Clinical Impact of Supplementation with Pasteurized Donor Human Milk by High-Temperature Short-Time Method versus Holder Method in Extremely Low Birth Weight Infants: A Multicentre Randomized Controlled Trial

Nosocomial infections are a frequent and serious problem in extremely low birth weight (ELBW) infants. Donor human milk (DHM) is the best alternative for feeding these babies when mother's own milk (MOM) is not available. Recently, a patented prototype of a High-Temperature Short-Time (HTST) pasteurizer adapted to a human milk bank setting showed a lesser impact on immunologic components. We designed a multicentre randomized controlled trial that investigates whether, in ELBW infants with an insufficient MOM supply, the administration of HTST pasteurized DHM reduces the incidence of confirmed catheter-associated sepsis compared to DHM pasteurized with the Holder method. From birth until 34 weeks postmenstrual age, patients included in the study received DHM, as a supplement, pasteurized by the Holder or HTST method. A total of 213 patients were randomized; 79 (HTST group) and 81 (Holder group) were included in the analysis. We found no difference in the frequency of nosocomial sepsis between the patients of the two methods-41.8% (33/79) of HTST group patients versus 45.7% (37/81) of Holder group patients, relative risk 0.91 (0.64-1.3), p = 0.62. In conclusion, when MOM is not available, supplementing during admission with DHM pasteurized by the HTST versus Holder method might not have an impact on the incidence of catheter-associated sepsis.

Effects of organizational and individual factors on nurses' practice of central line-associated bloodstream infection prevention

BACKGROUND

This study explored rarely investigated organizational factors (resource support and organizational culture) in conjunction with well-established individual factors (demographic characteristics, knowledge, and awareness) that impact nurses' practice of central line-associated bloodstream infection (CLABSI) prevention.

METHODS

Self-reported questionnaire data were collected from 173 nurses recruited from departments that use central venous catheters (ie, intensive care units, emergency rooms, hemodialysis rooms, and oncology wards) in tertiary hospitals in South Korea. Multiple regression analyses were performed to examine the effects of individual and organizational factors.

RESULTS

Organizational culture (ß = 0.350) had the greatest association with CLABSI prevention practice, followed by awareness (ß = 0.328) and department (ß = -0.217; all ps < 0.01). These variables explained 41.1% of the variance in CLABSI prevention practice (F = 20.996, P < .001). Higher self-reported CLABSI prevention practice was associated with a favorable organizational culture and higher awareness. Emergency room nurses' CLABSI prevention practice was notably inferior as compared to nurses in other departments.

DISCUSSION

Organizational culture is the most significant factor affecting nurses' practice of CLABSI prevention.

CONCLUSIONS

An organizational culture with environmental improvements and resource support as well as infection prevention education and awareness-building programs should be fostered.

Single-dose oral azithromycin prophylaxis in planned vaginal delivery for sepsis prevention: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The use of oral azithromycin (AZI) as a preventive measure against postpartum infections of planned vaginal births has garnered a lot of interest in recent years and has been the subject of many randomized controlled trials (RCTs). However, the results from these trials have not been consistent. Therefore, we aim to perform a systematic review and meta-analysis to determine whether the use of a single-dose of oral AZI is clinically significant.

METHODS

We systematically searched PubMed, Embase, and Cochrane Central for RCTs from May to June 2023, comparing a single dose of oral AZI with placebo in patients undergoing planned vaginal delivery at a minimum of 28 weeks of gestational age. The main outcomes were puerperal and neonatal sepsis. Statistical analyses were performed using Review Manager 5.4.1 (Cochrane Collaboration). Heterogeneity was assessed with I2 statistics.

RESULTS

Four RCTs were included (mothers, n = 42 235; newborns n = 42 492). Approximately 49.8% of mothers received a single dose of oral AZI for sepsis prophylaxis. Compared with placebo, AZI significantly reduced the incidence of puerperal sepsis (risk ratio [RR], 0.65 [95% confidence interval (CI), 0.55-0.77]; P < 0.001), mastitis or breast abscess (RR, 0.58 [95% CI, 0.42-0.79]; P < 0.001), endometritis (RR, 0.65 [95% CI, 0.54-0.77]; P < 0.001), wound infection (RR, 0.81 [95% CI, 0.69-0.96]; P = 0.013), infection rate (RR, 0.62 [95% CI, 0.51-0.76]; P < 0.001), and fever (RR, 0.50 [95% CI, 0.28-0.89]; P = 0.018) in mothers. No statistically significant differences were identified between groups regarding maternal all-cause mortality and the use of prescribed postpartum antibiotics. Similarly, no statistical differences were noted in the neonatal group regarding sepsis, infection rate, and all-cause mortality.

CONCLUSION

AZI appears to be an effective preventive measure against many postpartum infections in mothers but a substantial impact on neonatal outcomes has not yet been conclusively observed.

Can the use of azithromycin during labour reduce the incidence of infection among puerperae and newborns? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection among mothers and newborns.

DATA SOURCES

We independently searched the PubMed, Web of Science, Cochrane Library and EMBASE databases for relevant studies published before February, 2024.

METHODS

We included RCTs that evaluated the effect of prenatal oral or intravenous azithromycin or placebo on intrapartum or postpartum infection incidence. We included studies evaluating women who had vaginal births as well as caesarean sections. Studies reporting maternal and neonatal infections were included in the current analysis. Review Manager 5.4 was used to analyse 6 randomized clinical trials involving 44,448 mothers and 44,820 newborns. The risk of bias of each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Primary outcomes included the incidence of maternal sepsis and all-cause mortality and neonatal sepsis and all-cause mortality; secondary outcomes included maternal (endometritis, wound and surgical site infections, chorioamnionitis, and urinary tract infections) and neonatal outcomes (infections of the eyes, ears and skin). A random-effects model was used to test for overall effects and heterogeneity.

RESULTS

The pooled odds ratios (ORs) were as follows: 0.65 for maternal sepsis (95% CI, 0.55-0.77; I2, 0%; P < .00001); 0.62 for endometritis (95% CI, 0.52-0.74; I2, 2%; P < .00001); and 0.43 for maternal wound or surgical site infection (95% CI, 0.24-0.78; P < .005); however, there was great heterogeneity among the studies (I2, 75%). The pooled OR for pyelonephritis and urinary tract infections was 0.3 (95% CI, 0.17-0.52; I2, 0%; P < .0001), and that for neonatal skin infections was 0.48 (95% CI, 0.35-0.65; I2, 0%, P < .00001). There was no significant difference in maternal all-cause mortality or incidence of chorioamnionitis between the two groups. No significant differences were observed in the incidence of neonatal sepsis or suspected sepsis, all-cause mortality, or infections of the eyes or ears.

CONCLUSION

In this meta-analysis, azithromycin use during labour reduced the incidence of maternal sepsis, endometritis, incisional infections and urinary tract infections but did not reduce the incidence of neonatal-associated infections, except for neonatal skin infections. These findings indicate that azithromycin may be potentially beneficial for maternal postpartum infections, but its effect on neonatal prognosis remains unclear. Azithromycin should be used antenatally only if the clinical indication is clear and the potential benefits outweigh the harms.

Effect of oropharyngeal colostrum therapy on neonatal sepsis in preterm neonates: A systematic review and meta-analysis

Various studies have shown that oropharyngeal colostrum application (OPCA) is beneficial to preterm neonates. We performed a systematic review and meta-analysis to assess whether OPCA reduces the incidence of culture-proven neonatal sepsis in preterm neonates. Randomized controlled trials comparing OPCA with placebo or standard care in preterm neonates were included. Medline, Embase, Web of Science, Cumulated Index to Nursing and Allied Health Literature, Scopus, and CENTRAL were searched for studies published up to June 15, 2023. We used the Cochrane Risk of Bias tool, version 2, for risk of bias assessment, the random-effects model (RevMan 5.4) for meta-analysis, and Gradepro software for assessing the certainty of evidence. Twenty-one studies involving 2393 participants were included in this meta-analysis. Four studies had a low risk of bias, whereas seven had a high risk. Oropharyngeal colostrum significantly reduced the incidence of culture-proven sepsis (18 studies, 1990 neonates, risk ratio [RR]: 0.78, 95% confidence interval [95% CI]: 0.65, 0.94), mortality (18 studies, 2117 neonates, RR: 0.73, 95% CI: 0.59, 0.90), necrotizing enterocolitis (NEC) (17 studies, 1692 neonates, RR: 0.59, 95% CI: 0.43, 0.82), feeding intolerance episodes (four studies, 445 neonates, RR: 0.59, 95% CI: 0.38, 0.92), and the time to full enteral feeding (19 studies, 2142 neonates, mean difference: -2 to 21 days, 95% CI: -3.44, -0.99 days). There was no reduction in intraventricular hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, ventilator-associated pneumonia, neurodevelopmental abnormalities, hospital stay duration, time to full oral feeding, weight at discharge, pneumonia, and duration of antibiotic therapy. The certainty of the evidence was high for the outcomes of culture-positive sepsis and mortality, moderate for NEC, low for time to full enteral feeding, and very low for feeding intolerance. OPCA reduces culture-positive sepsis and mortality (high certainty), NEC (moderate certainty), and time to full enteral feeding (low certainty) in preterm neonates. However, scarcity of data from extremely premature infants limits the generalizability of these results to this population.

Central Line-Associated Bloodstream Infection Misclassifications-Rethinking the Centers for Disease Control and Prevention's Central Line-Associated Bloodstream Infection Definition and Its Implications

Centers for Medicare and Medicaid Services imparts financial penalties for central line-associated bloodstream infections (CLABSIs) and other healthcare-acquired infections. Data for this purpose is obtained from the Centers for Disease Control and Prevention (CDC)'s National Health Safety Network. We present examples of misclassification of bloodstream infections into CLABSI by the CDC's definition and present the financial implications of such misclassification and potential long-term implications.

Postoperative antibiotic prophylaxis for percutaneous nephrolithotomy and risk of infection: a systematic review and meta-analysis

PURPOSE

The aim of this study is to perform a high-quality meta-analysis using only randomized controlled trials (RCT) to better define the role of postoperative antibiotics in patients undergoing percutaneous nephrolithotomy (PCNL).

MATERIALS AND METHODS

A literature search for RCTs in EMBASE, PubMed, and Web of Science up to May 2023 was conducted following the PICO framework: Population-adult patients who underwent PCNL; Intervention-postoperative antibiotic prophylaxis until nephrostomy tube withdrawal; Control-single dose of antibiotic during the induction of anesthesia; and Outcome-systemic inflammatory response syndrome (SIRS) or sepsis and fever after PCNL. The protocol was registered on the PROSPERO database (CRD42022361579). We calculated odds ratios (OR) and 95% confidence intervals (CI). A random-effects model was employed, and the alpha risk was defined as < 0.05.

RESULTS

Seven articles, encompassing a total of 629 patients, were included in the analysis. The outcome of SIRS or sepsis was extracted from six of the included studies, while the outcome of postoperative fever was extracted from four studies. The analysis revealed no statistical association between the use of postoperative antibiotic prophylaxis until nephrostomy tube withdrawal and the occurrence of SIRS/sepsis (OR 1.236, 95% CI 0.731 - 2.089, p=0.429) or fever (OR 2.049, 95% CI 0.790 - 5.316, p=0.140).

CONCLUSION

Our findings suggest that there is no benefit associated with the use of postoperative antibiotic prophylaxis until nephrostomy tube withdrawal in patients undergoing percutaneous nephrolithotomy (PCNL). We recommend that antibiotic prophylaxis should be administered only until the induction of anesthesia in PCNL.

2% chlorhexidine gluconate aqueous versus 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin disinfection prior to percutaneous central venous catheterisation: the ARCTIC randomised controlled feasibility trial

OBJECTIVE

Catheter-related sepsis (CRS) is a major complication with significant morbidity and mortality. Evidence is lacking regarding the most appropriate antiseptic for skin disinfection before percutaneous central venous catheter (PCVC) insertion in preterm neonates. To inform the feasibility and design of a definitive randomised controlled trial (RCT) of two antiseptic formulations, we conducted the Antiseptic Randomised Controlled Trial for Insertion of Catheters (ARCTIC) feasibility study to assess catheter colonisation, sepsis, and skin morbidity.

DESIGN

Feasibility RCT.

SETTING

Two UK tertiary-level neonatal intensive care units.

PATIENTS

Preterm infants born <34 weeks' gestation scheduled to undergo PCVC insertion.

INTERVENTIONS

Skin disinfection with either 2% chlorhexidine gluconate (CHG)-aqueous or 2% CHG-70% isopropyl alcohol (IPA) before PCVC insertion and at removal.

PRIMARY OUTCOME

Proportion in the 2% CHG-70% IPA arm with a colonised catheter at removal.

MAIN FEASIBILITY OUTCOMES

Rates of: (1) CRS, catheter-associated sepsis (CAS), and CRS/CAS per 1,000 PCVC days; (2) recruitment and retention; (3) data completeness.

SAFETY OUTCOMES

Daily skin morbidity scores recorded from catheter insertion until 48 hours post-removal.

RESULTS

116 babies were randomised. Primary outcome incidence was 4.1% (95% confidence interval: 0.9% to 11.5%). Overall catheter colonisation rate was 5.2% (5/97); CRS 2.3/1000 catheter days; CAS 14.8/1000 catheter days. Recruitment, retention and data completeness were good. No major antiseptic-related skin injury was reported.

CONCLUSIONS

A definitive comparative efficacy trial is feasible, but the very low catheter colonisation rate would make a large-scale RCT challenging due to the very large sample size required. ARCTIC provides preliminary reassurance supporting potential safe use of 2% CHG-70% IPA and 2% CHG-aqueous in preterm neonates.

TRIAL REGISTRATION NUMBER

ISRCTN82571474.

The effect of minimizing central line days for very low birth weight infants through quality improvement

Blood culture proven sepsis is associated with increased mortality and morbidity. Given the extended hospitalization of very preterm infants, catheter-related blood stream infections (CRBSIs) play a substantial role in sepsis. The reported incidence of CRBSIs in neonates varies from 3.2 to 21.8 CRBSIs per 1000 catheter line days. Moreover, discrepancies in neonatal practices and potential neglect may lead to the unwarranted prolongation of central lines. This study aims to compare two distinct periods (Pre-QI vs. Post-QI) in relation to the central line insertion rate and duration, as well as blood culture proven sepsis, duration of total parenteral nutrition (TPN), and the progression of feeding. These factors are known to be associated with prolonged hospitalization and increased morbidities. A total of 210 very low birth weight infants (VLBWIs), defined as either less than 32 weeks of gestational age (GA) or weighing less than 1500 g, were admitted to the Neonatal Intensive Care Unit (NICU) at Seoul St. Mary's Hospital, The Catholic University of Korea, between January 2020 and June 2023. Fourteen infants were excluded from the study as they did not survive beyond 1 month of life, and one was excluded due to a congenital anomaly. Consequently, the analysis included 195 VLBWIs. The Quality Improvement (QI) initiative began in January 2022, marking the division into two distinct epochs: the Pre-QI period, encompassing the years 2020 to 2021, and the Post-QI period, spanning from 2022 to 2023. The primary outcome measures included PICC insertion rates, duration, and feeding advancement or feeding-related complications. The hospital outcome measures were also compared between the two periods. A total of 195 VLBWI were included in the analysis. The birth weight was significantly lower in the pre-QI period, with an average of 1023 g compared to 1218 g (P < 0.001). Severe BPD ≥ moderate was significantly lower in the post-QI period (36.2% vs. 53.9%) (P < 0.001) along with shorter mechanical ventilation days (12 ± 29 vs. 22 ± 27) (P = 0.046). The PICC insertion rate was significantly decreased from 95.6% in pre-QI period compared to 55.2% in post-QI period (P < 0.001) along with a notable reduction in blood culture-proven sepsis (25.6% vs. 10.5%, P = 0.008). CRBSI rate was reduced from 1.3 to 1.1 per 1000 catheter days in the post-QI period. Moreover, the time required to achieve full enteral feeding of 100 mL/kg/day was significantly shorter in the post-QI (24 ± 23 vs. 33 ± 25) (P = 0.006). Multivariable logistic regression analysis for sepsis revealed that both birth weight and pre/post QI consistently demonstrated an association with lower sepsis rates in the Post-QI period. QI has the potential to reduce the burden of unnecessary interventions and blood culture proven sepsis rate along with CRBSI rate, thereby, optimizing the better care of very preterm babies.

Efficacy of probiotics or synbiotics in critically ill patients: A systematic review and meta-analysis

BACKGROUND

This latest systematic review and meta-analysis aim to examine the effects of probiotic and synbiotic supplementation in critically ill patients.

METHODS

Relevant articles were retrieved from PubMed, Embase, the Cochrane Database, and the Web of Science. The primary output measure was the incident of ventilator-associated pneumonia, and the secondary outputs were diarrhea, Clostridium diffusion infection (CDI), incident of sepsis, incident of hospital acquired pneumonia, duration of mechanical exploitation, ICU mortality rate, length of ICU stay, in hospital mortality, and length of hospital stay. Data were pooled and expressed as Relative Risk(RR) and Standardized Mean Difference (SMD) with a 95 % confidence interval (CI).

RESULTS

33 studies were included in this systematic review and meta-analysis, with 4065 patients who received probiotics or synbiotics (treatment group) and 3821 patients who received standard care or placebo (control group). The pooled data from all included studies demonstrated that the treatment group has significantly reduced incidence of ventilation-associated pneumonia (VAP) (RR = 0.80; 95 % CI: 0.67-0.96; p = 0.021, I2 = 52.5 %) and sepsis (RR = 0.97; 95 % CI: 0.66-1.42; p = 0.032, I2 = 54.4 %), As well as significantly increased duration of mechanical exploitation (SMD = -0.47; 95 % CI: -0.74-0.20, p = 0.012, I2 = 63.4 %), ICU mobility (RR = 0.95; 95 % CI: 0.71-1.27; p = 0.004, I2 = 62.8 %), length of ICU stay (SMD = -0.29; 95 % CI: -0.58-0.01; p = 0.000, I2 = 82.3 %) and length of hospital stay (SMD = -0.33; 95 % CI: -0.57-0.08, p = 0.000, I2 = 74.2 %) than the control group. There were no significant differences in diarrhea, CDI, incidence of hospital acquired pneumonia, and in hospital mortality between the two groups.

CONCLUSION

Our meta-analysis showed that probiotic and synbiotic supplements are beneficial for critically ill patients as they significantly reduce the incidence of ventilator associated pneumonia and sepsis, as well as the duration of mechanical exploitation, length of hospital stay, length of ICU stay, and ICU mortality. However, this intervention has minimal impact on diarrhea, CDI, incidence of hospital acquired pneumonia, and in hospital mortality in critically ill patients.

Routine diversion following delayed IPAA construction does not reduce the incidence of pouch-related sepsis or failure in patients with ulcerative colitis

AIM

The aim of this study was to compare modified 2-stage and 3-stage IPAA construction techniques to evaluate the effect of diverting loop ileostomy following completion proctectomy and IPAA for ulcerative colitis. In addition, our overall institutional experience was reviewed to describe long-term outcomes and changes in staging trends over time.

METHODS

Our institutional database was searched to identify all cases of IPAA for ulcerative colitis between 1981 and 2018. Patient, pouch and outcome characteristics were abstracted. Primary study outcomes were the incidence of primary pouch failure and pouch-related sepsis. Failure was evaluated by Kaplan-Meier estimates of survival over time. The adjusted effect of pouch stage was evaluated using multivariable Cox and logistic regression models. Exploratory analysis evaluated the effect of stage on failure in the pouch related sepsis subgroup.

RESULTS

A total of 2105 patients underwent primary IPAA over the study period. The 5, 10 and 20-year pouch survival probabilities were 95.2%, 92.7% and 86.6%. The incidence of pouch related sepsis was 12.3%. Adjusted analysis demonstrated no difference in pouch failure (HR = 0.64: 95% 0.39-1.07, p = 0.09) or post-operative sepsis (aOR = 0.79: 95% CI 0.53-1.17, p = 0.24) by stage of construction. Among patients experiencing pouch sepsis, there was no difference in Kaplan-Meier estimates of pouch survival by stage (p = 0.90).

CONCLUSIONS

Pouch related sepsis and IPAA failure did not differ between modified 2-stage and 3-stage construction techniques. Among the sub-group of patients experiencing pouch related sepsis, there was no difference in failure between groups. The results suggest diverting ileostomy may be safely avoided following delayed pouch reconstruction in appropriately selected patients.

Intrapartum azithromycin to prevent maternal and neonatal sepsis and deaths: A systematic review with meta-analysis

OBJECTIVES

A systematic review with met-analysis was performed to summarise the evidence on the effect of intrapartum azithromycin on maternal and neonatal infections and deaths.

SEARCH STRATEGY

PubMed, Scopus and Web of Science databases were searched in March 2023.

SELECTION CRITERIA

Randomised controlled trials comparing intrapartum single-dose of azithromycin with placebo.

DATA COLLECTION AND ANALYSIS

Maternal infections, maternal mortality, neonatal sepsis, neonatal mortality. We used the random-effects Mantel-Haenszel method to calculate risk ratios (RR) with 95% confidence intervals (95% CI). We assessed risk of bias of the included studies and estimated the evidence certainty using the GRADE approach.

MAIN RESULTS

After screening 410 abstracts, five studies with 44 190 women and 44 565 neonates were included. The risk of bias was low in four and had some concerns in one of the studies. The risk of endometritis was 1.5% in the azithromycin group and 2.3% in the placebo group (RR 0.64, 95% CI 0.55-0.75), and the evidence certainty was high. The respective risk for chorioamnionitis was 0.05% and 0.1% (RR 0.50, 95% CI 0.22-1.18; evidence certainty moderate). The wound infection rate was lower in the azithromycin group (1.6%) than in the placebo group (2.5%), RR 0.52 (95% CI 0.30-0.89; moderate certainty evidence). The maternal sepsis rate was 1.1% in the azithromycin group and 1.7% in the placebo group (RR 0.66, 95% CI 0.56-0.77; evidence certainty high). Mortality rates did not show evidence of a difference (0.09% versus 0.08%; RR 1.26, 95% CI 0.65-2.42; moderate certainty evidence). The neonatal mortality rate was 0.7% in the azithromycin group and 0.8% in the placebo group (RR 0.94, 95% CI 0.76-1.16; moderate certainty evidence). The neonatal sepsis rate was 7.6% in the azithromycin group and 7.4% in the placebo group (RR 1.02, 95% CI 0.96-1.09; moderate certainty evidence).

CONCLUSIONS

Intrapartum administration of azithromycin to the mother reduces maternal postpartum infections, including sepsis. Impact on maternal mortality remains undecided. Azithromycin does not reduce neonatal sepsis or mortality rates.

Probiotics for the postoperative management of term neonates after gastrointestinal surgery

BACKGROUND

The intestinal microflora has an essential role in providing a barrier against colonisation of pathogens, facilitating important metabolic functions, stimulating the development of the immune system, and maintaining intestinal motility. Probiotics are live microorganisms that can be administered to supplement the gut flora. Neonates who have undergone gastrointestinal surgery are particularly susceptible to infectious complications in the postoperative period. This may be partly due to a disruption of the integrity of the gut and its intestinal microflora. There may be a role for probiotics in reducing the incidence of sepsis and improving intestinal motility, thus reducing morbidity and mortality and improving enteral feeding in neonates in the postoperative period.

OBJECTIVES

To evaluate the efficacy and safety of administering probiotics after gastrointestinal surgery for the postoperative management of neonates born from 35 weeks of gestation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and trial registries in August 2023. We checked reference lists of included studies and relevant systematic reviews for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that investigated the postoperative administration of oral probiotics versus placebo or no treatment in neonates born from 35 weeks of gestation who had one or more gastrointestinal surgical procedures. We applied no restrictions regarding the type or dosage of probiotics or the duration of treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods, and we used GRADE to assess the certainty of evidence.

MAIN RESULTS

We identified one RCT that recruited 61 neonates with a gestational age of 35 weeks or more. All infants were admitted to a neonatal intensive care unit and had surgery for gastrointestinal pathologies. There may be little or no difference in proven sepsis (positive bacterial culture, local or systemic) between infants who receive probiotics compared with those who receive placebo (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.16 to 2.55; 61 infants; low-certainty evidence). Probiotics compared to placebo may have little or no effect on time to full enteral feeds (mean difference (MD) 0.63 days, 95% CI -4.02 to 5.28; 61 infants; low-certainty evidence). There were no reported deaths prior to discharge from hospital in either study arm. Two weeks after supplementation, the infants who received probiotics had a substantially higher relative abundance of non-pathogenic intestinal microflora (Bifidobacteriaceae) than those who received placebo (MD 38.22, 95% CI 28.40 to 48.04; 39 infants; low-certainty evidence).

AUTHORS' CONCLUSIONS

This review provides low-certainty evidence from one small RCT that probiotics compared to placebo have little or no effect on the risk of proven sepsis (positive bacterial culture, local or systemic) or time to full-enteral feeds in neonates who have undergone gastrointestinal surgery. Probiotics may substantially increase the abundance of beneficial bacterial in the intestine of these neonates, but the clinical implications of this finding are unknown. There is a need for adequately powered RCTs to assess the role of probiotics in this population. We identified two ongoing studies. As neither reported the gestational age of prospective study participants, we are unsure if they will be eligible for inclusion in this review.

A new perfusion system to reduce the burden of central-venous-line-associated bloodstream infections in neonates

BACKGROUND

Central-venous-line-associated bloodstream infection (CLABSI) is a significant cause of morbidity and mortality in preterm infants. As there is large variation in the reported effect of multi-modal preventive strategies, it could be relevant to propose new additional strategies.

AIM

To assess the impact of a new perfusion system on CLABSI rate.

METHODS

A before-and-after study was performed in infants born at <32 weeks of gestation or with birth weight <1500 g who required a multi-perfusion system connected to a central venous line. In the first 12-month period ('before'), the pre-existing perfusion system (multiple stopcocks) was used. An intervention period then occurred with implementation of a new perfusion closed system, without change in 'bundles' related to various aspects of central line care. During the second 12-month period ('after'), the CLABSI rate was assessed and compared with the pre-intervention period.

FINDINGS

In total, 313 infants were included in this study (before: N=163; after: N=150), and 46% had birth weight <1000 g. The change in perfusion system resulted in a significant decrease in CLABSI rate from 11.3 to 2.2 per 1000 catheter-days (P<0.001). The period was independently associated with an 88% reduction in the risk of CLABSI after implementation of the new perfusion system [odds ratio (OR) 0.12, 95% confidence interval (CI) 0.03-0.39; P<0.001]. The duration of central line use was also associated with CLABSIs (for each additional day: OR 1.05, 95% CI 1.02-1.07; P<0.001).

CONCLUSIONS

Implementation of the new perfusion system was feasible in a large neonatal unit, and reduced the CLABSI rate soon after implementation.

Chlorhexidine-based versus non-chlorhexidine dressings to prevent catheter-related bloodstream infections: An evidence-based review

In patients with central venous catheters (CVCs) in situ, the development of catheter-related bloodstream infections (CRBSIs) is often linked with increased morbidity and mortality. Sterile gauze or transparent polyurethane dressings are conventionally used as extraluminal barriers; however, antimicrobial chlorhexidine CVC dressings could potentially reduce infection risk. This short evidence-based review examined the literature comparing the effectiveness of chlorhexidine-based CVC dressings against non-chlorhexidine dressings in reducing CRBSI occurrence. Four systematic reviews with meta-analysis were reviewed, all of which reported a statistically significant reduction in CRBSI occurrence on using chlorhexidine-based dressings. Further research is needed to determine the cost-effectiveness of chlorhexidine-based CVC dressings and their effectiveness in reducing CRBSIs in different catheter types and entry sites because infection risk is not uniform.

Effects of the care given to intensive care patients using an evidence model on the prevention of central line-associated bloodstream infections

It is important to put evidence-based guidelines into practice in the prevention of central line-associated bloodstream infections in intensive care patients. In contrast to expensive and complex interventions, a care bundle that includes easy-to-implement and low-cost interventions improves clinical outcomes. The compliance of intensive care nurses with guidelines is of great importance in achieving these results. The Translating Evidence into Practice Model provides guidance in how to implement the necessary guidelines. This quasi-experimental study used a post-test control group design in nonequivalent groups and was conducted in the anesthesia intensive care unit of a tertiary-level training and research hospital. All patients who were hospitalized in the intensive care unit, who had a central line during the study, and who met the inclusion criteria were included in the sample. The care bundle comprised education, and protocols for hand hygiene and the aseptic technique, maximum sterile barrier precautions, central line insertion trolley, and management of nursing care. To analyze the data, the independent samples t-test, the Mann-Whitney U test, chi-square test, dependent samples t-test, rate ratio, and relative risk were used with 95% confidence intervals. The rate of central line-associated bloodstream infections was significantly lower in the intervention group (2.85/1000 central line days) than in the control group (3.35/1000 central line days) (P = 0.042). The number of accesses to the central line by the nurses decreased significantly in the intervention group compared to the control group (P < 0.001). The mean score for the nurses' evidence-based guideline post-education knowledge (70.80 ± 12.26) was significantly higher than that pre-education (48.20 ± 14.66) (P < 0.001). Compliance with the guideline recommendations in central line-related nursing interventions and in the central line insertion process was significantly better in the intervention group than in the control group in many interventions (P < 0.05). The mean score for the nurses' attitude towards evidence-based nursing increased significantly over time (59.87 ± 7.23 at the 0th month; 63.79 ± 7.24 at the 6th month) (P < 0.001). Nursing care given by implementing the central line care bundle with the Translating Evidence into Practice Model affected the measures. Thanks to the implementation of the care bundle, the rate of infections and the number of accesses to the central line decreased, while the critical care nurses' knowledge of evidence-based guidelines, compliance with the guideline recommendations in central line-related nursing interventions, and attitudes towards evidence-based nursing improved.

Novel tripeptide RKH derived from Akkermansia muciniphila protects against lethal sepsis

OBJECTIVE

The pathogenesis of sepsis is complex, and the sepsis-induced systemic proinflammatory phase is one of the key drivers of organ failure and consequent mortality. Akkermansia muciniphila (AKK) is recognised as a functional probiotic strain that exerts beneficial effects on the progression of many diseases; however, whether AKK participates in sepsis pathogenesis is still unclear. Here, we evaluated the potential contribution of AKK to lethal sepsis development.

DESIGN

Relative abundance of gut microbial AKK in septic patients was evaluated. Cecal ligation and puncture (CLP) surgery and lipopolysaccharide (LPS) injection were employed to establish sepsis in mice. Non-targeted and targeted metabolomics analysis were used for metabolites analysis.

RESULTS

We first found that the relative abundance of gut microbial AKK in septic patients was significantly reduced compared with that in non-septic controls. Live AKK supplementation, as well as supplementation with its culture supernatant, remarkably reduced sepsis-induced mortality in sepsis models. Metabolomics analysis and germ-free mouse validation experiments revealed that live AKK was able to generate a novel tripeptide Arg-Lys-His (RKH). RKH exerted protective effects against sepsis-induced death and organ damage. Furthermore, RKH markedly reduced sepsis-induced inflammatory cell activation and proinflammatory factor overproduction. A mechanistic study revealed that RKH could directly bind to Toll-like receptor 4 (TLR4) and block TLR4 signal transduction in immune cells. Finally, we validated the preventive effects of RKH against sepsis-induced systemic inflammation and organ damage in a piglet model.

CONCLUSION

We revealed that a novel tripeptide, RKH, derived from live AKK, may act as a novel endogenous antagonist for TLR4. RKH may serve as a novel potential therapeutic approach to combat lethal sepsis after successfully translating its efficacy into clinical practice.

Bifidobacterium infantis as a probiotic in preterm infants: a systematic review and meta-analysis

BACKGROUND

Bifidobacterium infantis has special abilities to utilise human milk oligosaccharides. Hence we hypothesised that probiotic supplements containing B. infantis may confer greater benefits to preterm infants than probiotic supplements without B. infantis.

METHODS

A systematic review with meta-analysis was conducted according to standard guidelines. We selected RCTs evaluating probiotics compared to placebo or no treatment in preterm and/or low birth weight infants. Probiotic effects on Necrotizing Enterocolitis (NEC), Late Onset Sepsis (LOS) and Mortality were analysed separately for RCTs in which the supplemented probiotic product contained B. infantis and those that did not contain B. infantis.

RESULTS

67 RCTs were included (n = 14,606), of which 16 used probiotics containing B. infantis (Subgroup A) and 51 RCTs did not (Subgroup B) Meta-analysis of all RCTs indicated that probiotics reduced the risk of NEC, LOS, and mortality. The subgroup meta-analysis demonstrated greater reduction in the incidence of NEC in subgroup A than subgroup B [(relative risk in subgroup A: 0.38; 95% CI, 0.27-0.55) versus (0.67; 95% CI, 0.55-0.81) in subgroup B; p value for subgroup difference: 0.01].

CONCLUSIONS

These results provide indirect evidence that probiotic supplements that include B. infantis may be more beneficial for preterm infants. Well-designed RCTs are necessary to confirm these findings.

IMPACT

Evidence is emerging that beneficial effects of probiotics are species and strain specific. This systematic review analyses if B. infantis supplementation provides an advantage to preterm infants. This is the first systematic review evaluating the effects of probiotics containing B. infantis in preterm infants. The results of this systematic review provides indirect evidence that probiotics that include B. infantis may be more beneficial for preterm infants. These results will help in guiding future research and clinical practice for using B. infantis as a probiotic in preterm infants.

Implementation of Nephroprotective Measures to Prevent Acute Kidney Injury in Septic Patients: A Retrospective Cohort Study

BACKGROUND

Sepsis remains the leading cause of mortality in critically ill patients, and mortality is increased when acute kidney injury (AKI) occurs. The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends the implementation of supportive measures in patients at high risk for AKI. However, it remains unclear to what extent these nephroprotective measures are implemented in daily clinical practice in critically ill patients, especially those with high-risk exposures such as sepsis.

METHODS

We analyzed the Medical Information Mart for Intensive Care IV (MIMIC-IV) database to identify septic patients with and without AKI. The primary outcome of interest was the adherence to the KDIGO bundle consisting of avoidance of nephrotoxic agents, implementation of a functional hemodynamic monitoring, optimization of perfusion pressure and volume status, close monitoring of renal function, avoidance of hyperglycemia, and avoidance of radiocontrast agents. Secondary outcomes included the development of AKI, progression of AKI, the use of renal replacement therapy (RRT), mortality, and a composite end point consisting of progression of AKI and mortality within 7 days.

RESULTS

Our analysis included 34,679 patients with sepsis with 1.6% receiving the complete bundle (10% received 5, 42.3% 4, 35.4% 3, and 9.8% 2 bundle components). In 56.4%, nephrotoxic agents were avoided, and hemodynamic optimization was reached in 86.5%. Secondary end points were improved in patients with bundle adherence. Avoidance of nephrotoxic drugs and optimization of hemodynamics were significantly associated with lower rates of AKI and improved patient outcomes, including 30-day mortality.

CONCLUSIONS

Implementation of the KDIGO bundle is poor in patients with sepsis but may be associated with improved outcomes.

Effect of preoperative prophylactic antibiotic use on postoperative infection after percutaneous nephrolithotomy in patients with negative urine culture: a single-center randomized controlled trial

PURPOSE

To compare the effects of different preoperative antibiotic prophylaxis (ABP) regimens on the incidence of sepsis after percutaneous nephrolithotomy (PCNL) in patients with negative urine culture.

METHODS

A single-center, randomized controlled trial (June 2022-December 2023) included 120 patients with negative preoperative urine cultures for upper urinary tract stones who underwent PCNL (chictr.org.cn; ChiCTR2200059047). The experimental group and the control group were respectively given different levofloxacin-based preoperative ABP regimes, including 3 days before surgery and no ABP before surgery. Both groups were given a dose of antibiotics before the operation. The primary outcome was differences in the incidence of postoperative sepsis.

RESULTS

A total of 120 subjects were included, including 60 patients in the experimental group and 60 patients in the control group. The baseline characteristics of the two groups were comparable and intraoperative characteristics also did not differ. The sepsis rate was not statistically different between the experimental and control groups (13.3% vs.13.3%, P = 1.0). A multivariate logistic regression analysis revealed that body mass index (BMI) (OR = 1.3; 95% CI = 1.1-1.6; P = 0.003) and operating time (OR = 1.1; 95% CI = 1.0-1.1; P = 0.012) were independent risk factors of sepsis.

CONCLUSION

Our study showed that prophylactic antibiotic administration for 3 days before surgery did not reduce the incidence of postoperative sepsis in patients with negative urine cultures undergoing PCNL. For this subset of patients, we recommend that a single dose of antibiotics be given prior to the commencement of surgery seems adequate.

Analysis of Influencing Factors of Sepsis after Prostate Biopsy: A Meta-Analysis

OBJECTIVE

This study aimed to conduct a systematic review of studies investigating the influencing factors of sepsis in patients following prostate biopsy and to provide clinical references for the prevention and reduction of sepsis occurrence.

METHODS

A comprehensive computer search was performed on multiple databases, including PubMed, Web of Science, Embase, and Scope. The search period extended from the inception of each database to September 2023. Two independent researchers screened the literature, extracted data, evaluated the risk of bias, and conducted a meta-analysis using R software. The included studies comprised cohort and case-control studies, and the inverse variance method was utilized to combine odds ratio (OR) values with corresponding 95% confidence intervals (CIs).

RESULTS

The analysis included a total of 22 studies involving 374,021 patients. Meta-analysis results indicated that targeted prophylactic antibiotics (OR = 0.48, 95% CI [0.23, 0.98]), combined use of antibiotics (OR = 0.44, 95% CI [0.25, 0.76]), history of antibiotic use (OR = 2.54, 95% CI [1.49, 4.31]), and diabetes (OR = 2.95, 95% CI [1.25, 6.98]) may be influential factors for sepsis after prostate biopsy. However, factors such as biopsy procedure, positive biopsy, and previous biopsy did not exhibit a significant association with sepsis after prostate biopsy.

CONCLUSIONS

Targeted prophylactic antibiotics, combined use of antibiotics, history of antibiotic use, and diabetes are identified as influential factors for sepsis in patients after prostate biopsy. However, due to limitations in the quantity and quality of the included studies, further high-quality research is necessary to validate these findings.

Progress of research on organ protection of acupuncture and moxibustion in the prevention and treatment of sepsis

Sepsis is a major disease that threatens human life and health. Clinically, it is mainly based on supportive treatment and lacks specific treatment methods. Acupuncture has important clinical significance in the prevention and treatment of sepsis. In the present paper, we systematically searched CNKI and PubMed databases, included the clinical trials and animal experiments on the prevention and treatment of sepsis with acupuncture, summarized the clinical efficacy and the mechanism of acupuncture. Results indicate that the role of acupuncture therapies in improving sepsis involves inhibiting systemic inflammatory response, alleviating oxidative stress, regulating immune system, and resisting cell apoptosis, thus having a protective effect on multiple organs. The mechanism involves multiple signaling pathways and related factors.

Effect of colchicine on perioperative atrial fibrillation and myocardial injury after non-cardiac surgery in patients undergoing major thoracic surgery (COP-AF): an international randomised trial

BACKGROUND

Higher levels of inflammatory biomarkers are associated with an increased risk of perioperative atrial fibrillation and myocardial injury after non-cardiac surgery (MINS). Colchicine is an anti-inflammatory drug that might reduce the incidence of these complications.

METHODS

COP-AF was a randomised trial conducted at 45 sites in 11 countries. Patients aged 55 years or older and undergoing major non-cardiac thoracic surgery were randomly assigned (1:1) to receive oral colchicine 0·5 mg twice daily or matching placebo, starting within 4 h before surgery and continuing for 10 days. Randomisation was done with use of a computerised, web-based system, and was stratified by centre. Health-care providers, patients, data collectors, and adjudicators were masked to treatment assignment. The coprimary outcomes were clinically important perioperative atrial fibrillation and MINS during 14 days of follow-up. The main safety outcomes were a composite of sepsis or infection, and non-infectious diarrhoea. The intention-to-treat principle was used for all analyses. This trial is registered with ClinicalTrials.gov, NCT03310125.

FINDINGS

Between Feb 14, 2018, and June 27, 2023, we enrolled 3209 patients (mean age 68 years [SD 7], 1656 [51·6%] male). Clinically important atrial fibrillation occurred in 103 (6·4%) of 1608 patients assigned to colchicine, and 120 (7·5%) of 1601 patients assigned to placebo (hazard ratio [HR] 0·85, 95% CI 0·65 to 1·10; absolute risk reduction [ARR] 1·1%, 95% CI -0·7 to 2·8; p=0·22). MINS occurred in 295 (18·3%) patients assigned to colchicine and 325 (20·3%) patients assigned to placebo (HR 0·89, 0·76 to 1·05; ARR 2·0%, -0·8 to 4·7; p=0·16). The composite outcome of sepsis or infection occurred in 103 (6·4%) patients in the colchicine group and 83 (5·2%) patients in the placebo group (HR 1·24, 0·93-1·66). Non-infectious diarrhoea was more common in the colchicine group (134 [8·3%] events) than the placebo group (38 [2·4%]; HR 3·64, 2·54-5·22).

INTERPRETATION

In patients undergoing major non-cardiac thoracic surgery, administration of colchicine did not significantly reduce the incidence of clinically important atrial fibrillation or MINS but increased the risk of mostly benign non-infectious diarrhoea.

FUNDING

Canadian Institutes of Health Research, Accelerating Clinical Trials Consortium, Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario, Population Health Research Institute, Hamilton Health Sciences, Division of Cardiology at McMaster University, Canada; Hanela Foundation, Switzerland; and General Research Fund, Research Grants Council, Hong Kong.

Probiotics, Prebiotics, Lactoferrin, and Combination Products for Prevention of Mortality and Morbidity in Preterm Infants: A Systematic Review and Network Meta-Analysis

Importance

Modulation of intestinal microbiome by administering probiotics, prebiotics, or both may prevent morbidity and mortality in premature infants.

Objective

To assess the comparative effectiveness of alternative prophylactic strategies through a network meta-analysis (NMA) of randomized clinical trials.

Data Sources

MEDLINE, EMBASE, Science Citation Index Expanded, CINAHL, Scopus, Cochrane CENTRAL, and Google Scholar from inception until May 10, 2023.

Study Selection

Eligible trials tested probiotics, prebiotics, lactoferrin, and combination products for prevention of morbidity or mortality in preterm infants.

Data Extraction and Synthesis

A frequentist random-effects model was used for the NMA, and the certainty of evidence and inferences regarding relative effectiveness were assessed using the GRADE approach.

Main Outcomes and Measures

All-cause mortality, severe necrotizing enterocolitis, culture-proven sepsis, feeding intolerance, time to reach full enteral feeding, and duration of hospitalization.

Results

A total of 106 trials involving 25 840 preterm infants were included. Only multiple-strain probiotics were associated with reduced all-cause mortality compared with placebo (risk ratio [RR], 0.69; 95% CI, 0.56 to 0.86; risk difference [RD], -1.7%; 95% CI, -2.4% to -0.8%). Multiple-strain probiotics alone (vs placebo: RR, 0.38; 95% CI, 0.30 to 0.50; RD, -3.7%; 95% CI, -4.1% to -2.9%) or in combination with oligosaccharides (vs placebo: RR, 0.13; 95% CI, 0.05 to 0.37; RD, -5.1%; 95% CI, -5.6% to -3.7%) were among the most effective interventions reducing severe necrotizing enterocolitis. Single-strain probiotics in combination with lactoferrin (vs placebo RR, 0.33; 95% CI, 0.14 to 0.78; RD, -10.7%; 95% CI, -13.7% to -3.5%) were the most effective intervention for reducing sepsis. Multiple-strain probiotics alone (RR, 0.61; 95% CI, 0.46 to 0.80; RD, -10.0%; 95% CI, -13.9% to -5.1%) or in combination with oligosaccharides (RR, 0.45; 95% CI, 0.29 to 0.67; RD, -14.1%; 95% CI, -18.3% to -8.5%) and single-strain probiotics (RR, 0.61; 95% CI, 0.51 to 0.72; RD, -10.0%; 95% CI, -12.6% to -7.2%) proved of best effectiveness in reduction of feeding intolerance vs placebo. Single-strain probiotics (MD, -1.94 days; 95% CI, -2.96 to -0.92) and multistrain probiotics (MD, -2.03 days; 95% CI, -3.04 to -1.02) proved the most effective in reducing the time to reach full enteral feeding compared with placebo. Only single-strain and multistrain probiotics were associated with greater effectiveness compared with placebo in reducing duration of hospitalization (MD, -3.31 days; 95% CI, -5.05 to -1.58; and MD, -2.20 days; 95% CI, -4.08 to -0.31, respectively).

Conclusions and Relevance

In this systematic review and NMA, moderate- to high-certainty evidence demonstrated an association between multistrain probiotics and reduction in all-cause mortality; these interventions were also associated with the best effectiveness for other key outcomes. Combination products, including single- and multiple-strain probiotics combined with prebiotics or lactoferrin, were associated with the largest reduction in morbidity and mortality.

Limosilactobacillus reuteri DSM 17938 as a probiotic in preterm infants: An updated systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Our previous strain-specific systematic review (SR) showed that Lactobacillus reuteri (LR) DSM 17938 reduces necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and time to full feeds (TFF) in preterm infants. Considering progress in the field over the past 6 years, we aimed to update our SR.

METHODS

SR of randomized controlled trials (RCTs) and non-RCTs was conducted. MEDLINE, Embase, Emcare, Cochrane CENTRAL, and gray literature were searched in June 2023. Primary outcomes were TFF, NEC stage ≥II, LOS, and all-cause mortality. Meta-analysis was performed using random-effects model. Certainty of evidence (CoE) was summarized using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines. Trial sequential analysis (TSA) was applied for outcome of NEC in RCTs.

RESULTS

Twelve RCTs (n = 2284) and four non-RCTs (n = 1616) were included. Six RCTs and three non-RCTs were new. Meta-analysis of RCTs showed LR significantly reduced TFF (mean difference, -2.70 [95% CI, -4.90 to -1.31] days; P = 0.0001), NEC stage ≥II (risk ratio [RR], 0.57 [95% CI, 0.37-0.87]; P = 0.009; eight RCTs), and LOS (RR, 0.72 [95% CI, 0.54-0.97]; P = 0.03); but not mortality (RR, 0.76 [95% CI, 0.54-1.06]; P = 0.10). TSA showed diversity-adjusted required information size (DARIS) as 3624 for NEC. Overall CoE was "very low." Meta-analysis of non-RCTs showed LR reduced NEC (odds ratio, 0.34 [95% CI, 0.15-0.77]; P = 0.01) but not LOS. LR had no adverse effects.

CONCLUSIONS

Very low CoE suggests that LR DSM 17938 may reduce NEC and LOS and shorten TFF in preterm infants. Additional RCTs are required to confirm our findings.

Candida-induced granulocytic myeloid-derived suppressor cells are protective against polymicrobial sepsis

IMPORTANCE

Polymicrobial intra-abdominal infections are serious clinical infections that can lead to life-threatening sepsis, which is difficult to treat in part due to the complex and dynamic inflammatory responses involved. Our prior studies demonstrated that immunization with low-virulence Candida species can provide strong protection against lethal polymicrobial sepsis challenge in mice. This long-lived protection was found to be mediated by trained Gr-1+ polymorphonuclear leukocytes with features resembling myeloid-derived suppressor cells (MDSCs). Here we definitively characterize these cells as MDSCs and demonstrate that their mechanism of protection involves the abrogation of lethal inflammation, in part through the action of the anti-inflammatory cytokine interleukin (IL)-10. These studies highlight the role of MDSCs and IL-10 in controlling acute lethal inflammation and give support for the utility of trained tolerogenic immune responses in the clinical treatment of sepsis.

Protection against lethal sepsis following immunization with Candida species varies by isolate and inversely correlates with bone marrow tissue damage

Protection against lethal Candida albicans (Ca)/Staphylococcus aureus (Sa) intra-abdominal infection (IAI)-mediated sepsis can be achieved by a novel form of trained innate immunity (TII) involving Gr-1+ myeloid-derived suppressor cells (MDSCs) that are induced by inoculation (immunization) with low virulence Candida species [i.e., Candida dubliniensis (Cd)] that infiltrate the bone marrow (BM). In contrast, more virulent Candida species (i.e., C. albicans), even at sub-lethal inocula, fail to induce similar levels of protection. The purpose of the present study was to test the hypothesis that the level of TII-mediated protection induced by Ca strains inversely correlates with damage in the BM as a reflection of virulence. Mice were immunized by intraperitoneal inoculation with several parental and mutant strains of C. albicans deficient in virulence factors (hyphal formation and candidalysin production), followed by an intraperitoneal Ca/Sa challenge 14 d later and monitored for sepsis and mortality. Whole femur bones were collected 24 h and 13 d after immunization and assessed for BM tissue/cellular damage via ferroptosis and histology. While immunization with standard but not sub-lethal inocula of most wild-type C. albicans strains resulted in considerable mortality, protection against lethal Ca/Sa IAI challenge varied by strain was usually less than that for C. dubliniensis, with no differences observed between parental and corresponding mutants. Finally, levels of protection afforded by the Ca strains were inversely correlated with BM tissue damage (R 2 = -0.773). TII-mediated protection against lethal Ca/Sa sepsis induced by Candida strain immunization inversely correlates with BM tissue/cellular damage as a reflection of localized virulence.

Nasal Iodophor Antiseptic vs Nasal Mupirocin Antibiotic in the Setting of Chlorhexidine Bathing to Prevent Infections in Adult ICUs: A Randomized Clinical Trial

Importance

Universal nasal mupirocin plus chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) prevents methicillin-resistant Staphylococcus aureus (MRSA) infections and all-cause bloodstream infections. Antibiotic resistance to mupirocin has raised questions about whether an antiseptic could be advantageous for ICU decolonization.

Objective

To compare the effectiveness of iodophor vs mupirocin for universal ICU nasal decolonization in combination with CHG bathing.

Design, Setting, and Participants

Two-group noninferiority, pragmatic, cluster-randomized trial conducted in US community hospitals, all of which used mupirocin-CHG for universal decolonization in ICUs at baseline. Adult ICU patients in 137 randomized hospitals during baseline (May 1, 2015-April 30, 2017) and intervention (November 1, 2017-April 30, 2019) were included.

Intervention

Universal decolonization involving switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline).

Main Outcomes and Measures

ICU-attributable S aureus clinical cultures (primary outcome), MRSA clinical cultures, and all-cause bloodstream infections were evaluated using proportional hazard models to assess differences from baseline to intervention periods between the strategies. Results were also compared with a 2009-2011 trial of mupirocin-CHG vs no decolonization in the same hospital network. The prespecified noninferiority margin for the primary outcome was 10%.

Results

Among the 801 668 admissions in 233 ICUs, the participants' mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, -0.9% [95% CI, -9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]).

Conclusions and Relevance

Nasal iodophor antiseptic did not meet criteria to be considered noninferior to nasal mupirocin antibiotic for the outcome of S aureus clinical cultures in adult ICU patients in the context of daily CHG bathing. In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin.

Trial Registration

ClinicalTrials.gov Identifier: NCT03140423.

Previous use of statins does not improve the outcome of bloodstream infection after kidney transplantation

Previous studies have suggested that exposure to statins confers a protective effect in bloodstream infection (BSI) due to the anti-inflammatory and immunomodulatory properties attributed to these lipid-lowering drugs. Scarce evidence is available for the solid organ transplant population. Therefore, we compared the time to clinical cure (primary outcome) and the time to fever resolution, new requirement of intensive care unit admission or renal replacement therapy, and 30-day all-cause mortality (secondary outcomes) between kidney transplant (KT) recipients with post-transplant BSI that were receiving or not statin therapy for at least the previous 30 days. We included 80 KT recipients that developed 109 BSI episodes (43 [39.4%] and 66 [60.6%] episodes within the statin and non-statin groups, respectively). The median interval since the initial prescription to BSI was 512 days (interquartile range [IQR]: 172-1388). Most episodes were of urinary source and due to Enterobacterales. There were no differences in the median time to clinical cure in the statin and non-statin groups (3.4 [IQR: 3-6.8] versus 4 [IQR: 2-6] days; p-value = .112). The lack of effect was confirmed by multiple linear regression analysis adjusted for confounding factors (standardized β coefficient = 0.040; p-value = .709). No significant differences were observed for any of the secondary outcomes either. Vital signs and laboratory values at BSI onset and after 72-96 h were similar in both groups. In conclusion, previous statin therapy had no apparent protective effect on the outcome of post-transplant BSI among KT recipients.

Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self-investigations: A NBSIs frontline ownership intervention

BACKGROUND

Nosocomial bloodstream infections (NBSIs) are adverse complications of hospitalization. Most interventions focus on intensive care units. Data on interventions involving patients' personal care providers in hospitalwide settings are limited.

OBJECTIVE

To evaluate the impact of department-level NBSI investigations on infection incidence.

METHODS

Beginning in 2016, positive cultures, classified as suspected of being hospital acquired, were prospectively investigated by patients' unit-based personal healthcare providers using a structured electronic questionnaire. After analyzing the conclusions of the investigation, a summary was sent quarterly to the departments and to hospital management. NBSI rates and clinical data during a 5-year period (2014-2018) were calculated and compared before and after the intervention (2014-2015 versus 2016-2018), using interrupted time-series analysis.

RESULTS

Among 4,135 bloodstream infections (BSIs), 1,237 (30%) were nosocomial. The rate of NBSI decreased from 4.58 per 1,000 admissions days in 2014 and 4.82 in 2015, to 3.81 in 2016, 2.94 in 2017 and 2.86 in 2018. Following a 4-month lag after introducing the intervention, the NBSI rate per 1000 admissions dropped significantly by 1.33 (P = .04; 95% CI, -2.58 to -0.07). The monthly NBSI rate continued to decrease significantly by 0.03 during the intervention period (P = .03; 95% CI, -0.06 to -0.002).

CONCLUSIONS

Detailed department-level investigations of NBSI events performed by healthcare providers, increased staff awareness and frontline ownership and were associated with a decrease in NBSI rates hospitalwide.

Kaiser Permanente early-onset sepsis calculator as a safe tool for reducing antibiotic use among chorioamnionitis-exposed term neonates: Qatar experience

Being an important cause of early-onset neonatal sepsis, clinical chorioamnionitis in the mother results in frequent laboratory workup and antibiotic use for the neonate. Neonatal intensive care units (NICUs) in Qatar follow the categorical approach recommended by the Centers for Disease Control and Prevention, USA, and all chorioamnionitis-exposed neonates receive antibiotics.Our project aimed to reduce antibiotic use among chorioamnionitis-exposed, asymptomatic term babies by adopting the early-onset sepsis calculator (EOSCAL). Reduction of blood culture and NICU stay duration were added as secondary objectives later.The Institute of Healthcare Improvement Model of Improvement was used. Antibiotic use rate was the primary outcome measure. Blood culture rate and early transfer to the postnatal ward were added after 1 year. The process measures included the EOSCAL use rate and calculation error rate. The rate of positive culture among untreated babies within the first week was taken as a balancing measure. Monthly data were collected from February 2020 and entered as run charts. Calculation errors were dealt by multiple PDSAs. Additional outcome measures were added in January 2021. Data collection and monitoring continued till December 2022.Among 3837 inborn NICU admissions, 464 (12 %) were chorioamnionitis-exposed babies. Of them, 341 (74%) cases were eligible for inclusion. Among eligible cases, 270 (79%) did not receive antibiotics. Blood culture could be avoided among 106 (97% of low-risk babies) and NICU stay was reduced among 45 (92% of eligible low-risk babies). None of the untreated babies developed sepsis during the first week.Implementation of this project effectively and safely reduced the antibiotic use and blood culture rate among term, well-appearing babies exposed to chorioamnionitis. The project resulted in enhanced patient safety, experience and flow and reduced cost. It is recommendable to other NICU settings in Qatar.

Investigating potential drivers of increased central line...associated bloodstream infections during the coronavirus disease 2019 (COVID-19) Omicron surge

Central line...associated bloodstream infection rates increased during the Omicron surge at our rural academic medical center. To identify potential drivers of this increase, we investigated period- and patient-specific factors associated with the increase in central line...associated bloodstream infection. Increased central line utilization, decreased central line bundle compliance monitoring, increased proportion of traveling nurses, increased short-term venous catheter use in the internal jugular vein, increased multilumen catheter use, decreased port...associated infection, and increased patient acuity were significantly associated with the surge. Our results helped us target our local infection prevention efforts.

Effects of intravenous sivelestat sodium on prevention of acute respiratory distress syndrome in patients with sepsis: study protocol for a double-blind multicentre randomised controlled trial

INTRODUCTION

Sepsis is one of the most common risk factors for acute respiratory distress syndrome (ARDS). Neutrophil elastase (NE) is believed to be an important mediator of ARDS. When sepsis occurs, a large number of inflammatory factors are activated and released, which makes neutrophils migrate into the lung, eventually leading to the occurrence of ARDS. Sivelestat sodium is an NE inhibitor that can inhibit the inflammatory reaction during systemic inflammatory response syndrome and alleviate lung injury. Therefore, we hypothesise that intravenous sivelestat sodium may prevent the occurrence of ARDS in patients with sepsis.

METHODS AND ANALYSIS

This is a prospective, investigator-initiated, double-blind, adaptive, multicentre, randomised, controlled clinical trial with an adaptive 'sample size re-estimation' design. Patients meeting the inclusion criteria who were transferred into the intensive care unit will be randomly assigned to receive sivelestat sodium or placebo for up to 7 days. The primary outcome is the development of ARDS within 7 days after randomisation. A total of 238 patients will be recruited based on a 15% decrease in the incidence of ARDS in the intervention group in this study. A predefined interim analysis will be performed to ensure that the calculation is reasonable after reaching 50% (120) of the planned sample size.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of ZhongDa Hospital affiliated to Southeast University (identifier: Clinical Ethical Approval No. 2021ZDSYLL153-P03). Results will be submitted for publication in peer-reviewed journals and presented at relevant conferences and meetings.

TRIAL REGISTRATION NUMBER

NCT04973670.

Reducing Central Line-Associated Bloodstream Infections in a Burn Intensive Care Unit: Using a Business Framework for Quality Improvement

Central line-associated bloodstream infections (CLABSIs) pose a unique risk in burn patients, with rates of infection 2-3 times that of other Intensive Care Unit (ICU) populations. Here we present a detailed account of our experience in reducing CLABSI rates utilizing a business framework called the Four Disciplines of Execution (4DX). The Burn ICU CLABSI rate had risen to the 90th percentile nationally when compared to other burn units on the National Healthcare Safety Network. We applied the 4DX framework. This is a four-step method which includes creating a Wildly Important Goal, establishing measurable and accomplishable process measures, creating a scoreboard, and using a weekly meeting to provide accountability. Process changes included both physician and nursing practices. The physicians changed the criteria for when to order blood cultures, as well as requiring attending approval for cultures. The nurses engaged in a peer-observation practice improvement for "scrub the hub" and line dressing conditions and improved their own expertise for peripheral IV placement. The multidisciplinary team initiated a daily review of line indications to ensure removal as soon as possible. Overall, the CLABSI rate decreased from 7.39 infections per 1000 line days to 2.29 infections per 1000 line days over 1 year. We subsequently achieved over 635 days without a CLABSI. In conclusion, the 4DX was a successful quality improvement technique in our healthcare context. Because of the simplicity of implementation, we think it is broadly applicable in the healthcare setting.

Preventing the overdiagnosis of chest sepsis in children: A quality improvement project

RATIONALE

Respiratory infections in children are one of the most common causes of hospital attendances and a common cause of sepsis. Most of these infections turn out to be viral in nature. However, the overuse of antibiotics is common and with increasing problems with antimicrobial resistance, changes to antibiotic prescribing practices need to be implemented urgently.

AIMS AND OBJECTIVES

To test our hypothesis that a significant number of children and young people are diagnosed with and treated for 'chest sepsis' unnecessarily by evaluating adherence to British Thoracic Society and National Institute of Clinical Excellence sepsis guidelines, and to implement measures to prevent overdiagnosis.

DESIGN

A baseline audit undertaken, stratified patient risk as per NICE sepsis guidelines. Data were analysed to assess adherence to these guidelines following presentation of possible lower respiratory tract infection. Questionnaires were sent to Paediatric doctors in local hospitals and focus groups were held to qualitatively evaluate the barriers and facilitators to preventing overdiagnosis. These informed implemented measures.

RESULTS

The baseline audit showed 61% of children under two, who are more likely to have a viral chest infection were treated with intravenous antibiotics. Seventy-seven percent of children had blood tests and 88% had chest X-rays (CXRs) which are not routinely recommended. A total of 71% with a normal CXR had been treated with intravenous antibiotics. Barriers to preventing overdiagnosis included the over-sensitivity of the sepsis tool, anxiety and drug prescribing habits. Facilitators included visual cues and team work. Implemented changes including a revised sepsis pathway and raising awareness led to some positive changes. However, upon re-auditing there was no significant change in the number of children being overdiagnosed.

CONCLUSIONS

Initial audit results supported our hypothesis that children were being overdiagnosed, over-investigated and over-treated. Despite multimodal interventions aimed at understanding the drivers underpinning these issues, the re-audit results mirrored the baseline audit despite a transient improvement following our campaign to raise awareness and further work to change physician behaviour is required.

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care

Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain.

Using a Comprehensive On-Site Assessment Process to Reduce Central Line-Associated Bloodstream Infection Rates

Central line-associated bloodstream infection (CLABSI) rates increased substantially in the United States following the emergence of COVID-19 and subsequent surges. The pandemic resulted in hospital capacities being exceeded and crisis standards of care being implemented for sustained periods. As COVID-19 rates in the United States began to stabilize, some facilities did not return to previous CLABSI rates, indicating a change in practices that had a longer-term impact on CLABSI prevention. The authors' large health care system observed similar increases in CLABSI following the emergence of COVID-19, prompting investigation and intervention in the form of a quality improvement project. To identify changes related to ongoing increases in CLABSI, an assessment team conducted standardized on-site assessments at 11 facilities. Site assessments were considered an intervention, as they involved rigorous preassessment investigations and interviews, case reviews, practice observations, on-site staff interviews, and postassessment support for additional interventions. Nine facilities had enough postassessment data to analyze the impact of intervention. The overall CLABSI rate (infections per 1000 line days) at the 9 facilities in the 6 months prior to intervention was 1.42, and the postassessment rate in the 6 months following intervention was 0.44. This indicates the effectiveness of facility-specific investigation followed by targeted performance improvements to reduce the rate of CLABSI.

Research Progress of Macromolecules in the Prevention and Treatment of Sepsis

Sepsis is associated with high rates of mortality in the intensive care unit and accompanied by systemic inflammatory reactions, secondary infections, and multiple organ failure. Biological macromolecules are drugs produced using modern biotechnology to prevent or treat diseases. Indeed, antithrombin, antimicrobial peptides, interleukins, antibodies, nucleic acids, and lentinan have been used to prevent and treat sepsis. In vitro, biological macromolecules can significantly ameliorate the inflammatory response, apoptosis, and multiple organ failure caused by sepsis. Several biological macromolecules have entered clinical trials. This review summarizes the sources, efficacy, mechanism of action, and research progress of macromolecular drugs used in the prevention and treatment of sepsis.

Research Progress on Natural Small-Molecule Compounds for the Prevention and Treatment of Sepsis

Sepsis is a serious disease with high mortality and has been a hot research topic in medical research in recent years. With the continuous reporting of in-depth research on the pathological mechanisms of sepsis, various compounds have been developed to prevent and treat sepsis. Natural small-molecule compounds play vital roles in the prevention and treatment of sepsis; for example, compounds such as resveratrol, emodin, salidroside, ginsenoside, and others can modulate signaling through the NF-κB, STAT3, STAT1, PI3K, and other pathways to relieve the inflammatory response, immunosuppression, and organ failure caused by sepsis. Here, we discuss the functions and mechanisms of natural small-molecule compounds in preventing and treating sepsis. This review will lay the theoretical foundation for discovering new natural small-molecule compounds that can potentially prevent and treat sepsis.

Implementation of a 24-hour empiric antibiotic duration for negative early-onset sepsis evaluations to reduce early antibiotic exposure in premature infants

OBJECTIVE

Antibiotic exposure increases the risk of morbidity and mortality in premature infants. Many centers use at least 48 hours of antibiotics in the evaluation of early-onset sepsis (EOS, <72 hours after birth), yet most important pathogens grow within 24 hours. We investigated the safety and efficacy of reducing empiric antibiotic duration to 24 hours.

DESIGN

Quality improvement study.

SETTING

A tertiary-care neonatal intensive care unit.

PATIENTS

Inborn infants <35 weeks gestational age at birth (ie, preterm) admitted January 2019 through December 2020.

INTERVENTION

In December 2019, we changed the recommended duration of empiric antibiotics for negative EOS evaluations from 48 hours to 24 hours.

RESULTS

Patient characteristics before and after the intervention were similar. After the intervention, 71 preterm infants (57%) with negative EOS evaluations received ≤24 hours of antibiotics, an increase from 15 (10%) before the intervention. These 71 infants comprised 77% of infants with negative EOS blood cultures after excluding those treated as clinical sepsis (≥5 days of antibiotics). For all negative EOS blood cultures, the mean treatment duration decreased by 0.5 days from 3.9 days to 3.4 days. This finding equated to 2.4 fewer antibiotic days per 100 patient days for negative EOS blood cultures but similar antibiotic days per 30 patient days (7.2 days vs 7.5 days). This measure did not change over time. Subsequent sepsis evaluations <7 days after a negative EOS blood culture did not increase. Excluding contaminants, the median time to positivity was 13.2 hours (range, 8-23) in 8 positive blood cultures.

CONCLUSION

Implementation of a 24-hour antibiotic course for negative EOS evaluations safely reduced antibiotic exposure in 77% of infants <35 weeks gestational age at birth in whom EOS was ruled out. All clinically significant pathogens grew within 24 hours.

Effects of implementation of healthcare associated infection surveillance and interventional measures in the neonatal intensive care unit: Small steps matter

PURPOSE

Neonatal sepsis has been a global concern considering the mortality and morbidity. This study was undertaken to determine the effects of implementation of interventions namely healthcare associated infection (HAI) surveillance and hand hygiene (HH) monitoring in the neonatal intensive care unit (NICU).

MATERIALS AND METHODS

The cohort study was conducted in the NICU of a tertiary care hospital over a period of June-September 2021 (pre-intervention) to October-March 2022 (post-intervention). HAI surveillance of primary bloodstream infections (BSI) and HH monitoring was initiated as interventions post outbreak due to non-albicans Candida (NAC). The primary outcome of the interventions was to record any improvement in HH rates or any change in HAI rates in the 6 months intervention period. Characteristics of the pre- and post-intervention period were compared by Fisher exact test.

RESULTS

There was significant reduction in BSI cases in the post-intervention period (p ​< ​0.05). Mortality and BSI due to NAC were significantly more in the pre-intervention period even though low birth weight neonates (<2500 ​g) were significantly more in the post-intervention period (p ​< ​0.05). The HAI rate for primary BSI in the NICU was 10.82 per 1000 patient days. The overall adherence rate to HH was 10.68% (complete) and 73.35% (partial). HAI rates were seen to change reciprocally with changes in HH rates.

CONCLUSIONS

HAI rates of primary BSI in the NICU could be regulated by the effective implementation of HAI surveillance, HH monitoring, feedback meetings with the NICU staff and other simple interventional measures even in resource-limited setups.

Monoclonal antibodies against lipopolysaccharide protect against Pseudomonas aeruginosa challenge in mice

Pseudomonas aeruginosa is a common cause of hospital-acquired infections, including central line-associated bloodstream infections and ventilator-associated pneumonia. Unfortunately, effective control of these infections can be difficult, in part due to the prevalence of multi-drug resistant strains of P. aeruginosa. There remains a need for novel therapeutic interventions against P. aeruginosa, and the use of monoclonal antibodies (mAb) is a promising alternative strategy to current standard of care treatments such as antibiotics. To develop mAbs against P. aeruginosa, we utilized ammonium metavanadate, which induces cell envelope stress responses and upregulates polysaccharide expression. Mice were immunized with P. aeruginosa grown with ammonium metavanadate and we developed two IgG2b mAbs, WVDC-0357 and WVDC-0496, directed against the O-antigen lipopolysaccharide of P. aeruginosa. Functional assays revealed that WVDC-0357 and WVDC-0496 directly reduced the viability of P. aeruginosa and mediated bacterial agglutination. In a lethal sepsis model of infection, prophylactic treatment of mice with WVDC-0357 and WVDC-0496 at doses as low as 15 mg/kg conferred 100% survival against challenge. In both sepsis and acute pneumonia models of infection, treatment with WVDC-0357 and WVDC-0496 significantly reduced bacterial burden and inflammatory cytokine production post-challenge. Furthermore, histopathological examination of the lungs revealed that WVDC-0357 and WVDC-0496 reduced inflammatory cell infiltration. Overall, our results indicate that mAbs directed against lipopolysaccharide are a promising therapy for the treatment and prevention of P. aeruginosa infections.