RESUMEN
We conducted a comparative retrospective study to quantify the impact of coronavirus disease 2019 (COVID-19) on patient safety. We found a statistically significant increase in central-line-associated bloodstream infections and blood culture contamination rates during the pandemic. Increased length of stay and mortality were also observed during the COVID-19 pandemic.
Asunto(s)
COVID-19 , Sepsis , Cultivo de Sangre , Humanos , Pandemias , Estudios Retrospectivos , SARS-CoV-2RESUMEN
We describe 9 patients at a medical center in Detroit, Michigan, USA, with severe acute respiratory syndrome coronavirus 2 and Clostridioides difficile. Both infections can manifest as digestive symptoms and merit screening when assessing patients with diarrhea during the coronavirus disease pandemic. These co-infections also highlight the continued importance of antimicrobial stewardship.
Asunto(s)
Betacoronavirus , Clostridioides difficile , Infecciones por Clostridium/epidemiología , Coinfección/epidemiología , Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Adulto , Anciano , Antibacterianos/efectos adversos , Programas de Optimización del Uso de los Antimicrobianos , COVID-19 , Infecciones por Clostridium/inducido químicamente , Infecciones por Clostridium/microbiología , Coinfección/microbiología , Infecciones por Coronavirus/microbiología , Femenino , Humanos , Masculino , Michigan/epidemiología , Persona de Mediana Edad , Pandemias , Neumonía Viral/microbiología , Vigilancia de la Población , SARS-CoV-2RESUMEN
BACKGROUND: Basins used for patient bathing have been shown to be contaminated with multidrug-resistant organisms (MDROs) and have prompted the evaluation of alternatives to soap and water bathing methods. METHODS: We conducted a prospective, randomized, open-label interventional crossover study to assess the impact of replacing traditional bath basins with prepackaged washcloths on the incidence of hospital-associated infections (HAIs), MDROs, and secondarily, rates of skin deterioration. Unit-wide use of disposable washcloths over an 8-month period was compared with an 8-month period of standard care using basins. RESULTS: A total of 2,637 patients were included from 2 medical-surgical units at a single tertiary medical center, contributing 16,034 patient days. During the study period, there were a total of 33 unit-acquired infections, the rates of which were not statistically different between study phases (incidence rate ratio, 1.05; 95% confidence interval [CI], 0.50-2.23; P = .88). However, occurrence of skin integrity deterioration was significantly less in the intervention group (odds ratio, 0.44; 95% CI, 0.22-0.88; P = .02). CONCLUSIONS: Although we were unable to demonstrate a significant reduction in HAI or MDRO acquisition, we found a decrease in skin deterioration with the use of disposable washcloths and confirmed earlier findings of MDRO contamination of wash basins.
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Baños/métodos , Ropa de Cama y Ropa Blanca , Infección Hospitalaria/prevención & control , Infecciones Cutáneas Estafilocócicas/prevención & control , Adulto , Antiinfecciosos Locales/farmacología , Infección Hospitalaria/microbiología , Infección Hospitalaria/transmisión , Estudios Cruzados , Desinfectantes/farmacología , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Staphylococcus aureus Resistente a Meticilina/patogenicidad , Staphylococcus aureus Resistente a Meticilina/fisiología , Persona de Mediana Edad , Estudios Prospectivos , Infecciones Cutáneas Estafilocócicas/tratamiento farmacológico , Infecciones Cutáneas Estafilocócicas/microbiología , Infecciones Cutáneas Estafilocócicas/transmisiónRESUMEN
OBJECTIVE: To assess the impact of active alerting of positive blood culture data coupled with stewardship intervention on time to appropriate therapy, length of stay, and mortality in patients with gram-negative bacteremia. DESIGN: Quasi-experimental retrospective cohort study in patients with gram-negative bacteremia at the Detroit Medical Center from 2009 to 2011. SETTING: Three hospitals (1 community, 2 academic) with active antimicrobial stewardship programs within the Detroit Medical Center. PATIENTS: All patients with monomicrobial gram-negative bacteremia during the study period. INTERVENTION: Active alerting of positive blood culture data coupled with stewardship intervention (2010-2011) compared with patients who received no formalized stewardship intervention (2009). RESULTS: Active alerting and intervention led to a decreased time to appropriate therapy (8 [interquartile range (IQR), 2-24] vs 14 [IQR, 2-35] hours; P = .014) in patients with gram-negative bacteremia. After controlling for differences between groups, being in the intervention arm was associated with an independent reduction in length of stay (odds ratio [OR], 0.73 [95% confidence interval (CI), 0.62-0.86]), correlating to a median attributable decrease in length of stay of 2.2 days. Additionally, multivariate modeling of patients who were not on appropriate antimicrobial therapy at the time of initial culture positivity showed that patients in the intervention group had a significant reduction in both length of stay (OR, 0.76 [95% CI, 0.66-0.86]) and infection-related mortality (OR, 0.24 [95% CI, 0.08-0.76]). CONCLUSIONS: Active alerting coupled with stewardship intervention in patients with gram-negative bacteremia positively impacted time to appropriate therapy, length of stay, and mortality and should be a target of antimicrobial stewardship programs.
Asunto(s)
Antibacterianos , Bacteriemia/tratamiento farmacológico , Infección Hospitalaria/tratamiento farmacológico , Revisión de la Utilización de Medicamentos , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Tiempo de Internación , Sistemas Recordatorios , Centros Médicos Académicos/estadística & datos numéricos , Antibacterianos/uso terapéutico , Bacteriemia/microbiología , Infección Hospitalaria/microbiología , Femenino , Bacterias Gramnegativas/efectos de los fármacos , Infecciones por Bacterias Gramnegativas/microbiología , Hospitales Comunitarios/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
BACKGROUND: Gender reassignment surgery (i.e., male-to-female or female-to-male) entails a series of complex surgical procedures. We conducted a study to explore epidemiologic characteristics of patients who underwent genital reconstruction operations as components of gender reassignment and to analyze risk factors for surgical-site infections (SSIs) following these operations. METHODS: The study was a retrospective cohort study conducted from 1984-2008 at Harper University Hospital, a tertiary hospital with 625 beds in Detroit, Michigan. Surgical site infection was defined according to established criteria. RESULTS: Records were available for 82 patients who underwent a total of 1,383 operations as part of genital-reconstruction processes. Thirty-nine (47.6%) of the patients underwent female-to-male reassignment (FTM) and 43 (52.4%) underwent male-to-female reassignment (MTF). The average age of the study cohort was 39.5±9.8 y. Of the patients in the cohort, 56 (68.3%) were Caucasian and 67 (81.7%) were single. The average number of operative encounters per patient was 11.8±4.6 for FTM and 4.9±2.4 for MTF. Forty-three (52.4%) patients developed an SSI at least once during their genital reconstruction process, of whom 34 (87%) were in the FTM group and nine (21%) in the MTF group (p<0.001). Staphylococci were the most common pathogens (61%) isolated in these infections, followed by Enterobacteriaceae (50%), Enterococcus (39%), and Pseudomonas aeruginosa (33.3%). Surgical site infection was associated independently with an increased frequency of operative procedures and operating room encounters. CONCLUSIONS: More than 50% of patients who underwent genital reconstruction operations developed an SSI at some point during the genital reconstruction process. Surgical site infections are more common in FTM than in MTF reconstruction operations, and for both FTM and MTF, SSIs are associated independently with an increased frequency of total operative procedures and encounters.
Asunto(s)
Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Cirugía de Reasignación de Sexo/efectos adversos , Cirugía de Reasignación de Sexo/estadística & datos numéricos , Infección de la Herida Quirúrgica/epidemiología , Adulto , Bacterias/aislamiento & purificación , Femenino , Hongos/aislamiento & purificación , Genitales/cirugía , Humanos , Masculino , Michigan/epidemiología , Persona de Mediana Edad , Análisis Multivariante , Factores de Riesgo , Infección de la Herida Quirúrgica/microbiologíaRESUMEN
A case-case-control study was conducted to identify independent risk factors for recovery of Escherichia coli strains producing CTX-M-type extended-spectrum ß-lactamases (CTX-M E. coli) within a large Southeastern Michigan medical center. Unique cases with isolation of ESBL-producing E. coli from February 2010 through July 2011 were analyzed by PCR for blaCTX-M, blaTEM, and blaSHV genes. Patients with CTX-M E. coli were compared to patients with E. coli strains not producing CTX-M-type ESBLs (non-CTX-M E. coli) and uninfected controls. Of 575 patients with ESBL-producing E. coli, 491 (85.4%) isolates contained a CTX-M ESBL gene. A total of 319 (84.6%) patients with CTX-M E. coli (282 [74.8%] CTX-M-15 type) were compared to 58 (15.4%) non-CTX-M E. coli patients and to uninfected controls. Independent risk factors for CTX-M E. coli isolation compared to non-CTX-M E. coli included male gender, impaired consciousness, H2 blocker use, immunosuppression, and exposure to penicillins and/or trimethoprim-sulfamethoxazole. Compared to uninfected controls, independent risk factors for isolation of CTX-M E. coli included presence of a urinary catheter, previous urinary tract infection, exposure to oxyimino-cephalosporins, dependent functional status, non-home residence, and multiple comorbid conditions. Within 48 h of admission, community-acquired CTX-M E. coli (n = 51 [16%]) and non-CTX-M E coli (n = 11 [19%]) strains were isolated from patients with no recent health care contacts. CTX-M E. coli strains were more resistant to multiple antibiotics than non-CTX-M E. coli strains. CTX-M-encoding genes, especially bla(CTX-M-15) type, represented the most common ESBL determinants from ESBL-producing E. coli, the majority of which were present upon admission. Septic patients with risk factors for isolation of CTX-M E. coli should be empirically treated with appropriate agents. Regional infection control efforts and judicious antibiotic use are needed to control the spread of these organisms.
Asunto(s)
Infecciones por Escherichia coli/epidemiología , Proteínas de Escherichia coli/metabolismo , Escherichia coli/aislamiento & purificación , beta-Lactamasas/metabolismo , Anciano , Anciano de 80 o más Años , Atención Ambulatoria , Estudios de Casos y Controles , Ciprofloxacina/farmacología , Infecciones Comunitarias Adquiridas/microbiología , Farmacorresistencia Bacteriana Múltiple , Escherichia coli/efectos de los fármacos , Escherichia coli/enzimología , Escherichia coli/genética , Infecciones por Escherichia coli/tratamiento farmacológico , Proteínas de Escherichia coli/genética , Femenino , Genes Bacterianos , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Combinación Trimetoprim y Sulfametoxazol/farmacología , Estados Unidos/epidemiología , Catéteres Urinarios/microbiología , Infecciones Urinarias/microbiología , beta-Lactamasas/genéticaRESUMEN
BACKGROUND: Guidelines recommend that agents other than vancomycin be considered for some types of infection due to methicillin-resistant Staphylococcus aureus (MRSA) when the minimum inhibitory concentration (MIC) to vancomycin is 2 µg/mL or more. Alternative therapeutic options include daptomycin and linezolid, 2 relatively new and expensive drugs, and trimethoprim/sulfamethoxazole (TMP/SMX), an old and inexpensive agent. OBJECTIVE: To compare the clinical efficacy and potential cost savings associated with use of TMP/SMX compared to linezolid and daptomycin. METHODS: A retrospective study was conducted at Detroit Medical Center. For calendar year 2009, unique adults (age >18 years) with infections due to MRSA with an MIC to vancomycin of 2 µg/mL were included if they received 2 or more doses of TMP/SMX and/or daptomycin and/or linezolid. Data were abstracted from patient charts and pharmacy records. RESULTS: There were 328 patients included in the study cohort: 143 received TMP/SMX alone, 89 received daptomycin alone, 75 received linezolid alone, and 21 patients received a combination of 2 or more of these agents. In univariate analysis, patients who received TMP/SMX alone had significantly better outcomes, including in-hospital (p = 0.003) and 90-day mortality (p < 0.001) compared to patients treated with daptomycin or linezolid. Patients receiving TMP/SMX were also younger (p < 0.001), had fewer comorbid conditions (p < 0.001), had less severe acute severity of illness (p < 0.001), and received appropriate therapy more rapidly (p = 0.001). In multivariate models the association between TMP/SMX treatment and mortality was no longer significant. Antimicrobial cost savings associated with using TMP/SMX averaged $2067.40 per patient. CONCLUSIONS: TMP/SMX monotherapy compared favorably to linezolid and daptomycin in terms of treatment efficacy and mortality. Use of TMP/SMX instead of linezolid or daptomycin could potentially significantly reduce antibiotic costs. TMP/SMX should be considered for the treatment of MRSA infection with MIC of 2 µg/mL to vancomycin.
Asunto(s)
Antibacterianos/uso terapéutico , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Infecciones Estafilocócicas/tratamiento farmacológico , Acetamidas/administración & dosificación , Acetamidas/economía , Acetamidas/uso terapéutico , Adulto , Factores de Edad , Anciano , Antibacterianos/administración & dosificación , Antibacterianos/economía , Estudios de Cohortes , Ahorro de Costo , Daptomicina/administración & dosificación , Daptomicina/economía , Daptomicina/uso terapéutico , Costos de los Medicamentos , Femenino , Humanos , Linezolid , Masculino , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Análisis Multivariante , Oxazolidinonas/administración & dosificación , Oxazolidinonas/economía , Oxazolidinonas/uso terapéutico , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Infecciones Estafilocócicas/economía , Infecciones Estafilocócicas/microbiología , Factores de Tiempo , Resultado del Tratamiento , Combinación Trimetoprim y Sulfametoxazol/administración & dosificación , Combinación Trimetoprim y Sulfametoxazol/economía , Combinación Trimetoprim y Sulfametoxazol/uso terapéutico , Vancomicina/administración & dosificación , Vancomicina/farmacologíaRESUMEN
Linezolid is an important agent for the treatment of infections because of vancomycin-resistant Enterococcus (VRE). This study identified independent predictors for isolation of linezolid-resistant VRE (LZD-R-VRE) and analyzed outcomes associated with linezolid resistance. Immunosuppression, prior surgery, and previous exposure to ß-lactam antibiotics were independent predictors for isolation of LZD-R-VRE but not for LZD-susceptible-VRE. Prior exposure to linezolid was not a predictor for isolation of LZD-R-VRE.
Asunto(s)
Acetamidas/uso terapéutico , Farmacorresistencia Bacteriana , Enterococcus/efectos de los fármacos , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Infecciones por Bacterias Grampositivas/epidemiología , Oxazolidinonas/uso terapéutico , Vancomicina/farmacología , Acetamidas/farmacología , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Enterococcus/aislamiento & purificación , Femenino , Infecciones por Bacterias Grampositivas/microbiología , Humanos , Linezolid , Masculino , Persona de Mediana Edad , Oxazolidinonas/farmacología , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Therapeutic options are limited for infections because of Acinetobacter baumannii and carbapenem-resistant Enterobacteriaceae (CRE). Study aim was to compare the efficacy of colistin to tigecycline for the treatment of these types of infections. METHODS: A retrospective study was conducted at the Detroit Medical Center. Adult patients with infections because of A baumannii or CRE in 2009 who received ≥2 doses of colistin or tigecycline were studied. Risk factors, outcomes, and costs were analyzed. RESULTS: There were 82 patients with infections because of A baumannii, 12 with CRE, and 12 with A baumannii and CRE coinfection. Seventy-one patients received colistin, 16 received tigecycline, and 19 received both colistin and tigecycline. Seven isolates were nonsusceptible to colistin and 79 to tigecycline. Patients receiving colistin alone or in combination were more likely to die during their hospitalization than patients receiving only tigecycline (P = .002). However, patients receiving colistin had higher severity of acute illness and had notable delays in initiation of effective antimicrobial therapy (P < .001). CONCLUSION: Compared with patients who received tigecycline alone, patients who received colistin alone or in combination had a higher severity of acute illness indices and delays in initiation of effective therapy. This increased severity of illness contributed to the increased rate of mortality among patients treated with colistin for A baumannii or CRE infections.
Asunto(s)
Infecciones por Acinetobacter/tratamiento farmacológico , Antibacterianos/uso terapéutico , Colistina/uso terapéutico , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Minociclina/análogos & derivados , Resistencia betalactámica , Acinetobacter baumannii/efectos de los fármacos , Adulto , Anciano , Antibacterianos/farmacología , Carbapenémicos/farmacología , Estudios de Casos y Controles , Estudios de Cohortes , Enterobacteriaceae/efectos de los fármacos , Infecciones por Enterobacteriaceae/microbiología , Femenino , Humanos , Masculino , Michigan , Persona de Mediana Edad , Minociclina/uso terapéutico , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Tigeciclina , Resultado del TratamientoRESUMEN
Ertapenem is active against extended-spectrum-ß-lactamase (ESBL)-producing Enterobacteriaceae organisms but inactive against Pseudomonas aeruginosa and Acinetobacter baumannii. Due to a lack of therapeutic data for ertapenem in the treatment of ESBL bloodstream infections (BSIs), group 2 carbapenems (e.g., imipenem or meropenem) are often preferred for treatment of ESBL-producing Enterobacteriaceae, although their antipseudomonal activity is unnecessary. From 2005 to 2010, 261 patients with ESBL BSIs were analyzed. Outcomes were equivalent between patients treated with ertapenem and those treated with group 2 carbapenems (mortality rates of 6% and 18%, respectively; P = 0.18).
Asunto(s)
Antibacterianos/uso terapéutico , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Enterobacteriaceae/efectos de los fármacos , beta-Lactamasas/metabolismo , beta-Lactamas/uso terapéutico , Anciano , Estudios de Cohortes , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/microbiología , Farmacorresistencia Bacteriana , Enterobacteriaceae/enzimología , Infecciones por Enterobacteriaceae/microbiología , Ertapenem , Infecciones por Escherichia coli/tratamiento farmacológico , Infecciones por Escherichia coli/microbiología , Femenino , Humanos , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/microbiología , Klebsiella pneumoniae , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Long-term acute care (LTAC) facilities admit patients with complex, advanced disease states. Study aims were to determine the burden posed on hospitals associated with LTAC exposure and analyze the differences between "present on admission" (POA) multidrug-resistant (MDR), gram-negative organisms (GNO) and POA MDR gram-positive organisms (GPO). METHODS: A multicenter retrospective study was conducted in 13 hospitals from southeast Michigan, from September 1, 2008, to August 31, 2009. Cultures obtained in the first 72 hours of hospitalization (ie, POA) of MDR-GPO and MDR-GNO were reviewed. LTAC exposures in the previous 6 months and direct admission from a LTAC were recorded. RESULTS: Overall, 5,297 patients with 7,147 MDR POA cultures were analyzed: 2,619 (36.6%) were MDR-GNO, and 4,528 (63.4%) were MDR-GPO. LTAC exposure in the past 6 months was present in 251 (5.2%) infectious episodes and was significantly more common among POA MDR-GNO than MDR-GPO (158 [8.6%] and 94 [3.1%], respectively, odds ratio, 2.87; P < .001). Recent LTAC exposure was strongly associated with both carbapenem-resistant Enterobacteriaceae (CRE) (31.6% of all CRE cases, P < .001) and Acinetobacter baumannii (14.9% of all A baumannii cases, P < .001). CONCLUSION: Nearly 10% of MDR-GNO POA had recent LTAC exposure. Hospital efforts to control the spread of MDR-GNO should focus on collaborations and communications with referring LTACs and interventions targeted towards patients with recent LTAC exposure.
Asunto(s)
Antibacterianos/farmacología , Infección Hospitalaria/epidemiología , Bacterias Gramnegativas/efectos de los fármacos , Infecciones por Bacterias Gramnegativas/microbiología , Bacterias Grampositivas/efectos de los fármacos , Infecciones por Bacterias Grampositivas/microbiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Infección Hospitalaria/microbiología , Infección Hospitalaria/prevención & control , Farmacorresistencia Bacteriana Múltiple , Bacterias Gramnegativas/aislamiento & purificación , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Infecciones por Bacterias Gramnegativas/epidemiología , Bacterias Grampositivas/aislamiento & purificación , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Infecciones por Bacterias Grampositivas/epidemiología , Humanos , Cuidados a Largo Plazo , Michigan/epidemiología , Persona de Mediana Edad , Diálisis Renal , Estudios Retrospectivos , Centros de Atención Terciaria , Adulto JovenRESUMEN
The hospital environment is increasingly recognized as a reservoir for hospital-acquired pathogens. During a 44-month study period, a total of 1,103 basins from 88 hospitals in the United States and Canada were sampled. Overall, 62.2% of the basins (at least 1 basin at each hospital) were contaminated with commonly encountered hospital-acquired pathogens.
Asunto(s)
Bacterias/efectos de los fármacos , Bacterias/aislamiento & purificación , Baños , Farmacorresistencia Bacteriana Múltiple , Microbiología Ambiental , Canadá , Hospitales , Humanos , Estados UnidosRESUMEN
Carbapenem-resistant Klebsiella pneumoniae has spread worldwide and throughout the United States. Colistin is used extensively to treat infections with this organism. We describe a cluster of colistin-resistant, carbapenem-resistant K. pneumoniae infection cases involving three institutions in Detroit, MI. A cluster of five cases of colistin-resistant, carbapenem-resistant K. pneumoniae was identified at Detroit Medical Center (DMC) from 27 July to 22 August 2009. Epidemiologic data were collected, and transmission opportunities were analyzed. Isolates were genotyped by using pulsed-field gel electrophoresis and repetitive extragenic palindromic PCR. Data regarding the use of colistin were obtained from pharmacy records. The index case of colistin-resistant, carbapenem-resistant K. pneumoniae was followed 20 days later by four additional cases occurring in a 6-day interval. All of the patients, at some point, had stayed at one particular institution. The mean number of opportunities for transmission between patients was 2.3 ± 0.5, and each patient had at least one opportunity for transmission with one of the other patients. Compared to 60 colistin-susceptible, carbapenem-resistant K. pneumoniae controls isolated in the previous year at DMC, case patients were significantly older (P = 0.05) and the carbapenem-resistant K. pneumoniae organisms isolated from them displayed much higher MICs to imipenem (P < 0.001). Colistin use was not enhanced in the months preceding the outbreak. Genotyping revealed two closely related clones. This report of a colistin-resistant, carbapenem-resistant K. pneumoniae outbreak is strongly linked to patient-to-patient transmission. Controlling the spread and novel emergence of bacteria with this phenotype is of paramount importance.