderly care facilities. MRSA carriage is far more frequent than MRSA-positive clinical specimens in this setting, and the consequences of these epidemics in terms of morbidity, remain limited within these facilities. However, given that patients are continually transferred between long-term and acute-care facilities, it is reasonable to consider these units together with all other care units and to measure the effect of MRSA on a regional healthcare network, rather than on the scale of a given ward or hospital. With regard to the worldwide increase in morbidity associated with MRSA, the emergence of a community-based disease linked to these strains and the emergence of glycopeptide-resistant strains, the application of a voluntary strategy including screening, isolation and eventually, topical decolonization in elderly care facilities, appears to be an urgent matter of priority, even if this strategy will be expensive.

Relations between undernutrition and nosocomial infections in elderly patients

BACKGROUND

Hospital-acquired infections and malnutrition are of major concern in public health in elderly patients. However, the interactions between these two entities are not well established.

OBJECTIVES

To determine the incidence of nosocomial infections (NI) and its association with malnutrition.

SUBJECTS

185 hospitalised older adults aged 81.6+/-0.6 years old were nutritionally assessed on admission by measurement of anthropometric variables, serum nutritional proteins and evaluation of dietary intake. During hospitalisation, patients' progress was closely monitored, particularly for the detection of nosocomial infections.

RESULTS

The incidence rate of NI was 59% and the global infection rate was 7.6/1,000 bed days. The most common infection site was the urinary tract (n=63). The nutritional status of the population was studied by comparing three groups defined according to the absence (group I, n=116), presence of one infection (group II, n=38) or presence of more than one infection (group III, n=31). All but one anthropometric parameters varied among the three groups. Total energy intake also varied among the three groups. The group I had higher daily nutrient intake than the other two groups (respectively P=0.004 and P<0.0001). Albumin, transthyretin, and C-reactive protein levels differed significantly among the three groups (respectively P<0.0001, P<0.0001 and P=0.0003). Age, energy intake, length of hospital stay and the presence of a urinary catheter were independent risk factors of nosocomial infection.

CONCLUSION

Our findings show that patients with multiple NI were older, showed an altered nutritional status, a prolonged recovery, more frequently had urinary catheters and more discharge placement.

Is umbilical flora responsible for wound infection after laparoscopic surgery?

To our knowledge, the association of umbilical flora and infections has not been studied yet. The aim of this study was to identify the causative agents for trocar site infections and to highlight whether there is association between umbilical flora and trocar site infections. One hundred consecutive patients who had undergone laparoscopic surgery were studied. Microbiological samples were taken from the umbilicus before (group 1) and after (group 2) antisepsis with povidone-iodine. Microbiological assessment was done for wounds suspected to be infected, and the wounds with positive cultures were classified as group 3. The incidence of wound infection was 8%. One hundred percent of the infections were associated with the extraction trocar. Eighty-nine percent of all of the infections occurred after laparoscopic cholecystectomy, whereas 11% occurred after laparoscopic appendectomy. The micro-organisms in group 3 did not belong to the skin flora, unlike the micro-organisms in groups 1 and 2, but hospital-acquired pathogens were responsible for the infections. The umbilical flora and the bile are not the source of the surgical site infections after laparoscopic surgery in our study despite the considerations in the literature.

Surgical Site Infection in the Elderly Population

Surgical site infections (SSIs) account for 11% of nosocomial infections among older patients. This report reviews the available data and presents medical and surgical perspectives on the epidemiology, outcomes, and prevention of SSI in the elderly population. The risk for SSI does not seem to increase after the age of 65 years. Several risk factors for SSI are similar among elderly patients and younger patients, but financial factors and factors related to health services may differ between the groups. The clinical presentation of infection and the pathogens that cause infection are similar among elderly patients and younger patients. However, the mortality rate, the duration of hospitalization, and the costs associated with hospital care are greater for elderly patients with SSI than for younger patients with SSI. Several modalities for SSI prevention have been well studied in the general surgical population but have not been specifically evaluated in the elderly surgical population. Insights and opinions pertaining to modalities for SSI prevention in the elderly population and areas of import for future research are discussed.

Surgical-site infection due to Staphylococcus aureus among elderly patients: mortality, duration of hospitalization, and cost

OBJECTIVES

To examine the impact of surgical-site infection (SSI) due to Staphylococcus aureus on mortality, duration of hospitalization, and hospital charges among elderly surgical patients and the impact of older age on these outcomes by comparing older and younger patients with S. aureus SSI.

DESIGN

A nested cohort study.

SETTING

A 750-bed, tertiary-care hospital and a 350-bed community hospital.

PATIENTS

Ninety-six elderly patients (70 years and older) with S. aureus SSI were compared with 2 reference groups: 59 uninfected elderly patients and 131 younger patients with S. aureus SSI.

RESULTS

Compared with uninfected elderly patients, elderly patients with S. aureus SSI were at risk for increased mortality (odds ratio [OR], 5.4; 95% confidence interval [CI95], 1.5-20.1), postoperative hospital-days (2.5-fold increase; CI95, 2.0-3.1), and hospital charges (2.0-fold increase; CI95, 1.7-2.4; dollar 41,117 mean attributable charges per SSI). Compared with younger patients with S. aureus SSI, elderly patients had increased mortality (adjusted OR, 2.9; CI95, 1.1-7.6), hospital-days (9 vs 13 days; P = .001), and median hospital charges (dollar 45,767 vs dollar 85,648; P < .001).

CONCLUSIONS

Among elderly surgical patients, S. aureus SSI was independently associated with increased mortality, hospital-days, and cost. In addition, being at least 70 years old was a predictor of death in patients with S. aureus SSI.

Aging and infectious diseases in the developing world

Although demographic aging does not remain restricted to industrialized countries, the medical challenge arising from the aging population will be distinct in the developing world. This is particularly true with respect to infectious diseases, which have a distinct spectrum in the elderly population, as well as a greater overall relevance in the developing world. Tropical diseases have a specific presentation and epidemiology in elderly patients. Infectious diseases with a worldwide distribution impact elderly patients in the developing world in a specific manner, which is most obvious with respect to human immunodeficiency virus and tuberculosis but is also true with respect to "trivial" manifestations of infection, such as diarrhea and pneumonia. Malnutrition contributes in a major way to the immunodeficiency of elderly patients in the developing world. Poorly controlled use of antimicrobial drugs leads to multidrug-resistant microorganisms, which, together with the limited resources available for drug treatment, makes appropriate treatment of infections in elderly patients in developing countries very difficult. Infections in elderly patients will have an increasing impact on the public health and economy of developing countries.