Prevalence of lower respiratory tract infections in hospitalized patients in the United Kingdom and Eire--results from the Second National Prevalence Survey

Surviving COVID-19 and multiple complications post total laryngectomy

The clinical manifestation of novel COVID-19 is variable. Pre-existing carcinoma and other comorbidities have been associated with increased COVID-19-related morbidity and mortality. Surgical intervention for advanced laryngeal carcinoma in old age during the COVID-19 pandemic may pose multiple challenges to the patient and the treatment team. We report a case of a 67-year-old elderly man who developed SARS-CoV-2 infection on the 21st day following total laryngectomy and neck dissection. The postoperative period was complicated by sequential development of pulmonary embolism, neck infection, pharyngeal leak and COVID-19 which were managed successfully. No close contacts were positive on the reverse transcription-PCR test for SARS-CoV-2. The patient is in follow-up for the past 7 months without any recurrence or COVID-19-related morbidity. The successful recovery and no cross-infection may be attributed to early diagnosis, immediate intervention and properly implemented institutional infection control policy.

Seasonality of mortality and in-hospital complications in hip fracture surgery: Retrospective cohort research using a nationwide inpatient database

AIM

Among older patients undergoing hip fracture surgery, previous studies have shown a seasonal variation of in-hospital surgical complications. However, little is known about seasonal effects on mortality and systemic complications after hip fracture surgery. In the present study, we evaluated whether mortality and in-hospital systemic complications are influenced by seasonal differences.

METHODS

We enrolled patients from a nationwide database who underwent hip fracture surgery between 2010 and 2018. The primary outcome was in-hospital mortality. The secondary outcomes were in-hospital systemic complications. The association between the seasonality and in-hospital outcomes was investigated using multivariable Cox, logistic regression and causal mediation analysis.

RESULTS

With 425 856 patients (mean age 83.5 years; 79% women), overall in-hospital mortality was 5324 (1.2%). Fall and winter were associated with a higher mortality than spring (hazard ratio [HR] 1.16; P < 0.001; HR 1.14; P = 0.001, respectively). Across all the seasons, there were 36 834 overall systemic complications (8.6%), with respiratory infection being the most frequent (18 637 [4.4%]). Among these complications, only respiratory infection showed seasonal variation, with a higher prevalence in fall and winter. The mediated effect of respiratory infection on mortality was significantly higher in fall and winter compared with spring (fall, HR 1.06, proportion mediated 36.7%; winter, HR 1.14, proportion mediated 55.0%; all P < 0.001).

CONCLUSIONS

We found a significantly higher mortality in fall and winter after hip fracture surgery. Specifically, in winter, the increased in-hospital death was largely attributed to the increased incidence of respiratory infection. Geriatr Gerontol Int 2021; 21: 398-403.

COVID-19 and Total Laryngectomy—A Report of Two Cases

Objective:

To date, no cases have been reported on the effects of COVID-19 in laryngectomees.

Case Presentation:

We herein presented two clinical cases of laryngectomized patients affected by COVID-19, detailing their clinical course and complications.

Discussion:

In our experience, permanent tracheostomy did not significantly affect the choice of treatment. However, dedicated devices and repeated tracheal toilettes may be needed to deal with oxygen-therapy-related tracheal crusting.

Conclusion:

In conclusion, laryngectomees should be considered a vulnerable population that may be at risk for worse outcomes of COVID-19 due to anatomical changes in their airways. The role of the ENT specialist is to guide airway management and inform the support-staff regarding specific needs of these patients.

Nasal and Tracheal Cytological Changes After Total Laryngectomy in Long-Term Survivors

OBJECTIVE

Complete separation of upper and lower respiratory tract after total laryngectomy results in permanent effects on nasal cavities and tracheo-bronchial airways. Aim of this study is evaluating nasal and tracheal cytological alterations of mucosa in laryngectomy long-term survivors, analyzing the feasibility of scraping for cytological examination of tracheal mucosa.

METHODS

Twenty-five laryngectomy patients underwent symptoms' evaluation, endoscopic fiber optic examination, prick tests, and nasal and tracheal scraping for cytological exam. Twenty-five healthy subjects underwent the same assessment, except for tracheal scraping. Eleven laryngectomy patients accepted inferior turbinate biopsy for histological examination.

RESULTS

Nasal cytological analysis demonstrated mucous cell metaplasia in 20% of laryngectomized patients, but it was absent in all healthy subjects; no squamous cell metaplasia was found in both groups. In 15 patients (60%), bacteria were present, without inflammatory infiltrate. Tracheal cytological analysis demonstrated a quite high rate of squamous cell metaplasia (24%), neutrophilic infiltrate (32%), and presence of bacteria (40%). Histological examination of inferior turbinate showed submucosal stromal fibrosis in all patients and submucosal inflammatory infiltrate in 1 case (9%).

CONCLUSION

Nasal cavities and trachea of laryngectomy patients undergo long-term cytological and histological changes of mucosa and submucosa, probably due to airflow modifications.

Nasal and Tracheal Microbial Colonization in Laryngectomized Patients

OBJECTIVE

Complete separation of upper and lower respiratory tract after total laryngectomy results in loss of physiological nasal functions and presence of "unconditioned" inspired air in lower airways. Aim of this study is evaluating the presence of a microbial colonization of nasal cavities and trachea in laryngectomized long-term survivors.

METHODS

Twenty-five laryngectomized patients underwent symptoms' anamnestic evaluation, endoscopic fiber optic nasal and tracheal examination, specimen collection for microbiological exam, and culture. Enrolled patients had at least a 2-year follow-up period in order to evaluate long-term microflora.

RESULTS

Gram positive polimicrobic flora represented the main finding in nasal cavities and trachea (92% and 48% of patients, respectively). Other bacteria were non-fermenters Gram negative bacteria, Enterobacteriaceae and Staphylococcus aureus. The same microflora was demonstrated in nasal cavity and trachea in 5 patients (20%), while sterile nasal cavity and trachea were seen in 3 (12%) and 4 (16%) cases, respectively. No fungi were observed in nasal cavity and trachea.

CONCLUSION

Nasal cavities and trachea of laryngectomized patients are colonized by nonpathogenic and/or potentially pathogenic bacteria, in absence of signs and symptoms of infection. Colonizer microflora should be kept in mind when a culture from nasal or tracheal swabs is needed in daily practice.

Cost-effectiveness of heat and moisture exchangers compared to usual care for pulmonary rehabilitation after total laryngectomy in Poland

The beneficial physical and psychosocial effects of heat and moisture exchangers (HMEs) for pulmonary rehabilitation of laryngectomy patients are well evidenced. However, cost-effectiveness in terms of costs per additional quality-adjusted life years (QALYs) has not yet been investigated. Therefore, a model-based cost-effectiveness analysis of using HMEs versus usual care (UC) (including stoma covers, suction system and/or external humidifier) for patients after laryngectomy was performed. Primary outcomes were costs, QALYs and incremental cost-effectiveness ratio (ICER). Secondary outcomes were pulmonary infections, and sleeping problems. The analysis was performed from a health care perspective of Poland, using a time horizon of 10 years and cycle length of 1 year. Transition probabilities were derived from various sources, amongst others a Polish randomized clinical trial. Quality of life data was derived from an Italian study on similar patients. Data on frequencies and mortality-related tracheobronchitis and/or pneumonia were derived from a Europe-wide survey amongst head and neck cancer experts. Substantial differences in quality-adjusted survival between the use of HMEs (3.63 QALYs) versus UC (2.95 QALYs) were observed. Total health care costs/patient were 39,553 PLN (9465 Euro) for the HME strategy and 4889 PLN (1168 Euro) for the UC strategy. HME use resulted in fewer pulmonary infections, and less sleeping problems. We could conclude that given the Polish threshold of 99,000 PLN/QALY, using HMEs is cost-effective compared to UC, resulting in 51,326 PLN/QALY (12,264 Euro/QALY) gained for patients after total laryngectomy. For the hospital period alone (2 weeks), HMEs were cost-saving: less costly and more effective.

Impact of the socioeconomic status on the severity and outcome of community-acquired pneumonia among Egyptian children: a cohort study

BACKGROUND

Community-acquired pneumonia (CAP) is one of the five leading causes of death among children in developing countries, accounting for approximately three million deaths per year. Identification of the modifiable risk factors of CAP may help to reduce the burden of this disease. In this study, the impact of the socioeconomic status (SES) on the severity and outcome of CAP among Egyptian children was studied.

METHODS

This was a prospective longitudinal cohort study which included 1,470 children diagnosed with CAP, aged two to 15 years (median age 5.4 years). The diagnosis of CAP was based on clinical and radiological findings. A structured questionnaire and the patients' medical records were used for the data collection. The subjects were divided into two groups: mild and severe CAP. Social and demographic variables were compared, and a multivariate logistic regression analysis was performed.

RESULTS

THE MULTIVARIATE ANALYSIS SHOWED THAT A LOW MATERNAL EDUCATION LEVEL (OR: 3.8; 95% CI: 2.12 -6.70; P = .0001), unavailability of adequate medical care (OR: 3.1; 95% CI: 1.99 -4.88; P = .0001), a low family income (OR: 2.2; 95% CI: 0.99 -4.78; P = .047), and parents' smoking habits (OR: 2.0; 95% CI: 1.15 -3.55; P = .014) were significant independent predictive risk factors for severe CAP among Egyptian children.

CONCLUSION

Public health measures against these socio-demographic risk factors should be identified as priorities in order to help reduce the disease burden of deaths from severe CAP among Egyptian children.

Tracheostomy cannulas and voice prosthesis

Cannulas and voice prostheses are mechanical aids for patients who had to undergo tracheotomy or laryngectomy for different reasons. For better understanding of the function of those artificial devices, first the indications and particularities of the previous surgical intervention are described in the context of this review. Despite the established procedure of percutaneous dilatation tracheotomy e.g. in intensive care units, the application of epithelised tracheostomas has its own position, especially when airway obstruction is persistent (e.g. caused by traumata, inflammations, or tumors) and a longer artificial ventilation or special care of the patient are required. In order to keep the airways open after tracheotomy, tracheostomy cannulas of different materials with different functions are available. For each patient the most appropriate type of cannula must be found. Voice prostheses are meanwhile the device of choice for rapid and efficient voice rehabilitation after laryngectomy. Individual sizes and materials allow adaptation of the voice prostheses to the individual anatomical situation of the patients. The combined application of voice prostheses with HME (Head and Moisture Exchanger) allows a good vocal as well as pulmonary rehabilitation. Precondition for efficient voice prosthesis is the observation of certain surgical principles during laryngectomy. The duration of the prosthesis mainly depends on material properties and biofilms, mostly consisting of funguses and bacteries. The quality of voice with valve prosthesis is clearly superior to esophagus prosthesis or electro-laryngeal voice. Whenever possible, tracheostoma valves for free-hand speech should be applied. Physicians taking care of patients with speech prostheses after laryngectomy should know exactly what to do in case the device fails or gets lost.

Prospective controlled study of microbial colonization of the trachea in tracheotomized and laryngectomized patients with HME (heat and moisture exchanger)

CONCLUSION

The use of heat and moisture exchangers (HMEs) does not endanger tracheostomy patients in terms of additional exposure to pathogenic microorganisms.

OBJECTIVE

Stoma filters in the form of HMEs cause a beneficial convection of respiratory air in tracheotomized and laryngectomized patients. We investigated whether or not this may lead to an altered microbial ecology in the non-physiologically colonized lower respiratory tract.

MATERIALS AND METHODS

To test this hypothesis, material from the trachea of stoma patients was prospectively collected utilizing a standardized swab technique and subsequent aerobic quantitative culture assays of the suspended and serially diluted material. With this approach, we examined the microbial flora in 6 and 5 patients after laryngectomy/tracheostomy, respectively, without any protection, in 11 patients after laryngectomy with a bib, and in 8 laryngectomized patients with an HME.

RESULTS

In all three groups, Staphylococcus aureus and Candida albicans were most frequently demonstrated. The microbial count of facultative pathogenic agents ranged between 3×10(2) colony forming units (cfu)/ml and 10(6) cfu/ml and was similar in the three groups. With respect to the absence of inflammatory symptoms in every patient, all isolates could be regarded as colonizers. Among the antibiotics tested with each isolate, cefuroxime proved to be the most effective against the facultative pathogenic bacteria.

Tobacco use increases susceptibility to bacterial infection

Active smokers and those exposed to secondhand smoke are at increased risk of bacterial infection. Tobacco smoke exposure increases susceptibility to respiratory tract infections, including tuberculosis, pneumonia and Legionnaires disease; bacterial vaginosis and sexually transmitted diseases, such as chlamydia and gonorrhoea; Helicobacter pylori infection; periodontitis; meningitis; otitis media; and post-surgical and nosocomial infections. Tobacco smoke compromises the anti-bacterial function of leukocytes, including neutrophils, monocytes, T cells and B cells, providing a mechanistic explanation for increased infection risk. Further epidemiological, clinical and mechanistic research into this important area is warranted.

Correcting for bias when estimating the cost of hospital-acquired infection: an analysis of lower respiratory tract infections in non-surgical patients

Hospital acquired infections (HAI) are costly but many are avoidable. Evaluating prevention programmes requires data on their costs and benefits. Estimating the actual costs of HAI (a measure of the cost savings due to prevention) is difficult as HAI changes cost by extending patient length of stay, yet, length of stay is a major risk factor for HAI. This endogeneity bias can confound attempts to measure accurately the cost of HAI. We propose a two-stage instrumental variables estimation strategy that explicitly controls for the endogeneity between risk of HAI and length of stay. We find that a 10% reduction in ex ante risk of HAI results in an expected savings of pound 693 ($ US 984).

Parental smoking and infant respiratory infection: how important is not smoking in the same room with the baby?

OBJECTIVES

We sought to quantify the effect of good smoking hygiene on infant risk of respiratory tract infection in the first 12 months of life.

METHODS

A cohort of 4486 infants in Tasmania, Australia, was followed from birth to 12 months of age for hospitalization with respiratory infection. Case ascertainment was 98.2%.

RESULTS

Relative to the infants of mothers who smoked postpartum but never in the same room with their infants, risk of hospitalization was 56% (95% confidence interval [CI] = 13%, 119%) higher if the mother smoked in the same room with the infant, 73% (95% CI = 18%, 157%) higher if the mother smoked when holding the infant, and 95% (95% CI = 28%, 298%) higher if the mother smoked while feeding the infant.

CONCLUSIONS

Parents who smoke should not smoke with their infants present in the same room.

Promoter polymorphism in the endotoxin receptor (CD14) is associated with increased carotid atherosclerosis only in smokers: the Carotid Atherosclerosis Progression Study (CAPS)

BACKGROUND AND PURPOSE

The risk of atherosclerosis from endotoxemia is increased in smokers. Endotoxin is a potent mediator of inflammation, and smokers have elevated plasma levels of endotoxin. The endotoxin receptor CD14 can enhance the endotoxin-neutralization capacity of plasma. A functional polymorphism in the promoter region of the CD14 gene (CD14 -159C/T) was studied to determine its impact on common carotid artery (CCA) intima-media thickness (IMT) and any interactions with environmental inflammatory stimuli.

METHODS

A community population (n=992; aged 50 to 65 years) underwent genotypic examination for the CD14 -159 polymorphism by restriction fragment length polymorphism analysis.

RESULTS

The CC genotype was associated with increased CCA IMT. The age- and sex-adjusted odds ratio for IMT above the 75th percentile was 1.63 (95% CI, 1.19 to 2.24; P=0.002) and 1.70 (95% CI, 1.18 to 2.44; P=0.004) after additional adjustment for conventional risk factors. This gene effect was found only in current smokers and ex-smokers. Multivariate analysis in this group (n=503) increased the odds ratio to 2.02 (95% CI, 1.23 to 3.34; P=0.006). No significant interactions were found in nonsmokers or with alcohol consumption.

CONCLUSIONS

The CD14 -159 polymorphism is associated with increased CCA IMT in smokers from a general population. CD14 may modulate the inflammatory effects of smoking in atherogenesis.

Respiratory syncytial virus epidemics: the ups and downs of a seasonal virus

Respiratory syncytial virus (RSV) is the most common pathogen causing lower respiratory tract infections in infants worldwide. Lower respiratory tract infections caused by RSV occur epidemically, and the appearance of epidemics seems to vary with latitude, altitude and climate. This study uses a review of the literature on RSV seasonality to investigate whether a global pattern in RSV epidemics can be found. A comparison of morbidity and mortality caused by RSV in developed vs. developing countries is also presented. The seasons in which RSV epidemics occur typically depend on geographic location and altitude. During these seasons the epidemics tend to appear in clusters. Although the appearance pattern of these epidemics varies from one continent to another, they usually begin in coastal areas. RSV is the cause of one-fifth of lower respiratory infections worldwide. Generally RSV mortality is low, with a median value of zero. However, RSV mortality in developing countries is significantly higher than RSV mortality in developed countries.

A prospective study of tobacco smoking as a predictor of complications in general surgery

OBJECTIVE

To analyze whether tobacco smoking is related to nosocomial infection, admission to the intensive care unit, in-hospital death, and length of stay.

DESIGN

A prospective cohort study.

SETTING

The Service of General Surgery of a tertiary-care hospital.

PATIENTS

A consecutive series of patients admitted for more than 1 day (N = 2,989).

RESULTS

Sixty-two (2.1%) patients died and 503 (16.8%) acquired a nosocomial infection, of which 378 (12.6%) were surgical site and 44 (1.5%) were lower respiratory tract. Smoking (mainly past smoking) was associated with a worse health status (eg, longer preoperative stay and higher American Society of Anesthesiologists score). A long history of smoking (> or = 51 pack-years) increased postoperative admission to the intensive care unit (adjusted odds ratio [OR] = 2.86; 95% confidence interval [CI95], 1.21 to 6.77) and in-hospital mortality (adjusted OR = 2.56; CI95, 1.10 to 5.97). There was no relationship between current smoking and surgical-site infection (adjusted OR = 0.99; CI95, 0.72 to 1.35), whereas a relationship was observed between past smoking and surgical-site infection (adjusted OR = 1.46; CI95, 1.02 to 2.09). Current smoking and, to a lesser degree, past smoking augmented the risk of lower respiratory tract infection (adjusted OR = 3.21; CI95, 1.21 to 8.51). Smokers did not undergo additional surgical procedures more frequently during hospitalization. In the multivariate analysis, length of stay was similar for smokers and nonsmokers.

CONCLUSION

Smoking increases in-hospital mortality, admission to the intensive care unit, and lower respiratory tract infection, but not surgical-site infection. Deleterious effects of smoking are also observed in past smokers and they cannot be counteracted by hospital cessation programs.

Repeated point prevalence survey of nosocomial infections in a Greek university hospital

Two point prevalence surveys of nosocomial infections (NIs) were carried out in a Greek University hospital on an annual basis in 1998 and 1999. The overall prevalence of NIs was 9.5% and 9.1% in the first and second study, respectively. The average length of stay of patients in the hospital (ALOS) was 7.7 and 9.6 days in these two studies, respectively. Of the 97 NIs detected, the most frequent were lower respiratory tract infections (36%). Urinary tract infections, bloodstream infections, surgical site infections, and gastrointestinal infections were found in 25.8%, 19.6%, 7.2% and 4.1% of patients, respectively. The prevalence of antibiotic usage was 55.6% in 1998 and 54.1% in 1999. Empiric antibiotic therapy prevailed over prophylactic and rational therapies. These percentages are higher than those reported from other countries, emphasizing the need for rational antibiotic usage to decrease pharmacy expenses and discourage the development of resistant microorganisms. A nationwide network of surveillance of NIs in Greece is now being developed using these experiences.

Prevalence study of hospital-acquired infections in 14 Greek hospitals: planning from the local to the national surveillance level

A prevalence study of hospital-acquired infections (HAI) was carried out in 14 of 112 Greek hospitals (15.7%), scattered throughout Greece. Five of seven Greek university hospitals and nine regional hospitals participated in the one-day study, and 3925 hospitalized patients (10.5% of the total hospital beds in Greece) were recorded. The aim of this project was to organize a surveillance of HAI with the participation of the greatest possible number of Greek hospitals, transferring the experience from the local Cretan infection control network in an effort to create a nationwide network. Special attention was paid to recruit all Greek university hospitals in our attempt to expand the study base. Co-ordination of the participating centres, education of the infection control teams on surveillance methods, preparation of agreed definitions, and elaboration of the protocol for the collection of the data were the major objectives of this study. The difficulties, however, were limited resources and the lack of skilled personnel. The overall prevalence of HAI was found to be 9.3%. The most common HAI recorded involved lower respiratory tract infections (30.3%), followed by urinary tract infections (22.7%), bloodstream infections (15.8%), and surgical site infections (14.8%). The greatest prevalence rate was found in the adult ICU (48.4%), followed by the neonatal ICU (30.3%). The duration of hospitalization, the number of operations, the total number of used devices and invasive procedures were significantly correlated with HAI. Positive cultures were found in 51.5% of the cases. The most frequently isolated micro-organisms were: Pseudomonas aeruginosa (16.6%), Escherichia coli (10.8%), Klebsiella pneumoniae (10.3%), Staphylococcus epidermidis (8.1%) and Staphylococcus aureus (7.6%). The administration of antibiotics was also recorded. The prevalence of antibiotic use was 51.4%.