A survey of nosocomial infections and their influence on hospital mortality rates

Mutations in AR or SRD5A2 Genes: Clinical Findings, Endocrine Pitfalls, and Genetic Features of Children with 46,XY DSD

OBJECTIVE

Androgen insensivity syndrome (AIS) and 5α-reductase deficiency (5α-RD) present with indistinguishable phenotypes among the 46,XY disorders of sexual development (DSD) that usually necessitate molecular analyses for the definitive diagnosis in the prepubertal period. The aim was to evaluate the clinical, hormonal and genetic findings of 46,XY DSD patients who were diagnosed as AIS or 5α-RD.

METHODS

Patients diagnosed as AIS or 5α-RD according to clinical and hormonal evaluations were investigated. Sequence variants of steroid 5-α-reductase type 2 were analyzed in cases with testosterone/dihydrotestosterone (T/DHT) ratio of ≥20, whereas the androgen receptor (AR) gene was screened when the ratio was <20. Stepwise analysis of other associated genes were screened in cases with no causative variant found in initial analysis. For statistical comparisons, the group was divided into three main groups and subgroups according to their genetic diagnosis and T/DHT ratios.

RESULTS

A total of 128 DSD patients from 125 non-related families were enrolled. Birth weight SDS and gestational weeks were significantly higher in 5α-RD group than in AIS and undiagnosed groups. Completely female phenotype was higher in all subgroups of both AIS and 5α-RD patients than in the undiagnosed subgroups. In those patients with stimulated T/DHT <20 in the prepubertal period, stimulated T/DHT ratio was significantly lower in AIS than in the undiagnosed group, and higher in 5α-RD. Phenotype associated variants were detected in 24% (n=18 AIS, n=14 5α-RD) of the patients, revealing four novel AR variants (c.94G>T, p.Glu32*, c.330G>C, p.Leu110=; c.2084C>T, p.Pro695Leu, c.2585_2592delAGCTCCTG, p.(Lys862Argfs*16), of these c.330G>C with silent status remained undefined in terms of its causative effects.

CONCLUSION

T/DHT ratio is an important hormonal criterion, but in some cases, T/DHT ratio may lead to diagnostic confusion. Molecular diagnosis is important for the robust diagnosis of 46,XY DSD patients. Four novel AR variants were identified in our study.

Trends in mortality rates in female genital organs and breast cancers in Hungary between 1979 and 2013

OBJECTIVE

This study investigated annual and seasonal trends in deaths for cancers of the female genital organs and breast in Hungary between 1979 and 2013.

STUDY DESIGN

Data on the numbers of cancer deaths were obtained from the published nationwide population register. Joinpoint regression was applied to investigate the yearly trends in cancer mortality rates. Cyclic trends were investigated using logistic regression, Edwards' and Walter-Elwood methods.

RESULTS

The majority of deaths from cancers of the female genital organs and breast occurred in winter but using the observed numbers of deaths a significant seasonal pattern was only revealed for deaths from breast cancer with a peak in January and a nadir in July. However, seasonality in the proportion of deaths from female genital organs and breast cancers out of deaths from all causes detected a different peak and nadir. The proportion of female genital organs and breast cancer deaths out of deaths from all causes was higher around the end of summer and significant seasonal variation with a peak in August and nadir in February was revealed.

CONCLUSION

This Hungarian study suggests that there was a significant seasonal effect on female genital organs and breast cancer mortality. Both seasonal patterns are interesting and informative to potentiate prevention. Our findings suggest that infectious diseases may increase the risk of the mortality among the immune deficient patents.

[Incidence of urinary tract infections after cardiac surgery: comparative study accordind to catheterization device]

INTRODUCTION

Urinary tract infections (UTI) associated with urethral catheterization are the second cause of nosocomial infections in Intensive care units. We confirm a UTI when we get a result of 100,000 CFU/ml with at least one microorganism in a urine culture.

MAIN OBJECTIVE

Compare and determine the incidence of UTI in cardiac surgery postpoperative patients according to the catheterization device.

METHODS

A prospective, randomized analytical observational study of patients in the immediate cardiac surgery postoperative period. One group was probed with catheter Foley and one was inserted the catheter BIPFoley-Bactiguard® (CBF). The CBF is coated with noble metals (silver, gold and palladium) and biocompatible antimicrobial properties, covering the entire surface of the device and prevents the formation of biofilm, microbial adherence and colonization.

RESULTS

116 cases, 59.5% (69 cases) were negative for UTI and 40.5% (47 cases) were positive. Out of the positive UTI results, 25% were carriers of catheter Foley and 15.5% of CBF. Most common etiologic microorganisms: Escherichia coli 29.8% Klebsiella pneumonia 29.8%, Klebsiella oxytoca 9%.

CONCLUSION

With the data we have observed that patients catheterized BIPfoley-Bactiguard® are infected to a lesser extent than Foley carriers.

Proportion of Hospital Deaths Potentially Attributable to Nosocomial Infection

Objective:

To determine the fraction of hospital deaths potentially associated with nosocomial infection (NI).

Design:

A matched (1:1) case-control study.

Setting:

An 800-bed, tertiary-care, teaching hospital.

Patients:

All patients older than 14 years who were admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths that occurred in the hospital comprised the case group. For each case, a control patient was matched for primary admission diagnosis and admission date.

Outcome Measures:

The proportion of hospital deaths potentially associated with NI was estimated from the population attributable risk (PAR) adjusted for age, gender, service, severity of illness, length of stay, and quality of the medical record.

Results:

For stays longer than 48 hours, the PAR for all NIs was estimated to be 21.3% (95% confidence interval [CI95], 16.8%-30.5%). The greatest proportion of deaths potentially associated with NIs was observed in patients with only one infection (PAR, 15.0%; CI96, 10.9%-22.6%) and bacteremia or sepsis (PAR, 7.7%;CI95,4.6%-11.6%).

Conclusions:

NIs are associated with a large proportion of intrahospital deaths. This information may help clinicians and healthcare managers to assess the impact of programs for the prevention and control of NIs on intrahospital death.

Mortality Attributable to Nosocomial Infection: A Cohort of Patients With and Without Nosocomial Infection in a French University Hospital

Objective

To assess nosocomial infection (NI) as a risk factor for death and to estimate the population-attributable risk of death from NI.

Design.

A prospective cohort study of patients with and without NI.

Setting.

Nîmes University Hospital, Nîmes, France.

Patients.

Patients were recruited from May 7, 2001, to January 10, 2003. Patients in acute care and long-term care units who had NI were enrolled, and patients without NI were randomly selected and matched with patients with NI for age, sex, type of care (acute care vs. long-term care) and length of stay in hospital at study inclusion.

Outcome Measures.

Vital status within 60 days after study inclusion was assessed. We used conditional logistic regression to estimate the relative death risk from NI after adjusting for comorbidities, severity of the underlying disease, and all other confounding factors. The adjusted population-attributable risk was assessed using the Mantel-Haenszel method.

Results.

We recruited 1,914 patients with NI and 5,172 patients without NI. The median age of the patients with NI was 73 years; 1,045 (54.6%) were female. NI was associated with death within 60 days (adjusted odds ratio, 1.7 [95% confidence interval {CI}, 1.4—;2.2]; P-C.001). The adjusted population-attributable risk of death for all sites of infection was 1.7% (95% CI, 1.4-2.1). If we consider the NI incidence to be 3%-6% in French hospitals, the population-attributable risk of death from NI would range from 2.1% (95% CI, 1.7%-2.5%) to 4.0% (95% CI, 3.3%-4.9%).

Conclusion.

In this study, NI appeared to have a significant impact on mortality. Multicenter studies will be needed to confirm these results.

Estrus cycle: influence on cardiac function following trauma-hemorrhage

Since cardiac function is depressed in males but not in proestrus (PE) females following trauma-hemorrhage (T-H), we examined whether different estrus cycles influence cardiac function in female rats under those conditions. We hypothesized that females in the PE cycle only will have normal cardiac function following T-H and resuscitation. Sham operation or T-H was performed in five groups of rats (250–275 g) including PE, estrus (E), metestrus (ME), diestrus (DE), and ovariectomized (OVX) females ( n = 6–7 per group). Cardiac function was determined 2 h after T-H, following which cardiomyocytes were isolated and nuclei extracted. Cardiomyocyte IL-6 and NF-κB expressions were measured using Western blotting. Moreover, plasma IL-6, estradiol, and progesterone levels were measured using ELISA or EIA kits. Results (1-way ANOVA) indicated that following T-H, 1) cardiac function was depressed in DE, E, ME, and OVX groups but maintained in the PE group; 2) the PE group had the highest plasma estrogen level; 3) plasma IL-6 levels increased significantly in DE, E, ME, and OVX groups, but the increase was attenuated in the PE group; 4) cardiomyocyte IL-6 protein level increased significantly in DE, E, ME and OVX groups after TH, but the increase was attenuated in the PE group; and 5) cardiomyocyte NF-κB expression increased significantly but was attenuated in the PE group. These data collectively suggest that the estrus cycle plays an important role in cardiac function following TH. The salutary effect seen in PE following TH is likely due to a decrease in NF-κB-dependent cardiac IL-6 pathway.

Sexual dimorphism in innate immune responses to infectious organisms

Gender has long been known to be a contributory factor in the incidence and progression of disorders associated with immune system dysregulation. More recently, evidence has accumulated that gender may also play an important role in infectious disease susceptibility. In general, females generate more robust and potentially protective humoral and cell-mediated immune responses following antigenic challenge than their male counterparts. In contrast, males have frequently been observed to mount more aggressive and damaging inflammatory immune responses to microbial stimuli. In this article we review the evidence for sexual dimorphism in innate immune responses to infectious organisms and describe our recent studies that may provide a mechanism underlying gender-based differences in conditions such as bacterial sepsis.

Clinical outcome of immunonutrition in a heterogeneous intensive care population

OBJECTIVE

To study the effect of a high-protein enteral formula enriched with arginine, glutamine, and antioxidants and containing omega3 fatty acids and a mixture of fibers, on the clinical outcome of a heterogeneous intensive care (ICU) population.

DESIGN AND SETTING

A randomized, prospective, double blind, controlled, two-center clinical trial in two intensive care units in The Netherlands.

PATIENTS AND PARTICIPANTS

A total of 597 adult ICU patients expected to require enteral tube feeding for more than 2 days were randomized to receive immunonutrition or an isocaloric control formula.

INTERVENTIONS

Patients received either the immunonutrition or the control feed.

MEASUREMENTS AND RESULTS

Intention-to-treat and per-protocol analyses showed no statistically significant difference in clinical outcome parameters between the two groups. Results of the intention-to-treat analysis in control vs. immunonutrition were: median ICU length of stay in days, 8.0 (IQR 5.0-16.0) vs. 7.0 (4.0-14.0); median hospital length of stay in days, 20.0 (IQR 10.0-34.0) vs. 20.0 (10.0-35.0); median days of ventilation, 6.0 (IQR 3.0-12.0) vs. 6.0 (IQR 3.0-12.0); ICU mortality, 26.8% vs. 28.2%; in-hospital mortality, 36.4% vs. 38.5%; infectious complications, 41.7% vs. 43.0%.

CONCLUSIONS

The results of this largest randomized, controlled trial found that in the general ICU population immunonutrition has no beneficial effect on clinical outcome parameters. These results are consistent with the literature that is currently available.

Nosocomial infections and hospital mortality: a multicentre epidemiology study

The aim of this study was to evaluate the number of deaths associated with nosocomial infections (NI) and the contribution of these NI to death. A multicentre descriptive study was conducted in 16 tertiary-care hospitals (14 222 beds) in Northern France. Medical records of consecutive patients who died at least 48 h after admission were reviewed for cause of death, NI and disease severity, before admission and before NI onset. The contribution of NI to death was assessed by agreement between two physicians according to a three-category scale of probability. Among the 1945 patients who died during the study, 26.6% had an NI. According to the agreed diagnosis, NI contributed to the deaths of 284 (14.6%) patients(certainly for 6.6% and possibly for 8%), thereby ranking NI as the fourth most frequent cause of death. Considering the deaths that had not been anticipated independently of NI two weeks before they occurred, NI definitely contributed to 2.8% of them. Lower respiratory tract, bloodstream and surgical wound infections were responsible for 39, 20 and 14%, respectively,of all NI in these patients. The impact of NI on in-hospital mortality seems to be lower than had previously been estimated in France based on US data from the 1970s and 1980s. To improve healthcare quality, further studies are needed to elucidate the processes that may contribute to fatal severe NI.

Device-associated nosocomial infection rates in intensive care units of Argentina

BACKGROUND

Nosocomial infections are an important public health problem in many developing countries, particularly in the intensive care unit (ICU) setting. No previous data are available on the incidence of device-associated nosocomial infections in different types of ICUs in Argentina.

METHODS

We performed a prospective nosocomial infection surveillance study during the first year of an infection control program in six Argentinean ICUs. Nosocomial infections were identified using the Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System definitions, and site-specific nosocomial infection rates were calculated.

RESULTS

The rate of catheter-associated bloodstream infections in medical-surgical ICUs was 30.3 per 1,000 device-days; it was 14.2 per 1,000 device-days in coronary care units (CCUs). The rate of ventilator-associated pneumonia in medical-surgical ICUs was 46.3 per 1,000 device-days; it was 45.5 per 1,000 device-days in CCUs. The rate of symptomatic catheter-associated urinary tract infections in medical-surgical ICUs was 18.5 per 1,000 device-days; it was 12.1 per 1,000 device-days in CCUs.

CONCLUSION

The high rate of nosocomial infections in Argentinean ICUs found during our surveillance suggests that ongoing targeted surveillance and implementation of proven infection control strategies is needed in developing countries such as Argentina.

Current concepts in the diagnosis and management of trauma-related sepsis

Traumatic injury is common, and accounts for a large health care burden. Trauma and in particular haemorrhagic shock are closely related to the onset of multiple organ failure, the systemic inflammatory response and sepsis. Despite overall improvements in the care of septic critically ill patients there has been little impact on morbidity and mortality. In recent years our understanding of sepsis both as an illness and at a molecular level has led to the development of a number of therapeutic interventions. This article outlines the current evidence for such interventions and points to possible future research that is required in the diagnosis and management of trauma-related sepsis.

[Respiratory infections in adults hospitalized in internal medicine and pneumology departments. DIRA (Adult Respiratory Infection Day) study]

INTRODUCTION

Respiratory tract infections (RIs) are frequent processes that can require hospitalization or affect already hospitalized patients. The Foundation for the Study of Infection has promoted the DIRA (Adult Respiratory Infection Day) Project, with the aim of investigating and assessing the impact of this problem, particularly in Internal Medicine and Pneumology Departments.

METHODS

Prospective prevalence study involving 158 physicians in 100 Internal Medicine and Pneumology Departments. Data were collected on predetermined days, once every three months (total of four data sets) and included information on number of patients attended, number of patients with infection, and epidemiologic, clinical, microbiologic and treatment characteristics of patients with RI.

RESULTS

A total of 3,596 patients were hospitalized at the four time points. Among these, 39.1% presented clinical symptoms consistent with infection and 34.3% of these were RIs. The mean age of RI patients was 65.6 years, 68.8% were males, 84.1% had an underlying disease (most frequently chronic obstructive pulmonary disease) and 25.1% had one or more predisposing factors. Pneumonia was the most frequent diagnosis (41.3% of RIs). RI was documented microbiologically in 15.8% of cases. Antibiotic treatment was applied in 99.7% of patients with acute bronchitis and 81.8% of those with upper respiratory tract infection; penicillins were the most frequent treatment. Data are presented by diagnosis.

CONCLUSIONS

A substantial rate of respiratory infections was found in patients admitted to hospital Internal Medicine and Pneumology Departments, with pneumonia being the most frequent. There was a paucity of microbiologic documentation. It is likely that antibiotic treatment was not justified in the majority of patients with upper respiratory tract infections. A combination of two or more antimicrobial agents was used in about half of cases.

Factors related to hospital stay among patients with nosocomial infection acquired in the intensive care unit

OBJECTIVES

To assess the influence of nosocomial infection on length of stay in the intensive care unit (ICU) and to determine the relative effect of other factors on extra length of hospitalization associated with nosocomial infection.

DESIGN

Prospective cohort multicenter study in the context of the ENVIN-UCI project.

SETTING

Medical or surgical ICUs of 49 different hospitals in Spain.

METHODS

All consecutive patients (N = 6,593) admitted to ICUs of the participating hospitals who stayed for more than 24 hours during a 3-month period (from January 15 to April 15, 1996) were included. Length of ICU stay was compared between patients with and without nosocomial infections. RESULTS Uninfected patients (N = 5,868) had a median stay in the ICU of 3 days, whereas the median for infected patients (N = 725) was 17 days (P < .001). The median for infected patients with one episode of nosocomial infection was 13 days. The greatest length of stay (40 days) was among patients admitted to the ICU because of medical diseases, with an infection acquired before admission to the ICU, and with the largest number of nosocomial infection episodes. In extended stays, nosocomial infection was significantly associated with length of hospitalization (day 21; odds ratio, 22.38; 95% confidence interval 16.6 to 30.4), whereas an effect of variables related to severity of illness on admission (Acute Physiology and Chronic Health Evaluation II score, urgent surgery, and infection prior to ICU admission) was not found.

CONCLUSIONS

The presence of nosocomial infection and the number of infection episodes were the variables with the strongest association with prolonged hospital stay among ICU patients.

Alcohol, injury, and cellular immunity

It is widely accepted that alcohol exposure is a causative factor in the occurrence of burn or other traumatic injury. It is less well known that individuals who have consumed alcohol before sustaining an injury suffer from increased morbidity and mortality compared with the morbidity and mortality of non-alcohol-consuming subjects with similar injuries. Complications due to bacterial infection are the most common burn sequelae in injured patients and are frequently associated with depressed immunity. Independently, alcohol exposure and injury have been shown to influence cellular immunity negatively. These changes in immunity are closely linked to injury- or alcohol-induced alterations in the cytokine milieu in both clinical studies and animal models. Not surprisingly, the combination of insult of alcohol exposure and burn injury results in immune suppression that is greater in magnitude and duration compared with either insult alone. The combined effects of alcohol and injury on immunity have been examined in a limited number of studies. However, results of these studies support the suggestion that altered cytokine production is an integral part of the immune dysregulation and increased mortality that is observed. In particular, the increased presence of macrophage-derived mediators observed after burn or alcohol exposure alone seems to be synergistically increased in a combined injury model. Although more research is needed, it is likely that therapeutic modalities that include manipulation of cytokine networks to boost cellular immunity may improve outcome for patients who sustain injuries subsequent to consuming alcohol.

Hospital-acquired infections following the 1999 Marmara earthquake

In this study, medical records of all casualties admitted to our hospital following the Marmara earthquake, which struck northwest Turkey and resulted in the destruction of several towns in the Marmara region, were evaluated retrospectively. The time buried under the rubble, demographic data, type of medical and surgical therapies performed, type of injury and data on infection were analysed. Between 17 August and 25 September 1999, 630 trauma victims were received at our hospital and 532 (84%) of them were hospitalized. The mean age of hospitalized patients (312 males, 220 females) was 32 years (2-90 years). Two hundred and twenty patients were hospitalized for more than 48 h. Forty-one of them (18.6%) had 43 hospital-acquired infection (HAI) episodes, which were mostly wound infections (46.5%). A total of 143 culture specimens was collected and 48 yielded the following potential pathogens: 15 Acinetobacter baumanii (31.2%), nine Staphylococcus aureus (18.7%), seven Pseudomonas aeruginosa (14.6%), six Escherichia coli (12.5%), six Klebsiella pneumoniae (12.5%), two Stenotrophomonas maltophilia (4.2%) and three various Pseudomonas spp. (6.3%). All S. aureus strains were found to be resistant to methicillin in vitro. Two strains of A. baumannii and one P. aeruginosa were found to be resistant to all antimicrobials including carbapenems. Fifty-three victims died (10%) and 36 of those died during the first 48 h because of severe injuries and multi-organ failure. After 48 h of hospitalization, the mortality rate was significantly higher in those patients with HAI (14/41) than those without (3/179) (34.1% vs. 1.7%, P<0.05). In conclusion, trauma is the significant factor associated with HAI and a high incidence of Acinetobacter strains was responsible for HAI in trauma patients.

Proportion of hospital deaths potentially attributable to nosocomial infection

OBJECTIVE

To determine the fraction of hospital deaths potentially associated with nosocomial infection (NI).

DESIGN

A matched (1:1) case-control study.

SETTING

An 800-bed, tertiary-care, teaching hospital.

PATIENTS

All patients older than 14 years who were admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths that occurred in the hospital comprised the case group. For each case, a control patient was matched for primary admission diagnosis and admission date.

OUTCOME MEASURES

The proportion of hospital deaths potentially associated with NI was estimated from the population attributable risk (PAR) adjusted for age, gender, service, severity of illness, length of stay, and quality of the medical record.

RESULTS

For stays longer than 48 hours, the PAR for all NIs was estimated to be 21.3% (95% confidence interval [CI95], 16.8%-30.5%). The greatest proportion of deaths potentially associated with NIs was observed in patients with only one infection (PAR, 15.0%; CI95, 10.9%-22.6%) and bacteremia or sepsis (PAR, 7.7%; CI95, 4.6%-11.6%).

CONCLUSIONS

NIs are associated with a large proportion of intrahospital deaths. This information may help clinicians and healthcare managers to assess the impact of programs for the prevention and control of NIs on intrahospital death.

Risk factors for intrahospital infection in newborns

BACKGROUND

Intrahospital infection (IHI) in the newborn (NB) is a morbidity problem that increases mortality rates in this age group because the infecting microorganism is more aggressive. The objective of this study was to compare risk factors for localized or systemic IHIs between groups of NBs with and without IHIs.

METHODS

This was a retrospective study of two groups of patient records from January 1995 to December 1998. Group A (cases) was made up of 73 patients with documented IHIs and Group B (controls), 105 patients without IHIs. Descriptive and inferential statistics (Student t, Mann-Whitney U, Wilcoxon rank sum, Chi square, and Fisher exact tests) were used. Odds ratio (OR) and multiple logistic regression were used to study risk factors. Statistical significance was considered at p <0.05.

RESULTS

Average gestational age was 35.4 +/- 4.3 weeks in Group A patients and 37.4 +/- 3.2 weeks for Group B patients with p = 0.001. Risk factors studied by means of OR (low birth weight, prematurity of 30 weeks of gestational age or less, prolonged intrahospital stay, etc.) showed statistical significance. Also showing significance were other not-well-studied factors such as higher numbers of diagnoses and blood transfusions. After multivariate analysis, the group of risk factors more associated with IHIs included vein dissection for insertion of central venous catheter, orotracheal intubation, and prolonged intrahospital stay (12 days or more) with an accumulative r of 0.6112.

CONCLUSIONS

We conclude that there are several known risk factors for IHIs and others not well described to date that must be avoided to the extent possible in the NB, particularly in the premature newborn population.

Epidemiologic methods for the prevention of nosocomial infections

There is an ongoing controversy in Europe about the benefits and limitations of epidemiologic methods for the prevention and control of hospital-acquired infections. Hospital epidemiology, aimed at measuring the necessity, or effect, of preventive strategies for nosocomial infection control, is still an unknown field in many European institutions. The conceptual framework presented here is not intended as a complete review of modern hospital epidemiology, but should be considered rather a viewpoint which tries to bridge the gap between microbiology-based hospital hygiene and hospital epidemiology in Europe. The explanatory power and limitations of descriptive, analytical and interventional epidemiology are described. Based on the assumption that nosocomial infections have causal and preventive factors that can be identified through systematic investigation, epidemiologic methods add important knowledge to reduce hospital-acquired infections.

Nosocomial infections in pediatric patients: a European, multicenter prospective study. European Study Group

OBJECTIVES

To determine the site and bacterial epidemiology of nosocomial infections (NIs) in children.

DESIGN

6-month prospective study with periodic chart review during hospitalization using a uniform prospective questionnaire in each unit, analyzed at a coordinating center.

SETTING

20 units in eight European countries: 5 pediatric intensive care units (PICUs), 7 neonatal units, 2 hematology-oncology units, 8 general pediatric units.

PARTICIPANTS

All children hospitalized during the study period with an NI according to Centers for Disease Control and Prevention criteria.

RESULTS

The overall incidence of NI was 2.5%, ranging from 1% in general pediatric units to 23.6% in PICUs. Bacteria were responsible for 68% (gram-negative bacilli, 37%; gram-positive cocci, 31%), Candida for 9%, and viruses for 22% of cases. The proportion of lower respiratory tract infections was 13% in general pediatric units and 53% in PICUs. Bloodstream infections were most frequent in neonatal units (71% of NIs) and were associated with a central venous catheter in 66% of cases. Coagulase-negative Staphylococcus (CNS) was the main pathogen. Eleven percent of NI were urinary tract infections. Gastrointestinal infections were most commonly viral and accounted for 76% of NIs in general pediatric units. The prevalence of antimicrobial resistance depended on the type of unit. The highest rates were observed in PICUs: 26.3% of Staphylococcus aureus and 89% of CNS were methicillin-resistant, and 37.5% of Klebsiella pneumoniae had an extended-spectrum beta-lactamase. Mortality due to NI was 10% in PICUs and 17% in neonatal units.

CONCLUSIONS

We found large differences in NI frequency and microbial epidemiology in this European study. Viruses were the main pathogens in general pediatrics units. Catheter-related sepsis and CNS were frequent in newborns. A high frequency of multiresistant bacteria was observed in some units. Clinical monitoring of NIs and bacterial resistance profiles are required in all pediatric units.

Management of infections in the trauma patient

Infections play a leading role in the morbidity and mortality of injured patients. This article discusses risk factors that can increase the chances of a nosocomial infection. It also discusses common types of infection, causative organisms, and the approach to the febrile trauma patient.

Sex steroids regulate pro- and anti-inflammatory cytokine release by macrophages after trauma-hemorrhage

Studies indicate that macrophage immune responses in males are depressed after trauma-hemorrhage, whereas they are enhanced in females under such conditions. Nonetheless, the involvement of male and female sex steroids in this gender-dependent dimorphic immune response after trauma-hemorrhage remains unclear. To study this, male C3H/HeN mice were castrated and treated with pellets containing either vehicle, 5alpha-dihydrotestosterone (DHT), 17beta-estradiol, or a combination of both steroid hormones for 14 days before soft tissue trauma (i.e., laparotomy) and hemorrhagic shock (35 +/- 5 mmHg for 90 min followed by adequate fluid resuscitation) or a sham operation. Twenty-four hours later the animals were killed, plasma was obtained, and Kupffer cell and splenic and peritoneal macrophage cultures were established. For DHT-treated mice, we observed significantly decreased releases of the proinflammatory cytokines interleukin 1beta (IL-1beta) and IL-6 by splenic macrophage (-50 and -57%, respectively) and peritoneal macrophage (-51 and -52%, respectively) cultures after trauma-hemorrhage compared with releases by cultures of cells from mice subjected to a sham operation; in contrast, responses of splenic and peritoneal macrophage cultures from other groups subjected to trauma-hemorrhage did not change significantly. In addition, only DHT-treated animals exhibited increased Kupffer cell IL-6 release (+634%). The release of IL-10 in DHT-treated hemorrhaged animals was increased compared with that in sham-operated animals but was decreased in estrogen-treated mice under such conditions. These results suggest that male and female sex steroids exhibit divergent immunomodulatory properties with respect to cell-mediated immune responses after trauma-hemorrhage.

APACHE II and ISS scores as predictors of nosocomial infections in trauma patients

BACKGROUND

Nosocomial infections affect more than 2 million patients annually in the United States at a cost of $4.5 billion. The aim of this study is to identify the role of the APACHE II score and the Injury Severity Scale (ISS) as independent predictors of nosocomial infections in trauma patients admitted to the intensive care unit (ICU).

METHODS

A retrospective chart review of 113 trauma patients admitted to the ICU was conducted by an infectious disease physician. Demographic data and incidence of nosocomial infections were recorded. Multivariate logistic regression analysis was used to determine variables that are predictive of the occurrence of nosocomial infections.

RESULTS

Presence or absence of intubation, ICU length of stay, APACHE II score, and ISS were related to the presence of infections; however, only the ICU length of stay was an independent predictor of a nosocomial infection, with an odds ratio of 1.81. By linear regression, 17% of the variance in the ICU duration of stay was a result of the APACHE II score in patients with a score >/=5.

CONCLUSION

APACHE II score and ISS score were not good predictors of the incidence of nosocomial infections in trauma patients admitted to the ICU, but the APACHE II score has a modest correlation with the duration of stay in the ICU. A stratified cohort study could identify the subset of patients for which the APACHE II score predicts a prolonged stay in the ICU, thus an increased risk of infection.

Nosocomial infection, indices of intrinsic infection risk, and in-hospital mortality in general surgery

The objectives of this paper are to assess whether two indices of intrinsic infection risk (the SENIC and the NNIS index) predict in-hospital mortality and the attributable in-hospital mortality due to nosocomial infection in surgical patients. A prospective study on 4714 patients admitted to three hospitals has been carried out. The relative risk and its 95% confidence interval (CI) were estimated. Multiple-risk factors adjusted for odds ratios (OR) were yielded by logistic regression analysis. Overall, 119 patients (2.5%) died before hospital discharge. Both the SENIC and the NNIS indices were related to in-hospital mortality in crude data. After controlling for several variables (age, sex, ASA score, cancer, renal failure, diabetes mellitus, stay at the ICU), the SENIC index did not show any significant trend with mortality (P = 0.252), whereas the trend was significant for the NNIS index (P < 0.001). Risk of death in patients with one nosocomial infection was 7.5%, and in patients developing more than one nosocomial infection was 17.1%. After adjusting for several confounding variables, the development of an organ/space surgical site infection was significantly related to mortality (OR = 4.5, 95% CI 1.5-15.6) as was blood infection (OR = 17.3, 95% CI 3.5-87.0). The association of a surgical site infection and either a respiratory tract infection or a blood infection also increased significantly the risk of in-hospital mortality (OR = 3.3, 95% CI 1.2-8.7). In conclusion, the NNIS index is a good predictor of in-hospital mortality. Patients developing an organ/space surgical site infection and/or a blood infection have an increased risk of in-hospital mortality.

Incidence of nosocomial pneumonia in a medical intensive care unit and general medical ward patients in a public hospital in Bombay, India

We prospectively studied the incidence of hospital-acquired pneumonia in 1886 consecutive admissions to an 1800 bed hospital in Bombay; 991 of them to general medical wards and 895 to a 17-bed medical intensive care unit (ICU). The average bed occupancy in the general wards was 56 patients in a ward with 40 beds. Staffing in the general ward was two nurses for 56 patients, and in the ICU three nurses for 17 beds. One hundred and sixty-eight patients developed nosocomial pneumonia: 18 (1.8%) in general wards and 150 (16.7%) in the ICU. Common isolates included Pseudomonas spp (44%) and Klebsiella spp (34%). The most frequently used antibiotics were cefotaxime (34%), amikacin (25%), gentamicin (23%) and ofloxacin (13%). Crude mortality in general ward patients was 88.9 vs 14.6% in patients without pneumonia. The corresponding figures for ICU patients were 67.4 vs 37.1%; 40% of the crude mortality in ICU patients with pneumonia was attributable to the infection. Infected patients stayed an additional 5.8 days in the ICU and 6.7 days in the general ward. Costs of additional stay and antibiotics accounted for 18.6% of the ICU budget. The incidence of nosocomial pneumonia was lower than expected, despite occupancy exceeding bed capacity, low nurse:patient ratios, and extensive reuse of disposable respiratory therapy equipment. Nevertheless, nosocomial pneumonia imposes a significant financial burden on the already scarce resources available for intensive care in developing countries like India.

[Influence of nosocomial infection on mortality in an intensive care unit]

OBJECTIVE

To evaluate the association between nosocomial infections (NI) and the mortality of Intensive Care Unit (ICU) patients, adjusting for the effect on mortality of other predictive variables.

METHODS

Prospective study on 944 concurrent patients admitted for at least 24 hours in the ICU of a tertiary level hospital between February and November of 1994. The association between NI (diagnosed using CDC criteria) and mortality was studied using multivariable logistic regression.

RESULTS

The cummulative incidence of mortality in the ICU was 11.2% (CI95% = 9.9-12.5). This incidence was significantly higher in infected patients with a crude mortality relative risk of 2.2 (CI95% = 1.5-3.1). In the multivariable analysis, the effect of NI (global, pneumonias, of the urinary tract and bacteriemias) on adjusted mortality depended on the patient's Acute Pysiology and Chronic Health Evaluation II (APACHE II) score. With low APACHE II scores, NI was associated with an increased mortality risk. Conversely, with higher APACHE II scores, the relevance of NI as a determinant of mortality decreased and prognosis was mainly associated with the patient's severity of illness.

CONCLUSIONS

The association between NI and mortality, adjusting for other prognostic factors for mortality, is confirmed.

Proportion of hospital deaths associated with adverse events

OBJECTIVES

To determine the fraction of hospital deaths potentially associated with the occurrence of adverse events (AE).

DESIGN

A paired (1:1) case-control study.

SETTING

An 800-bed, teaching tertiary care hospital.

PATIENTS

All patients older than 14 years admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible. All 524 consecutive deaths (death rate of 3.74%) that occurred in the hospital comprised the case group. For each case, a control patient was matched for both primary diagnosis on admission and admission date.

MEASUREMENTS

The proportion of hospital deaths associated with adverse events (defined as problems of any nature and seriousness faced by the patient during hospitalization, and potentially traceable to clinical or administrative management) was estimated from attributable risks adjusted for age, sex, service, severity of illness, length of stay, and quality of the medical record.

RESULTS

For stays longer than 48 hours, the adjusted attributable risk for all adverse events was estimated to be 0.51 (0.40-0.61). When the data were stratified according to the category of adverse event, the attributable risks remained significant except for administrative problems. The greatest proportion of deaths associated with adverse events was observed for surgical adverse events [0.56 (0.38-0.71)] and nosocomial infection [0.22 (0.14-0.28)].

CONCLUSIONS

A significant proportion of intrahospital deaths were associated with AE. These results suggest the need to consider programs focused on the prevention of mortality from AE.

Economic analysis of nosocomial infections in a Turkish university hospital

Nosocomial infections constitute an important health problem with morbidity, and high mortality, prolongation of hospital stay, and increased costs of direct patient care. This study was conducted in Hacettepe University Hospital in order to determine the cost of nosocomial infections and length of hospitalization by matching infected patients with uninfected controls. Data collected from 102 individuals with nosocomial infection (group A) and 102 controls without nosocomial infection (group B) were recorded by using a computer program (dbase IV). Urinary tract infections, surgical wound infections and bacteremias were the most common nosocomial infections. Patients were generally located in Internal Medicine, Neurosurgery, General Surgery Clinics. The mean total length of stay was 35.1 and 14.8 days for group A and group B, respectively (p<0.001). The average hospital cost was US $2280 for group A, and US $698 for group B (p<0.001). Mortality rates were 19.6% for patients with nosocomial infections and 2.9% for uninfected controls (p<0.0001). We conclude that the high economic expense which nosocomial infection represents justifies measures to control this entity.

Proinflammatory cytokines: indicators of infection in high-risk patients

Proinflammatory cytokines play an eminent role in pathophysiology of infection and inflammation. Their actual clinical importance is, however, uncertain. In this study, we tested the hypothesis that inflammatory cytokines could be useful in detection of infections in high-risk patients. We prospectively studied the diagnostic value of determination of concentrations of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), and the 55- and 75-kd soluble TNF receptors (sTNFR-p55 and sTNFR-p75) in detection of nosocomial infections in 52 patients with acute ischemic stroke, as an exemplary high-risk group, and compared these findings to those of conventional inflammatory indicators of inflammation (C-reactive protein and leukocyte count). After 1 week of hospitalization, 27% of the patients had minor or moderately severe nosocomial infections. This subpopulation exhibited significantly increased concentrations of IL-6 and sTNFR-p55 but not of IL-1beta, TNF-alpha, or sTNFR-p75. As expected, levels of C-reactive protein and leukocytes were increased in infected patients. The sensitivity and specificity for detection of nosocomial infections at day 7 of hospitalization was highest for IL-6, followed by C-reactive protein and the leukocyte count. The data suggest that the proinflammatory cytokine IL-6, in addition to its considerable pathophysiologic importance in systemic inflammation, may be valuable in detection of infections in high-risk patients.