Reducing the risk of acquiring antimicrobial-resistant bacteria

Adverse drug events in a sentinel hospital in the State of Goiás, Brazil

This was a retrospective, descriptive and documental study with the aim of identifying adverse drug events which occurred in the medication administration process and to classify these medication errors. This study was developed in the internal medicine unit of a general hospital of Goiás, Brazil. Report books used by nursing staff from the period 2002 to 2007, were analyzed. A total of 230 medication errors were identified, most of which occurred in the preparation and administration of the medications (64.3%). Medication errors were of omission (50.9%), of dose (16.5%), of schedule (13.5%) and of administration technique (12.2%) and were more frequent with antineoplastic and immunomodulating agents (24.3%) and anti-infective agents (20.9%). It was found that 37.4% of drugs were high alert medications. Considering the medication errors detected it is important to promote a culture of safety in the hospital.

The burden of Clostridium difficile in surgical patients in the United States

BACKGROUND

Clostridium difficile colitis is the predominant hospital-acquired gastrointestinal infection in the United States and has emerged as an important nosocomial cause of morbidity and death. Although several institutional studies have examined the effects of C. difficile on hospitalized patients, its nationwide impact on surgical patients has yet to be defined.

METHODS

To provide a national estimate of the burden of C. difficile, we performed a five-year retrospective analysis of the Agency for Healthcare Research and Quality's National Inpatient Sample Database, which represents a stratified 20% sample of hospitals in the United States, from 1999 to 2003. All surgical inpatient discharge data from 997 hospitals in 37 states were analyzed to determine the association of C. difficile infections with patient demographics, hospital characteristics, surgical procedure, length of stay (LOS), total charges, and in-hospital mortality rate. Univariate analysis was performed to identify any association between the presence of C. difficile infection and the outcome variables using chi-square contingency table analysis or the Student t-test following the exclusion of patients with other medical complications. Multivariate regression analysis was used to determine whether the presence of C. difficile infection was an independent predictor of increased LOS, total charges, and in-hospital mortality rate when controlling for surgery type, age, sex, payor, and hospital characteristics.

RESULTS

Clostridium difficile infection was reported as a discharge diagnosis for 8,113 (0.52%) of all 1,553,597 inpatients who had undergone a general surgical procedure. The incidence increased significantly in 2002 (34% higher than in 2001; p < 0.0001). The following patient and hospital characteristics were associated with the highest incidence of C. difficile infection (all p < 0.0001): Age > 64 years (0.95%); Medicare beneficiary status (0.94%); north-eastern hospital location (0.73%); and large (0.55%), urban (0.56%), or teaching hospital (0.61%). Patients undergoing an emergency operation were at higher risk than those having operations performed electively (0.8% vs. 0.3%; p < 0.0001). Colectomy, small-bowel resection, and gastric resection were associated with the highest risk of C. difficile infection (incidence after colectomy 1.11%; odds ratio [OR] 2.77, 95% confidence interval [CI] 2.65, 2.89, p < 0.0001; small-bowel resection 1.17%, OR 2.40, 95% CI 2.26, 2.54, p < 0.0001; gastric resection 1.02%, OR 2.26, 95% CI 2.03, 2.52, p < 0.0001). Patients undergoing cholecystectomy and appendectomy had the lowest risk of C. difficile infection (cholecystectomy 0.41%, OR 0.37, 95% CI 0.35, 0.39, p < 0.0001; appendectomy 0.20%, OR 0.45, 95% CI 0.42, 0.49, p < 0.0001). Multivariable analysis demonstrated that C. difficile was an independent predictor of LOS, which increased by 16.0 days (95% CI 15.6, 16.4 days; p < 0.0001) in the presence of infection. Total charges increased by $77,483 (95% CI $75,174, $79,793; p < 0.0001), and there was a 3.4-fold increase in the mortality rate (95% CI 3.02, 3.77; p < 0.0001) compared with patients who did not acquire C. difficile.

CONCLUSIONS

Epidemiologic data suggest that the incidence of C. difficile infection is increasing in U.S. surgical patients and that the infection is most prevalent after emergency operations and among patients having intestinal tract resections. Infection with C. difficile is an independent predictor of increased LOS, total charges, and mortality rate after surgery and represents a considerable burden to both patients and hospitals. Preventing C. difficile infection offers a potentially significant improvement in patient outcomes, as well as a reduction in hospital costs and resource expenditures.

ESBL-producing Enterobacteriaceae: controlling the spread of infection

Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae were first reported in Europe in the 1980s and have since become a worldwide problem. This has resulted in increased morbidity, mortality and cost in treating the infections they cause (Paterson et al, 2001; Bisson et al, 2002). In the UK the prevalence of ESBL rose from 5.4% in 1997 to 22.7% in 1999 (Goossens, 2000). ESBL are not the only beta-lactamases to present resistance to 1st, 2nd and 3rd generation cephalosporins but are the most important. New strains produce a particular type of ESBL, the CTX-M type, which is able to break down a wider range of antibiotics. These strains were unrecorded in the UK prior to 2000. They have spread rapidly since 2003, causing infections such as urinary tract infections (UTIs) in hospital patients as well as those treated in the community (Livermore associated infection (HAI). Their antimicrobial resistance is commonly caused by the production of beta-lactamases, therefore this article discusses methods used to limit the emergence of ESBL-producing strains and to prevent the spread of those already present.

Antimicrobial resistance in critical care

Patients presenting with active infections or at increased risk for infections pose a significant challenge in critical care nursing. It is important for critical care nurses to use effective antimicrobial strategies in patient management to reduce the potential development of antimicrobial resistance. They should be involved actively in promoting patient management through development of research-based nursing guidelines and protocols.