Epidemiology of nosocomial infection and resistant organisms in patients admitted for the first time to an acute rehabilitation unit

Antimicrobial stewardship strategy implementation and impact in acute care spinal cord injury and disorder units

CONTEXT

Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D).

OBJECTIVE

The goal of this study was to assess key ASP leader and SCI/D clinicians' perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies.

METHOD

SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact ("high", "mild", "low") and perceived level of implementation ("not", "partially", "fully") for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher's exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders).

RESULTS

AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation.

CONCLUSION

Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

Charting the landscape of the environmental exposome

The exposome depicts the total exposures in the lifetime of an organism. Human exposome comprises exposures from environmental and humanistic sources. Biological, chemical, and physical environmental exposures pose potential health threats, especially to susceptible populations. Although still in its nascent stage, we are beginning to recognize the vast and dynamic nature of the exposome. In this review, we systematically summarize the biological and chemical environmental exposomes in three broad environmental matrices-air, soil, and water; each contains several distinct subcategories, along with a brief introduction to the physical exposome. Disease-related environmental exposures are highlighted, and humans are also a major source of disease-related biological exposures. We further discuss the interactions between biological, chemical, and physical exposomes. Finally, we propose a list of outstanding challenges under the exposome research framework that need to be addressed to move the field forward. Taken together, we present a detailed landscape of environmental exposome to prime researchers to join this exciting new field.

Impact of healthcare-associated infections on functional outcome of severe acquired brain injury during inpatient rehabilitation

To describe healthcare-associated infections in inpatient neuro-rehabilitation and their impact on functional outcome, a multicenter observational study with severe acquired brain injury (sABI) patients was performed. Patients were divided into infected (INF-group) or not infected (noINF-group) and assessed at admission and discharge, by means of the Glasgow Coma Scale (GCS), the Rancho Los Amigos Levels of Cognitive Functioning Scale (LCF), the Disability Rating Scale (DRS), and the modified Barthel Index (mBI). One hundred-nineteen patients were included in the INF-group, and 109 in the noINF-group. Culture specimens were found positive for bloodstream (43.8%), respiratory tract (25.7%), urinary tract (16.2%), gastro-intestinal system (8.6%) and skin (2.4%) infections. Multiple microorganisms were the most frequent (58.1%) and 55.5% of patients needed functional isolation due to multidrug resistant germs. The functional status of both groups improved after rehabilitation, but multivariable analyses showed that the INF-group showed a significantly lower gain to GCS (p = 0.008), DRS (p = 0.020) and mBI (p = 0.021) compared to the noINF-group. Length of stay (LOS) and number of skipped rehabilitative sessions were not statistically different between the groups; mortality rate was significantly higher in the INF-group (p = 0.04). Infected sABI patients showed longer LOS, significant increased mortality, and a lower functional outcome than not infected patients.

Antimicrobial stewardship in spinal cord injury: A multidisciplinary approach

Context: In a global environment of escalating antimicrobial resistance and limited new antibiotic development, there is a desire to optimize antibiotic use across all settings to preserve options for the future. Despite this, antibiotics continue to be prescribed inappropriately in many settings. Patients with a spinal cord injury (SCI) are particularly vulnerable to receiving multiple courses of antibiotics, yet there is limited data reviewing antimicrobial stewardship (AMS) programs in this patient population.Hypothesis: Adopting AMS rounds will reduce days of antibiotic treatment.Intervention: We implemented a systematic bedside AMS multidisciplinary team (MDT) ward round within the SCI Unit at our hospital, where a collaborative inter-speciality and inter-professional approach was undertaken to address antibiotic prescriptions. A retrospective audit of antibiotic prescriptions was performed one month prior and one month during the intervention.Outcome measures: An infectious disease consultant led a multidisciplinary, multispecialty ward rounding team, looking at antibiotic appropriateness and guideline compliance. The effectiveness of this intervention was assessed by retrospectively looking at antibiotic days of usage per patient day of occupancy.Results: Antibiotic consumption significantly decreased following the AMS intervention, from 69.8 to 24.3 days on treatment per 100 patient days (P < 0.001). Following implementation of the ward round the proportion of therapeutic guideline compliant prescriptions significantly rose from 18% in April to 56% in August (P < 0.001).Conclusions: Utilizing a collaborative inter-speciality and inter-professional AMS approach and providing face to face feedback about the appropriateness of antibiotic prescribing can help optimize antibiotic usage within a SCI unit.

Optimising patients with long-term spinal cord injury for nephrectomy: A review of pre-, peri- and post-operative factors to safeguard outcomes

Objectives:

To review the potential challenges a urologist may encounter when embarking on simple/partial/radical nephrectomy in patients with long-term spinal cord injury and propose strategies to pre-empt and manage these.

Materials and methods:

Comprehensive literature review via PubMed, MEDLINE® and Google™ Scholar searching for relevant scientific articles published to date in English. Recommendations for strategies to safeguard surgical outcomes discussed with a panel of experienced upper-tract urologists.

Results:

Pre-operative considerations:  - urethral assessment via flexible cystoscopy due to higher incidence of urethral pathology in spinal cord injury;  - assessing for chronic constipation and distended bowel; and  - considering glomerular filtration rate assessment by radio-isotope techniques, such as 51chromium-EDTA Peri-operative considerations:  - adequate theatre staffing for safe patient transfer; and  - planned choice of incision, due to higher incidence of previous abdominal surgery, stoma bags and/or foreign body devices. Post-operative considerations:  - ensuring attending medical staff are trained to recognise autonomic dysreflexia;  - early re-mobilisation with physiotherapists experienced in treating spinal cord injury; and  - attentive antibiotic stewardship due to higher risk of hospital-acquired or urinary infections

Conclusions:

Patients with long-term spinal cord injury pose significant potential challenges in the pre-, peri- and post-operative stages of nephrectomy. Familiarisation and optimisation of such factors is recommended to safeguard outcomes.

Level of evidence:

Not applicable for this multicentre audit.

The gut-brain axis and beyond: Microbiome control of spinal cord injury pain in humans and rodents

Spinal cord injury (SCI) is a devastating injury to the central nervous system in which 60 to 80% of patients experience chronic pain. Unfortunately, this pain is notoriously difficult to treat, with few effective options currently available. Patients are also commonly faced with various compounding injuries and medical challenges, often requiring frequent hospitalization and antibiotic treatment. Change in the gut microbiome from the "normal" state to one of imbalance, referred to as gut dysbiosis, has been found in both patients and rodent models following SCI. Similarities exist in the bacterial changes observed after SCI and other diseases with chronic pain as an outcome. These changes cause a shift in the regulation of inflammation, causing immune cell activation and secretion of inflammatory mediators that likely contribute to the generation/maintenance of SCI pain. Therefore, correcting gut dysbiosis may be used as a tool towards providing patients with effective pain management and improved quality of life.

Healthcare facility-onset, healthcare facility-associated Clostridioides difficile infection in Veterans with spinal cord injury and disorder

Objective: To describe the burden and risk of healthcare facility-onset, healthcare facility-associated (HO-HCFA) Clostridioides difficile infection (CDI) in Veterans with spinal cord injury and disorder (SCI/D). Design: Retrospective, longitudinal cohort study from October 1, 2001-September 30, 2010. Setting: Ninety-four acute care Veterans Affairs facilities. Participants: Patients with SCI/D. Outcomes: Incidence rate of HO-HCFA CDI. Methods: Rates of CDI were determined, and crude unadjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated. Multivariable Poisson random-effects regression analyses were used to assess factors independently associated with the rate of CDI. Results: 1,409 cases of HO-HCFA CDI were identified. CDI rates in 2002 were 13.9/10,000 person-days and decreased to 5.5/10,000 person-days by 2010. Multivariable regression analyses found that antibiotic (IRR = 18.79, 95% CI 14.09-25.07) and proton-pump inhibitor (PPI) or H2 blocker use (IRR = 7.71, 95% CI 5.47-10.86) were both independently associated with HO-HCFA CDI. Exposure to both medications demonstrated a synergistic risk (IRR = 37.55, 95% CI 28.39-49.67). Older age, Northeast region, and invasive respiratory procedure in the prior 30 days were also independent risk factors, while longer SCI duration and care at a SCI center were protective. Conclusion: Although decreasing, CDI rates in patients with SCI/D remain high. Targeted antimicrobial stewardship and pharmacy interventions that reduce antibiotic and PPI/H2 blocker use could have profound benefits in decreasing HO-HCFA CDI in this high-risk population.

Long-term prescribing of nitrofurantoin for urinary tract infections (UTI) in veterans with spinal cord injury (SCI)

CONTEXT/OBJECTIVE

To evaluate the impact of long-term nitrofurantoin for UTI prophylaxis in veterans with SCI.

DESIGN

Matched pairs study.

SETTING

Veterans cared for at VA facilities from 10/1/2012-9/30/2013.

PARTICIPANTS

Veterans.

INTERVENTIONS

n/a.

OUTCOMES MEASURES

UTI, positive urine cultures, resistant cultures.

METHODS

Cases receiving long-term nitrofurantoin (≥90 days supply) were matched to controls by facility. Controls were patients who did not receive long-term nitrofurantoin with a history of ≥3 positive urine cultures and at least one diagnosis of UTI or asymptomatic bacteriuria in the previous year.

RESULTS

122 SCI cases were identified and matched to 196 controls. After adjusting for differences in baseline demographic characteristics, UTIs were less frequent in cases (OR = 0.60 [95% CI 0.44-0.72]). Cases had a greater mean number of days between positive urine cultures as compared to controls (<0.0001). Cases were more likely to have isolates resistant to nitrofurantoin (P ≤ 0.0001); however, the frequency of multi-drug resistant organisms isolated from the urine was not significantly different.

CONCLUSIONS

Long-term prescription of nitrofurantoin may reduce UTIs in veterans with SCI and there is no evidence that it promotes multi-drug resistance. Future prospective studies should be conducted prior to incorporating routine use of long-term nitrofurantoin into clinical care.

A Focused Review of Safety Considerations in Cancer Rehabilitation

Cancer and its treatments introduce various adverse effects that may affect survivors' physical, cognitive and psychological functioning. Frequently both tolerance to activity and exercise are affected as well. Rehabilitation providers should have substantive knowledge about the effect of cancer progression and common side effects associated with antineoplastic treatment to safely integrate rehabilitation interventions. Rehabilitation may mitigate loss of function and disability; however, these patients are among the most medically complex that providers treat. This report provides a focused review that synthesizes the current evidence regarding disease progression and oncology-directed treatment side effects within the context of safety considerations for rehabilitation interventions throughout the continuum of cancer care. Descriptive information regarding the evidence for precautions and contraindications is provided so that rehabilitation providers can promote a safe plan of rehabilitation care. It is incumbent upon but also challenging for rehabilitation providers to stay up to date on the many advances in cancer treatment, and there are many gaps in the literature regarding safety issues. Although further research is needed to inform care, this review provides clinicians with a framework to assess patients with the goal of safely initiating rehabilitation interventions.

Optimizing adherence to advice from antimicrobial stewardship audit and feedback rounds

We examined adherence to antimicrobial stewardship prospective audit and feedback rounds in a rehabilitation service compared with the remainder of the acute hospital, and explored the reasons for this. Between October 2014 and December 2015, we retrospectively assessed the rate of non-adherence to advice from antimicrobial stewardship prospective audit and feedback rounds between the rehabilitation service and the acute hospital, along with the source of the patient referral. Compared with the rehabilitation service, acute hospital medical staff were almost twice as likely to not adhere to advice provided on antimicrobial stewardship prospective audit and feedback rounds (13.8% vs. 7.6%, p < 0.0001, relative risk 1.8 [95% confidence interval 1.3, 2.5]). In the rehabilitation service, referrals were more likely to come from medical staff (61.9% vs. 16.3%, p < 0.0001). These findings may be explained by regular, direct engagement of the antimicrobial stewardship team with the rehabilitation service clinical team, a model potentially applicable to other settings.

An Antimicrobial Stewardship Program Based on Systematic Infectious Disease Consultation in a Rehabilitation Facility

OBJECTIVE To assess the impact of an antimicrobial stewardship program (ASP) on antibiotic consumption, Clostridium difficile infections (CDI), and antimicrobial resistance patterns in a rehabilitation hospital. DESIGN Quasi-experimental study of the periods before (from January 2011 to June 2012) and after (from July 2012 to December 2014) ASP implementation. SETTING 150-bed rehabilitation hospital dedicated to patients with spinal-cord injuries. INTERVENTION Beginning in July 2012, an ASP was implemented based on systematic bedside infectious disease (ID) consultation and structural interventions (ie, revision of protocols for antibiotic prophylaxis and education focused on the appropriateness of antibiotic prescriptions). Antibiotic consumption, occurrence of CDI, and antimicrobial resistance patterns of selected microorganisms were compared between periods before and after the ASP implementation. RESULTS Antibiotic consumption decreased from 42 to 22 defined daily dose (DDD) per 100 patient days (P<.001). The main reductions involved carbapenems (from 13 to 0.4 DDD per 100 patient days; P=.01) and fluoroquinolones (from 11.8 to 0.99 DDD per 100 patient days; P=.006), with no increases in mortality or length of stay. The incidence of CDI decreased from 3.6 to 1.2 cases per 10,000 patient days (P=.001). Between 2011 and 2014, the prevalence of extensively drug-resistant (XDR) strains decreased from 55% to 12% in P. aeruginosa (P<.001) and from 96% to 73% in A. baumannii (P=.03). The prevalence of ESBL-producing strains decreased from 42% to 17% in E. coli (P=.0007) and from 62% to 15% in P. mirabilis (P=.0001). In K. pneumoniae, the prevalence of carbapenem-resistant strains decreased from 42% to 17% (P=.005), and the prevalence of in methicillin-resistant S. aureus strains decreased from 77% to 40% (P<.0008). CONCLUSIONS An ASP based on ID consultation was effective in reducing antibiotic consumption without affecting patient outcomes and in improving antimicrobial resistance patterns in a rehabilitation hospital. Infect Control Hosp Epidemiol. 2016;1-7.

Older Is Not Wiser, Immunologically Speaking: Effect of Aging on Host Response to Clostridium difficile Infections

Clostridium difficile infection (CDI) is the most common cause of antibiotic-associated diarrhea and a significant burden on the health care system. Aging has been identified in the literature as a risk factor for CDI as well as adverse outcome from CDI. Although this effect of advanced age on CDI could be partially explained by clinical factors associated with aging, biologic factors are important. Innate immune system, responsible for immediate response to acute infections, plays a major role in CDI pathogenesis. Impairment in function of innate immunity with aging, demonstrated in other infection models, may lead to worse outcome with CDI. C. difficile toxin-specific antibody response protects the host against initial and recurrent infections as shown in observational studies and clinical trial. Effect of aging on antibody response to CDI has not been demonstrated, but the results from vaccine studies in other infections suggest a negative effect on humoral immunity from aging. Although intestinal microbiota from healthy people confers resistance to CDI by preventing C. difficile colonization, changes in composition of microbiota with aging may affect that resistance and increase risk for CDI. There are also age-associated changes in physiology, especially of the gastrointestinal tract, that may play a role in CDI risk and outcomes. In this review, we will first discuss the epidemiology of CDI in the elderly people, then the alteration in innate immunity, humoral response, and microbiota that increases susceptibility to CDI and severe disease and lastly, the physiological and functional changes that may modify outcomes of infection.

Blood stream infections due to multidrug-resistant organisms among spinal cord-injured patients, epidemiology over 16 years and associated risks: a comparative study

STUDY DESIGN

Retrospective study.

OBJECTIVES

We aimed to describe the epidemiology of multidrug-resistant organisms (MDROs) during bloodstream infection (BSI) and identify associated risks of MDROs among patients with spinal cord injury (SCI).

SETTING

A teaching hospital, expert center in disability, in France.

METHODS

We studied a retrospective cohort of all BSIs occurring in SCI patients hospitalized over 16 years. We described the prevalence of MDRO BSI among this population and its evolution over time and compared the BSI population due to MDROs and due to non-MDROs.

RESULTS

A total of 318 BSIs occurring among 256 patients were included in the analysis. The most frequent primary sites of infection were urinary tract infection (34.0%), pressure sore (25.2%) and catheter line-associated bloodstream infection (11.3%). MDROs were responsible for 41.8% of BSIs, and this prevalence was stable over 16 years. No significant associated factor for MDRO BSI could be identified concerning sociodemographic and clinical characteristics, primary site of infection and bacterial species in univariate and multivariate analyses. BSI involving MDROs was not associated with initial severity of sepsis compared with infection without MDROs (43.8 vs 43.6%, respectively) and was not associated either with 30th-day mortality (6.2 vs 9%, respectively).

CONCLUSION

During BSI occurrence in an SCI population, MDROs are frequent but remain stable over years. No associated risk can be identified that would help optimize antibiotic treatment. Neither the severity of the episode nor the mortality is significantly different when an MDRO is involved.

Peripheral Neuropathy After Fecal Microbiota Transplantation for Clostridium difficile Infection: A Case Report

We present a case of a 71-year-old man with Clostridium difficile infection who underwent fecal transplantation. The patient was found to have a predominantly demyelinating sensorimotor peripheral polyneuropathy upon electrodiagnostic testing. To our knowledge, only one case of peripheral neuropathy after fecal transplantation has previously been reported. Although the exact cause of this patient's neuropathy cannot be confirmed, it has been speculated that the pathophysiology is an immune-mediated process. Given the increasing incidence of C difficile infections and the emergence of fecal transplantation as treatment, it is important to note that peripheral neuropathy is a potential adverse complication.

Evaluating implementation of methicillin-resistant Staphylococcus aureus (MRSA) prevention guidelines in spinal cord injury centers using the PARIHS framework: a mixed methods study

BACKGROUND

To prevent methicillin-resistant Staphylococcus aureus (MRSA) in Spinal Cord Injury and Disorder (SCI/D) Centers, the "Guidelines for Implementation of MRSA Prevention Initiative in the Spinal Cord Injury Centers" were released in July 2008 in the Veterans Affairs (VA) Health Care System. The purpose of this study was to use the Promoting Action on Research Implementation in Health Systems (PARiHS) framework to evaluate the experiences of implementation of SCI/D MRSA prevention guidelines in VA SCI/D Centers approximately 2-3 years after the guidelines were released.

METHODS

Mixed methods were used across two phases in this study. The first phase included an anonymous, web-based cross-sectional survey administered to providers at all 24 VA SCI/D Centers. The second phase included semi-structured telephone interviews with providers at 9 SCI/D Centers. The PARiHS framework was used as the foundation of both the survey questions and semi-structured interview guide.

RESULTS

The survey was completed by 295 SCI/D providers (43.8 % response rate) from 22 of the 24 SCI/D Centers (91.7 % participation rate). Respondents included nurses (57.3 %), therapists (24.4 %), physicians (11.1 %), physician assistants (3.4 %), and other health care professionals (3.8 %). Approximately 36 % of the SCI/D providers surveyed had not seen, did not remember seeing, or had never heard of the MRSA SCI/D guidelines, whereas 42.3 % of providers reported that the MRSA SCI/D guidelines were fully implemented in their SCI/D Center. Data revealed numerous barriers and facilitators to guideline implementation. Facilitators included enhanced leadership support and provider education, focused guideline dissemination to reach SCI/D providers, and strong perceived evidence supporting the guidelines. Barriers included lack of awareness of the guidelines among physical therapists and physician assistants and challenges in cohorting/isolating MRSA-positive patients and following contact precautions.

CONCLUSIONS

Successful implementation of MRSA infection prevention guidelines in SCI/D settings requires (1) guideline dissemination that reaches the full range of SCI/D providers working in inpatient, outpatient, and other care settings, (2) provider education that is frequent and systematic, (3) strong leadership support, and (4) that barriers unique to the recommendations are addressed. These findings may be used to inform selection of implementation strategies and optimize infection prevention beyond MRSA as well as in other specialty care populations.

Epidemiology of Hospital-Acquired Infections in Veterans With Spinal Cord Injury and Disorder

Objective.

To describe the epidemiology of hospital-acquired infections (HAIs) in veterans with spinal cord injury and disorder (SCI&D).

Design.

Retrospective medical record review.

Setting.

Midwestern Department of Veterans Affairs spinal cord injury center.

Participants.

A total of 226 patients with SCI&D hospitalized at least once during a 2-year period (October 1, 2001, through September 30, 2003).

Results.

A total of 549 hospitalizations were included in the analysis (mean duration of hospitalization, 33.7 days); an HAI occurred during 182 (33.2%) of these hospitalizations. A total of 657 HAIs occurred during 18,517 patient-days in the hospital (incidence rate, 35.5 HAIs per 1,000 patient-days). Almost half of the 226 patients had at least 1 HAI; the mean number of HAIs among these patients was 6.0 HAIs per patient. The most common HAIs were urinary tract infection (164 [25.0%] of the 657 HAIs; incidence rate, 8.9 cases per 1,000 patient-days), bloodstream infection (111 [16.9%]; incidence rate, 6.0 cases per 1,000 patient-days), and bone and joint infection (103 [15.7%]; incidence rate, 5.6 cases per 1,000 patient-days). The most common culture isolates were gram-positive bacteria (1,082 [45.6%] of 2,307 isolates), including Staphylococcus aureus, and gram-negative bacteria (1,033 [43.6%] of isolates), including Pseudomonas aeruginosa. Multivariate regression demonstrated that predictors of HAI were longer length of hospital stay (P = .002), community-acquired infection (P = .007), and use of a urinary invasive device (P = .01) or respiratory invasive device (P = .04).

Conclusions.

The overall incidence of HAIs in persons with SCI&D was higher than that reported for other populations, confirming the increased risk of HAI in persons with spinal cord injury. The increased risk associated with longer length of stay and with community-acquired infection suggests that strategies are needed to reduce the duration of hospitalization and to effectively treat community-acquired infection, to decrease infection rates. There is significant room for improvement in reducing the incidence of HAIs in this population.

Comparison of bacterial strains and antibiotic susceptibilities in urinary isolates of spinal cord injury patients from the community and hospital

STUDY DESIGN

A one-year epidemiological survey.

OBJECTIVE

To compare bacterial strains and antimicrobial susceptibilities of urinary isolates from hospital and community spinal cord injury (SCI) patients.

SETTING

A specialized SCI unit in a freestanding rehabilitation hospital.

METHODS

From June 2012 through May 2013, urine cultures were obtained from all of the newly admitted patients. Bacterial strains and antimicrobial susceptibilities were compared between patients from community and hospital settings.

RESULTS

The proportion of Enterobacteriaceae in the total urinary isolates from hospital-dwelling patients was smaller than that from community-dwelling patients (66.0 vs. 85.5%, P<0.001), while the proportions of Pseudomonas, Acinetobacter and Enterococcus species were relatively larger (8.7%, 6.0% and 12.0% vs. 2.8%, 0.7% and 2.8%, respectively, P<0.05). The isolates from hospital-dwelling patients showed lower susceptibility to ampicillin, amoxicillin-clavulanic acid, trimethoprim-sulfamethoxazole and all generations of cephalosporin (P<0.05), and a higher prevalence of extended-spectrum beta-lactamase (ESBL)-producers (41.7 vs. 5.4%, P<0.001), compared with those from community-dwelling patients. The susceptibility rates to levofloxacin were lower than 50% in both community and hospital-dwelling patients.

CONCLUSION

Broader-spectrum antibiotics should be considered in treating nosocomial urinary tract infection (UTI) of SCI patients because of the relatively wide variety of organisms and higher frequency of antibiotic-resistant strains, including ESBL-producing Enterobacteriaceae in hospital-derived specimens. Furthermore, in areas with high prevalence of fluoroquinolone resistance, fluoroquinolones should be used with caution during empirical treatment for UTI in SCI patients.

Recurrence of Clostridium difficile infection among veterans with spinal cord injury and disorder

BACKGROUND

Recurrent Clostridium difficile (CDI) infection is a growing concern; however, there are little data on impact of recurrent CDI on those with spinal cord injury and disorder (SCI/D). Therefore, the objective of this study was to identify risk factors associated with recurrence of CDI among Veterans with SCI/D.

METHODS

This was a retrospective cohort study with data from outpatient, inpatient, and extended care settings at 83 Department of Veterans Affairs facilities from 2002 to 2009.

RESULTS

Of 1,464 cases of CDI analyzed, 315 cases (21.5%) had a first recurrence of CDI. Multivariable regression demonstrated that risk factors significantly associated with increased recurrence were concomitant fluoroquinolone use (odds ratio [OR], 1.39; 95% confidence interval [CI]: 1.08-1.80), whereas concomitant tetracycline use (OR, 0.35; 95% CI: 0.14-0.90), and cerebrovascular accident (OR, 0.46; 95% CI: 0.25-0.85) were associated with decreased recurrence. A subanalysis in those with health care facility-onset CDI showed that increased length of stay postinitial CDI was a significant risk factor for recurrence as was concomitant use of fluoroquinolones and that tetracycline remained protective for recurrence.

CONCLUSION

Concomitant fluoroquinolone use was a risk factor for the recurrence of CDI. In contrast, tetracyclines and cerebrovascular accident were protective. Length of stay greater than 90 days from the initial CDI episode was also a risk factor for recurrence among those with health care facility-onset CDI. Future studies should focus on effective strategies to prevent these risk factors among the SCI/D population.

The impact of a "search and destroy" strategy for the prevention of methicillin-resistant Staphylococcus aureus infections in an inpatient rehabilitation facility

OBJECTIVE

To determine how the implementation of a methicillin-resistant Staphylococcus aureus (MRSA) control program in an inpatient rehabilitation facility (IRF) affects MRSA health care-associated infections (MRSA-HAIs).

DESIGN

A retrospective chart review.

SETTING

IRF affiliated with Vidant Medical Center, an 861-bed, acute-care teaching hospital for The Brody School of Medicine at East Carolina University.

PATIENTS

Seventy-nine adult patients in the IRF who developed a MRSA-HAI from February 2005 through January 2011.

INTERVENTIONS

Both the acute care hospital and the affiliated inpatient rehabilitation unit began screening 100% of admissions for MRSA nasal carriage, with decolonization of positive carriers, starting in February 2007.

MAIN OUTCOME MEASUREMENTS

Yearly rates of MRSA-HAI per 1000 patient-days were compared in the IRF before and after the intervention.

RESULTS

The weighted mean monthly infection rate before the intervention (February 2005 through January 2007) was 1.0714 per 1000 patient days compared with 0.6557 per 1000 patient days after the intervention (February 2007 through January 2011). The decreased infection rates after the intervention were statistically significant (P = .0315).

CONCLUSIONS

The implementation of an all-admissions MRSA screening program with decolonization of positive carriers in an IRF affiliated with an acute care hospital resulted in decreased MRSA-HAI rates in the IRF. When developing surveillance guidelines for MRSA, IRFs should be cognizant of infection rate trends and of the affiliated hospital's scope of policies and practices for infection prevention and control.

Prevention of methicillin-resistant Staphylococcus aureus infections in spinal cord injury units

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) are a concern in the 22 acute care Veterans Affairs (VA) spinal cord injury units where patients with unique rehabilitation and medical needs and a high risk of infection are treated.

METHODS

A bundle was implemented in VA spinal cord injury units consisting of nasal surveillance for MRSA on admission/in-hospital transfer/discharge, contact precautions for patients colonized or infected with MRSA, an emphasis on hand hygiene, and an institutional culture change where infection control became everyone's responsibility.

RESULTS

From October 2007, through June 2011, there were 51,627 admissions/transfers/discharges and 816,254 patient-days of care in VA spinal cord injury units. The percentage of patients screened increased to >95.0%. The mean admission MRSA prevalence was 38.6% ± 19.1%. Monthly HAI rates declined 81% from 1.217 per 1,000 patient-days to 0.237 per 1,000 patient-days (P < .001). Bloodstream infections declined by 100% (P = .002), skin and soft-tissue infections by 60% (P = .007), and urinary tract infections by 33% (P = .07).

CONCLUSION

Universal surveillance, contact precautions, hand hygiene, and an institutional culture change was associated with significant declines in MRSA HAIs in a setting with a high prevalence of MRSA colonization and a high risk for infection.

Left-sided brain injury associated with more hospital-acquired infections during inpatient rehabilitation

OBJECTIVE

To test the hypothesis that a left-dominant brain immune network (LD-BIN) might affect the occurrence of infection during inpatient rehabilitation of stroke and traumatic brain injury (TBI).

DESIGN

A retrospective analysis was performed on electronic medical records between January 2009 and December 2010. All patients with left- or right-sided stroke or TBI were included into the study. The LD-BIN hypothesis was tested by comparing HAI rates depending on whether patients had left- or right-sided brain lesions.

SETTING

A large inpatient rehabilitation hospital.

PARTICIPANTS

Among the patients (N=2236) with stroke or TBI who had either a left- or right-sided brain lesion, 163 patients were identified with HAIs.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

Frequency of HAIs.

RESULTS

In the 163 patients identified with HAIs with a diagnosis of stroke or TBI, chi-square analysis revealed a significantly higher proportion of HAIs among patients with left-sided (n=98; 60.1%) relative to right-sided (n=65; 39.9%) brain injuries (χ(2)=6.68, P<.01). These effects could not be attributed to either clinical or demographic factors.

CONCLUSIONS

Our findings are consistent with the hypothesis that an LD-BIN may mediate vulnerability to infection during rehabilitation of patients with stroke or TBI. Further translational research investigating novel means of managing patients based on brain lesion location, and modulating the LD-BIN via behavioral and physiologic interventions, may result in neuroscience-based methods to improve infection resistance in brain-injured patients.

Patient safety in rehabilitation medicine: traumatic brain injury

This article describes patient safety after traumatic brain injury (TBI). Patient safety in rehabilitation after TBI is important. Thorough assessment on initial evaluation, vigilance for medical and procedural errors, appropriate communication between medical professionals, and evaluation of systems-based practices increases patient safety. It is the responsibility of the rehabilitation treatment team to ensure that appropriate measures are taken to reduce risk of adverse events. This article is intended to promote discussion of patient safety after TBI within rehabilitation teams and to help improve outcomes throughout the spectrum of recovery.

Knowledge and use of antimicrobial stewardship resources by spinal cord injury providers

OBJECTIVE

To assess the knowledge and the use of antimicrobial stewardship resources, such as hospital antibiograms and infectious disease consultants, by spinal cord injury or disorder (SCI/D) providers.

DESIGN AND SETTING

Anonymous Internet-based, cross-sectional survey.

PARTICIPANTS

A total of 314 SCI/D physicians, nurse practitioners, and physician assistants who prescribe antibiotics were invited to complete a survey.

MAIN OUTCOME MEASUREMENTS

Knowledge of and behaviors related to antibiograms and infectious disease (ID) consults.

RESULTS

A total of 118 providers (80 physicians, 20 nurse practitioners, 18 physician assistants) completed the survey (37.6% response rate). Approximately one-third of respondents indicated that they did not have access to (11.0%) or were unsure of (28.0%) the existence of facility antibiograms. Half of the providers indicated that they never used antibiograms to determine treatment for their SCI/D patients. Respondent factors associated with viewing facility antibiograms were older age, employment at SCI/D specialty centers, a longer duration since completion of training, and years of SCI/D patient care. Nearly all respondents (95%) indicated that they believed that improving access to antibiotic prescribing data or antibiograms would reduce antibiotic resistance. More than one-third reported that they never or seldom used ID consults.

CONCLUSIONS

A significant portion of SCI/D providers who prescribe antibiotics do not have access to facility antibiograms or are unaware of their existence and thus could not use them for determining antibiotic treatment. Interventions could include formal education of providers on how to access antibiograms and the use of ID physicians as a resource, as well as providing technologic support, such as electronic facility-level antibiograms as part of the medical record system, which can be easily identified if a provider is making a decision on an antibiotic.

Urinary tract infections in patients admitted to rehabilitation from acute care settings: a descriptive research study

The use of an indwelling urinary catheter comes with associated risks. At a hospital in southern California, nurses on the acute rehabilitation unit suspected their patients were arriving from acute care with undiagnosed urinary tract infections (UTIs). This descriptive research study quantified the incidence of UTI on admission to a rehabilitation unit and correlations with catheter use. During the study period, 132 patients were admitted to acute rehabilitation from an acute care setting, and 123 met criteria to participate in the study. Among participants, 12% had a UTI upon admission. Questionnaires examined nursing attitudes toward appropriate urinary catheter use and proactive catheter removal. The data revealed that nurses want to be involved in decisions about urinary catheter use and that medical/surgical and rehabilitation nurses agree strongly about advocating for patients with indwelling urinary catheters.

Healthcare-acquired infections in rehabilitation units of the Lombardy Region, Italy

BACKGROUND

Little data are available on the frequency and risk factors for infection in patients in rehabilitation units.

METHODS

This was a 2-year retrospective cohort study conducted in 131 rehabilitation units (RUs) of the Lombardy Region, including those for patients requiring musculoskeletal, cardiac, respiratory, neurological and general geriatric rehabilitation. RUs were stratified into three groups by infection rate calculated from administrative data, and a random sample of RUs in each group was selected for analysis. Discharges from these RUs were randomly selected for chart review, and healthcare-acquired infection was confirmed using CDC/NHSN definitions. A logistic regression analysis explored the association among demographic variables of age, sex, type of rehabilitation unit, Charlson comorbidity score, and location prior to RU admission for selected infections.

RESULTS

For the 3,028 discharges from 28 RUs, hospital administrative data had a sensitivity of 0.45 and a positive predictive value of 0.89 to identify infections in the chart review. At least one infection occurred in 14.9% of patient discharges, with 71% of infections being urinary, 8.0% respiratory, and 5% skin and soft tissue. Urinary infection was associated with female sex [odds ratio (OR) 1.48, 95% confidence interval (CI) 1.13-1.93], age 75-85 years (OR 2.21, 95% CI 1.12-4.34), Charlson comorbidity score of ≥3 (OR 1.54, 95% CI 1.10-2.17), and the transfer from acute care (OR 1.45, 95% CI 1.04-2.02). For respiratory infection, male sex (OR 3.06, 95% CI 1.51-6.18), comorbidity score of 1 or 2 (OR 2.16, 95% CI 1.08-4.36), and transfer from a healthcare setting other than an acute care hospital were independent risks (OR 3.14, 95% CI 1.15-8.53).

CONCLUSION

Infections are common in residents of these rehabilitation units, and risk factors may differ with type of infection. The proportion of infections which may be prevented and effective prevention strategies need to be determined.

Predictors and outcomes of antibiotic adequacy for bloodstream infections in veterans with spinal cord injury

OBJECTIVE

To identify predictors and outcomes associated with receiving inadequate empirical antimicrobial treatment for bloodstream infections (BSIs) in persons with spinal cord injury (SCI).

DESIGN

Retrospective cohort study from October 1, 1997, through September 30, 2004.

SETTING

A Department of Veterans Affairs SCI center that serves approximately 700 patients a year.

PARTICIPANTS

Hospitalized patients with SCI (N=123) who had 1 or more BSIs during the study period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Adequacy of antimicrobial treatment (inadequate treatment was defined as the absence of antimicrobial agents for a particular organism within 2 days after the collection of blood cultures and/or the microorganism's resistance to the antimicrobial administered), hospital length of stay (LOS) post-BSI infection, and in-hospital and 30-day mortality. Cluster-adjusted multivariable models were assessed.

RESULTS

Over one third (88; 37.4%) of the 235 episodes of BSI identified received inadequate empirical antibiotic treatment. Having a polymicrobial BSI was associated with inadequate treatment (odds ratio [OR]=3.28; 95% confidence interval [CI]=1.62-6.65; P=.001). Factors protective against inadequate therapy included having a comorbid pressure ulcer (OR=0.37; 95% CI=0.21-0.68; P=.001) or a BSI that was not primary (OR=0.30; 95% CI=0.15-0.58; P<.0001). Mortality did not differ between the inadequate and adequate treatment groups (11.4% vs 10.9%; P=.92). Similarly LOS postinfection was not affected by treatment status (inadequate treatment median=22d vs adequate treatment median=27d; P=.98).

CONCLUSIONS

Over one third of patients received inadequate empirical treatment, which was associated with having a polymicrobial BSI. However, inadequate treatment was not associated with increased mortality or LOS postinfection.

Nosocomial transmission of highly resistant microorganisms on a spinal cord rehabilitation ward

BACKGROUND/OBJECTIVE

To study the mechanism of nosocomial transmission of highly resistant microorganisms (HRMOs).

DESIGN

A prospective observational study.

SETTING

A spinal cord ward of a rehabilitation center.

PARTICIPANTS

Patients admitted to the spinal cord rehabilitation ward.

OUTCOME MEASURES

HRMOs present in urine and feces. HRMOs, Enterobacteriaceae: (1) that produced an extended-spectrum beta-lactamase (ESBL), (2) that were resistant to carbapenems, (3) that fluoroquinolones and aminoglycosides (for Escherichia coli and Klebsiella species), or other Enterobacteriaceae species that were resistant to 2 of 3 of the following types of antibiotics (fluoroquinolones, aminoglycosides, cotrimoxazole).

METHODS

Bacterial growth, identification and sensitivity were tested in urine cultures of 46 patients and faeces cultures of 15 patients. Data were collected on demographic characteristics, underlying diseases, reason and date of admission, room number, method of catheterization (suprapubic, clean intermittent catheterization or indwelling Foley catheter) and antibiotic use.

RESULTS

Nine different HRMOs (7 E. coli, 1 Enterobacter cloacae, and 1 Citrobacter koseri) were isolated in urine samples from 15 patients. E. coli resistant to gentamicin, tetracycline, amoxicillin, cotrimoxazole, and ciprofloxacin were isolated from 8 patients during the study (cluster 1). One strain of multiresistant E coli found before the start of the study was not found during the study period (cluster 2). E coli strains producing an ESBL and resistant to tetracycline, cotrimoxazole, and ciprofloxacin were isolated from urine samples of 3 patients (cluster 3). Ciprofloxacin-resistant E. coli were present in feces of 3 patients (2 in cluster 1). Catheterization was found to be significantly more prevalent in patients with HRMOs. Most of the patients in cluster 1 were treated with antibiotics before the first isolation of the strain.

CONCLUSIONS

HRMOs from urine samples were strongly correlated with the use of catheterization. A close correlation was found between prior use of antibiotics and colonization of the urinary tract on the level of the individual patient, which has been rarely described in the literature.

Bloodstream infections and setting of onset in persons with spinal cord injury and disorder

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

Health-care-associated (HCA) bloodstream infection (BSI) has been shown to be a distinct epidemiologic category in the general adult population, but few studies have examined specific patient populations. The objective of this study was to assess characteristics associated with BSI that occurred in the hospital (hospital-acquired, HA BSI), from health-care contact outside the hospital (HCA BSI) or in the community (community-acquired, CA BSI) in veterans with spinal cord injury and disorder (SCI&D).

SETTING

Two United States Department of Veterans Affairs hospitals.

METHODS

All patients with SCI&D with a positive blood culture admitted to study hospitals over a 7-year period (1 October 1997 to 30 September 2004). Demographics, medical characteristics and causative organisms were collected.

RESULTS

Four hundred and thirteen episodes of BSI occurred in 226 patients, with a rate of 7.2 BSI episodes per 100 admissions: 267 (64.7%) were HA BSI, 110 (26.6%) were HCA BSI and 36 (8.7%) were CA BSI. Antibiotic resistance was more common in those with HA BSI (65.5%) compared with that in those with HCA (49.1%, P=0.001) and CA BSI (22.2%, P<0.0001). Methicillin resistance in Staphylococcus aureus was highly prevalent; HA BSI (84.5%), HCA BSI (60.6%) and CA BSI (33.3%).

CONCLUSION

HCA BSI comprises one-quarter of all BSIs in hospitalized patients with SCI&D. Although those with HCA and CA BSI share similarities, several differences in medical characteristics and causal microorganism are noted. Treatment and management strategies for HCA and CA infections need to vary.

Poor functional status as a risk factor for surgical site infection due to methicillin-resistant Staphylococcus aureus

OBJECTIVE

To identify risk factors for surgical site infection (SSI) due to methicillin-resistant Staphylococcus aureus (MRSA).

DESIGN

Prospective case-control study.

SETTING

One tertiary and 6 community-based institutions in the southeastern United States.

METHODS

We compared patients with SSI due to MRSA with 2 control groups: matched uninfected surgical patients and patients with SSI due to methicillin-susceptible S. aureus (MSSA). Multivariable logistic regression was used to determine variables independently associated with SSI due to MRSA, compared with each control group.

RESULTS

During the 5-year study period, 150 case patients with SSI due to MRSA were identified and compared with 231 matched uninfected control patients and 128 control patients with SSI due to MSSA. Two variables were independently associated with SSI due to MRSA in both multivariable regression models: need for assistance with 3 or more activities of daily living (odds ratio [OR] compared with uninfected patients, 3.97 [95% confidence interval {CI}, 2.18-7.25]; OR compared with patients with SSI due to MSSA, 3.88 [95% CI, 1.91-7.87]) and prolonged duration of surgery (OR compared with uninfected patients, 1.98 [95% CI, 1.11-3.55]; OR compared with patients with SSI due to MSSA, 2.33 [95% CI, 1.17-4.62]). Lack of independence (ie, poor functional status) remained associated with an increased risk of SSI due to MRSA after stratifying by age.

CONCLUSIONS

Poor functional status was highly associated with SSI due to MRSA in adult surgical patients, regardless of age. A patient's level of independence can be easily determined, and this information can be used preoperatively to target preventive interventions.

[Urinary tract infection and neurogenic bladder]

One of the main complications of spinal cord injury is neurogenic bladder when the bladder fails to empty spontaneously. Urinary tract infection is the leading cause of morbidity and the second cause of mortality in these subjects. Patient education and personalized medical follow-up must ensure adapted management depending on the risk factors and the voiding mode. The risk of urinary tract infection can be decreased by perfect neurological control of detrusor activity combined with a method of drainage: intermittent self-catheterization. Despite these measures, many patients experience recurrent symptomatic urinary tract infections. Repeated antibiotic therapy increases the risk of selection of multiresistant bacteria without reducing either the incidence or the severity of symptomatic urinary tract infections. Asymptomatic bacteriuria is very frequent in patients treated by intermittent catheterization and does not justify antibiotic therapy, as antiseptics and urinary alkalinizers or acidifiers have been shown to be effective. "Antibiocycle" strategies could have a beneficial role by significantly decreasing the number of infections and hospitalizations with no major ecological risks, by using molecules that are well tolerated orally with a low selection pressure. All febrile urinary tract infections require rapid investigation and an urgent urological and infectious diseases opinion (abscess, severe sepsis, resistance). The SPILF-AFU 2002 consensus conference provided answers to major questions concerning the definition, treatment and prevention of nosocomial urinary tract infection, especially in a context of neurogenic bladder.

Long-term outcomes from nosocomial infections in persons with spinal cord injuries and disorders

BACKGROUND

Nosocomial infection may contribute to poor long-term consequences in persons who have spinal cord injuries and disorders (SCI&D).

METHODS

This is a cohort study of individuals who had SCI&D and were hospitalized at least once during 2002. They were followed for 3 years to assess inpatient (IP) admissions, total IP length of stay (LOS), outpatient (OP) visits, and mortality. Count data models and a Cox proportional hazards model were used to assess the relationship between previous infection and subsequent IP and OP use and long-term mortality, respectively.

RESULTS

Of persons who had SCI&D, 59% had at least one nosocomial infection. Multivariable regression indicated that veterans who had SCI&D had more IP admissions (b = 0.405; P < .0001) and longer IP LOS (b = 0.843; P < .0001) if they had a previous infection; however, infection status was not a predictor of future OP visits. Survival time was lower (913.93 versus 1034.75 days, P = .004) in the infection group. Death rate was higher in the nosocomial infection group (30.11% versus 10.77%; P = .004), but the association did not achieve significance in the Cox proportional hazards model (P = .12).

CONCLUSIONS

Nosocomial infections have serious subsequent consequences that result in future hospitalization and shorter survival. Efforts to prevent nosocomial infections are needed to reduce long-term adverse effects in persons who have SCI&D.

Guidelines for Quality Management of Apallic Syndrome / Vegetative State

INTRODUCTION

Epidemiology in Europe shows constantly increasing figures for the apallic syndrome (AS)/vegetative state (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage and high-standard activating home nursing for completely dependent end-stage cases secondary to progressive neurological disease. Management of patients in irreversible permanent AS/VS has been the subject of sustained scientific and moral-legal debate over the past decade.

METHODS

A task force on guidelines for quality management of AS/VS was set up under the auspices of the Scientific Panel Neurotraumatology of the European Federation of Neurological Societies to address key issues relating to AS/VS prevalence and quality management. Collection and analysis of scientific data on class II (III) evidence from the literature and recommendations based on the best practice as resulting from the task force members' expertise are in accordance with EFNS Guidance regulations.

FINDINGS

The overall incidence of new AS/VS full stage cases all etiology is 0.5-2/100.000 population per year. About one third are traumatic and two thirds non traumatic cases. Increasing figures for hypoxic brain damage and progressive neurological disease have been noticed. The main conceptual criticism is based on the assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathological findings and the uncertainty of clinical assessment due to varying inclusion criteria. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. This is why sine qua non diagnostics of the clinical features and appropriate treatment of AS/VS patients of "AS full, remission, defect and end stages" require further professional training and expertise for doctors and rehabilitation personnel.

INTERPRETATION

Management of AS aims at the social reintegration of patients or has to guarantee humanistic active nursing if treatment fails. Outcome depends on the cause and duration of AS/VS as well as patient's age. There is no single AS/VS specific laboratory investigation, no specific regimen or stimulating intervention to be recommended for improving higher cerebral functioning. Quality management requires at least 3 years of advanced training and permanent education to gain approval of qualification for AS/VS treatment and expertise. Sine qua non areas covering AS/VS institutions for early and long-term rehabilitation are required on a population base (prevalence of 2/100.000/year) to quicken functional restoration and to prevent or treat complications. Caring homes are needed for respectful humane nursing including basal sensor-motor stimulating techniques. Passive euthanasia is considered an act of mercy by physicians in terms of withholding treatment; however, ethical and legal issues with regard to withdrawal of nutrition and hydration and end of life discussions raise deep concerns. The aim of the guideline is to provide management guidance (on the best medical evidence class II and III or task force expertise) for neurologists, neurosurgeons, other physicians working with AS/VS patients, neurorehabilitation personnel, patients, next-of-kin, and health authorities.

Hematologic abnormalities within the first week after acute isolated traumatic cervical spinal cord injury: a case-control cohort study

STUDY DESIGN

Case-control cohort study.

OBJECTIVE

To evaluate 1) the hematologic abnormalities within the first week following isolated acute cervical spine trauma or spinal cord injury (SCI); and 2) the influence of age, sex, and severity of SCI on these hematologic abnormalities.

SUMMARY OF BACKGROUND DATA

Given that autonomic nervous system has a critical role in the regulation of the hematopoietic system, we sought to evaluate the potential association between hematologic abnormalities within the first week posttrauma and the severity of SCI.

METHODS

All consecutive individuals with isolated acute cervical spine trauma admitted to our institution from 1998 to 2000 were reviewed. Exclusion criteria included preexisting medical comorbidities and polytrauma. The study population was divided into a SCI group and a control group (individuals with spine trauma without neurologic impairment). The SCI group was subdivided into patients with motor complete SCI (American Spinal Injury Association [ASIA] Grades A/B) and individuals with motor incomplete SCI (ASIA Grades C/D).

RESULTS

There were 21 SCI individuals (15 male, 6 female; ages 17-83 years; mean, 57 years) and 11 controls (6 male, 5 female; ages 18-75 years; mean, 41 years). When controlled for age, SCI individuals showed a significantly higher frequency of reduced hemoglobin concentration (RHC), leukocytosis, lymphopenia, and thrombocytopenia than controls within the first week posttrauma. Blood hemoglobin concentration, lymphocyte, and platelet counts in the SCI group were significant lower than the controls. The SCI group showed a significant higher leukocyte count than the controls. The degree of RHC and lymphopenia was significantly correlated with the severity of SCI.

CONCLUSION

Our results indicate that patients with isolated cervical SCI have significantly greater frequency of RHC, leukocytosis, lymphopenia, and thrombocytopenia than controls during the first week posttrauma. The degree of RHC and lymphopenia was significantly associated with the severity of SCI. While the mechanisms underlying these clinically important hematologic consequences of SCI remain undetermined, evidence from the literature suggests that acute autonomic denervation of the hematopoietic system could play a key role.

Prevalence and Natural History of Colonization With Fluoroquinolone-Resistant Gram-Negative Bacilli in Community-Dwelling People With Spinal Cord Dysfunction

OBJECTIVES

To estimate the prevalence of colonization with fluoroquinolone-resistant gram-negative bacilli (GNB) and to assess risk factors for and define the natural history of colonization.

DESIGN

Cross-sectional study with follow-up of up to 1 year.

SETTING

Multiple outpatient sites.

PARTICIPANTS

Eighty-four community-dwelling adults with spinal cord dysfunction.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Colonization of perineum with fluoroquinolone-resistant GNB.

RESULTS

Overall, 24% of this community-dwelling cohort was colonized with fluoroquinolone-resistant GNB with resistance to both levofloxacin and gatifloxacin. The use of any antibiotic in the last 90 days was most strongly associated with an increased risk of colonization with fluoroquinolone-resistant GNB (relative risk, 2.3; 95% confidence interval, 1.1-4.8; P=.05). Incontinence was significantly more common among those with fluoroquinolone-resistant GNB colonization. Among the participants with incontinence (n=42), the use of intermittent catheterization (vs suprapubic, urethral, or condom catheters or overflow incontinence) was significantly protective. Colonization was not associated with an increase in urinary tract infection and was often transient.

CONCLUSIONS

Fluoroquinolone resistance among GNB colonizing community-dwelling people with spinal cord dysfunction is common. Colonization is more common among those receiving antibiotics and less common among those continent of urine. Among those with incontinence, those using intermittent catheterization have less colonization.

Application of molecular techniques to the study of hospital infection

Nosocomial infections are an important source of morbidity and mortality in hospital settings, afflicting an estimated 2 million patients in United States each year. This number represents up to 5% of hospitalized patients and results in an estimated 88,000 deaths and 4.5 billion dollars in excess health care costs. Increasingly, hospital-acquired infections with multidrug-resistant pathogens represent a major problem in patients. Understanding pathogen relatedness is essential for determining the epidemiology of nosocomial infections and aiding in the design of rational pathogen control methods. The role of pathogen typing is to determine whether epidemiologically related isolates are also genetically related. To determine molecular relatedness of isolates for epidemiologic investigation, new technologies based on DNA, or molecular analysis, are methods of choice. These DNA-based molecular methodologies include pulsed-field gel electrophoresis (PFGE), PCR-based typing methods, and multilocus sequence analysis. Establishing clonality of pathogens can aid in the identification of the source (environmental or personnel) of organisms, distinguish infectious from noninfectious strains, and distinguish relapse from reinfection. The integration of molecular typing with conventional hospital epidemiologic surveillance has been proven to be cost-effective due to the associated reduction in the number of nosocomial infections. Cost-effectiveness is maximized through the collaboration of the laboratory, through epidemiologic typing, and the infection control department during epidemiologic investigations.

Control of an ACC-1-producing Klebsiella pneumoniae outbreak in a physical medicine and rehabilitation unit

This article describes an outbreak of ACC-1-producing Klebsiella pneumoniae involving 40 patients. These were mainly men under 40 years old with a spinal cord injury, in a physical medicine and rehabilitation unit. The main risk factors were prolonged hospital stay, multiple-bed rooms, tracheostomy care and assisted defaecation. The outbreak was only controlled after the introduction of rigorous patient placement (i.e. single rooms or cohorting in the same room), while allowing the patients to have free access to the various technical services (e.g. physiotherapy and occupational therapy) and living spaces necessary for re-education.

Colonisation à bactéries multirésistantes en service de médecine physique et réadaptation

The objective of this study was to evaluate the management of multiresistant bacteria infection in French rehabilitation units. We e-mailed a questionnaire to French rehabilitation practitioners asking them what they did and what they knew about multiresistant bacteria colonisation. Their answers are described and analysed. We received 60 answers representing most of the country's rehabilitation centers. Routine screening was rare, but multiresistant bacteria were often looked for when certain risk factors were present. Methicillin-resistant Staphylococcus aureus and multiresistant enterobacteria were the usual target germs. In general, respondents asked for evidence-based recommendations that are also applicable without too great a prejudice (for the rehabilitation as well as for the psychological state) for a patient hospitalised in a rehabilitation unit. The legal risks and the costs involved are also to be tested. Many questions lay unanswered, although the literature is rich in descriptions of this area. The opposition between the medical advice of isolation and the readaptation objectives of a rehabilitation unit are strong. This study aims to highlight the most important uncertainties so as to promote prospective studies and enlighten the legal authorities.

High prevalence of nosocomial infections in rehabilitation units accounted for by urinary tract infections in patients with spinal cord injury

This study (part of the nationwide French prevalence survey of 2001) was organized to investigate the prevalence and risk factors of nosocomial infections (NIs) and the resistant flora in patients hospitalized in rehabilitation units. Two hundred and eighty-six patients were included from two hospitals in the 'Hospices Civils de Lyon' group. Patients were classified into those with and without a spinal cord injury (SCI). Seventy-eight (27.3%) patients had an SCI. They were younger and more often characterized by a low Activity of Daily Life score, bladder incontinence and chronic respiratory disease. Urinary catheterization and mechanical ventilation were more common in these patients. The NI prevalence rate was higher in the SCI group (21.8% vs 4.3%, P<0.00001), particularly for urinary tract infections (UTIs, 19.2% vs 3.4%, P<0.00001). There was a positive relationship between the number of risk factors and NI acquisition. Multi-variate analysis showed that the only independent risk factor for NI acquisition was indwelling urinary catheterization [odds ratio (OR): 11.64, 95% confidence intervals (CI): 2.53-53.65, P=0.002]. Marginally significant factors were chronic kidney or liver disease (OR: 5.84, 95%CI: 0.80-42.68, P=0.082) and SCI (OR: 2.97, 95%CI: 0.61-14.60, P=0.179). The prevalence of antibiotic-resistant micro-organisms was high (nine cases of resistant organisms for 31 infection sites), but there were no differences between the groups. The high rate of NIs, especially UTIs, in SCI patients was not due to an independent effect of SCI but was probably due to the high number of risk factors. These high-risk patients need targeted NI surveillance.

The effects of gender on clinical and neurological outcomes after acute cervical spinal cord injury

The potential clinical relevance of gender on clinical and neurological outcome after spinal cord injury (SCI) has received little attention. In order to address this issue, we examined all consecutive cases of acute traumatic cervical SCI admitted to our institution from 1998 to 2000. There were 38 males (ages 17-89 years, mean of 51.6) and 17 females (ages 18-84 years, mean of 63.2). Both groups were comparable regarding level (C1 to C7) and severity of SCI (ASIA A to D) at admission. Age differences between the groups approached significance (p = 0.057), and thus this factor was treated as a covariate in the analysis. Co-morbidities were as frequent in men (86.8%) as in women (76.5%). The therapeutic approaches, length-of-stay in the acute care unit, mortality, and discharge disposition were similar in men and women. During hospitalization, 44.7% of men and 52.9% of women developed post-SCI secondary complications without any significant gender-related differences. Both groups showed a similar incidence of infections, cardiovascular complications, thromboembolism, and pressure sores. Univariate analysis revealed a trend for higher incidence of psychiatric complications (p = 0.054) and deep venous thrombosis (p = 0.092) in women, which was confirmed by multivariate analysis. Neurological outcome was not correlated with gender. A similar number of males and females (42.1%, 47.1%) showed evidence of neurological recovery as revealed by an improvement in ASIA scores. Moreover, 18.4% of males and 29.4% of females recovered to ASIA E status. Our data suggest a shift in the demographics of acute SCI with an increasing incidence in elderly women. Although neurological outcomes were not significantly related to gender, we observed a trend for higher rates of reactive depression and deep venous thrombosis in women. These issues may be of key clinical importance in developing improved management protocols for SCI so as to maximize functional recovery and quality-of-life.

Intérêt du dépistage actif des bactéries multirésistantes dans les services de médecine physique et réadaptation

OBJECTIVES

The objective of this study was to evaluate the epidemiology of antibiotic-resistant bacteria among motor impaired patients admitted to an acute rehabilitation unit.

METHODS

From January 2000 to December 2002, the acute rehabilitation units of R. Poincare Hospital have screened patients for methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase enterobacteria (ESBL-EB) carriage by nasal and rectal swab at admission, every month and exit.

RESULTS

Finally, MRSA was isolated form screening or diagnosis samples of 360 patients and ESBL-EB from screening or diagnosis samples of 170 patients, corresponding respectively to an incidence of 3.6 for 1000 days of hospitalization (DH) and 1.7 for 1000 DH. 66% (236/360) of MRSA carriers and 58% of ESBL-EB carriers were identified only by screening samples. Carriage origin was identified for year 2002: Cases were imported for 40% (26/65) of MRSA carriers and 43% (18/42) of ESBL-EB carriers. The median acquisition delays were of 31 days [3-154] for MRSA and 19 days [3-317] for ESBL-EB.

CONCLUSION

This allowed to set up contact precautions for more than 2 fold patients that would have allowed diagnosis samples alone.

Severe acute diarrhea

Acute diarrhea is commonly caused by an infection. Severe acute diarrhea warrants immediate medical evaluation and hospitalization. Indications for stool studies include fever; bloody diarrhea; recent travel to an endemic area; recent antibiotics; immunosuppression; and occupational risks, such as food handlers. Noninfectious causes include inflammatory bowel disease, radiation enteritis, and intestinal ischemia. Management of severe acute diarrhea includes intravenous fluid rehydration and empiric antibiotics. Use of antidiarrheal agents is controversial when invasive pathogens are suspected.

Urinary infections in patients with spinal cord injury

STUDY DESIGN

A retrospective study concerning urinary tract infections in spinal cord injury (SCI) patients.

OBJECTIVES

To check whether the regular (1/week) urine cultures allow a more accurate treatment of urinary tract infections in SCI patients compared to empiric treatment.

SETTING

Ghent University Hospital, East-Flanders, Belgium.

METHODS

Group 1: 24 tetraplegic patients; group 2: 22 paraplegic patients; group 3: 28 other polytrauma patients as controls. These groups were chosen as catheterisation and other voiding methods differ according to the underlying pathology.

RESULTS

An average of four clinically significant episodes of bacteriuria were found for groups 1 and 2, while group 3 experienced very few urinary infections. The mean species turnover of the first two groups was 2. No statistically significant difference was found in antibiotic-resistance patterns of organisms isolated.

CONCLUSION

Despite different catheterisation techniques in para- and tetraplegic patients, we conclude that: (1) the number of episodes of clinical significant nosocomial urinary infections is not different; (2) the mean species turnover is the same; (3) because of the species turnover, the value of regular urine cultures for 'documented' treatment of clinical relevant urinary infections seems to be limited. So urine culture could be performed less frequently or only when therapy becomes mandatory; (4) No oral antibiotic with superior activity was found: treatment is best started empirically (after sampling for urine culture) and adjusted to the resulting antibiotic sensitivity screening.