Microbial resistance: lessons from the EPIC study

In 1992, a one day point prevalence study (EPIC) was conducted in European intensive care units (ICUs) to determine the prevalence of nosocomial infection among ICU patients. Of the 10,038 patients included, 45 % were infected and 21 % had a nosocomial ICU-acquired infection. Many of the organisms responsible for these infections were resistant to commonly used antibiotics. For example, 60 % of the Staphylococcus aureus isolated were resistant to methicillin and 46 % of Pseudomonas aeruginosa were resistant to gentamicin. The incidence of nosocomial infection varied between countries as did the incidence of antibiotic resistance. Mortality rates were higher in countries with higher rates of nosocomial infection and higher again in those countries with higher rates of resistant organisms. Antibiotic resistance is rising and clearly efforts to contain its development and spread are vital. Basic infection control procedures such as hand-washing must be developed and implemented, and antibiotic prescribing needs to be rationalized. The international variations in resistance rates, even within Europe, highlight the importance of being familiar with local resistance patterns when prescribing. The assistance of an infectious diseases specialist can be invaluable in providing a global overview of the local microbial milieu and of antibiotic resistance patterns. Epidemiological studies of this sort can provide useful information which can be used to stimulate debate on the reasons behind regional differences in infection and help in the development of strategies to combat the rising tide of microbial antibiotic resistance.     

Microbial resistance: lessons from the EPIC study. European Prevalence of Infection

In 1992, a one day point prevalence study (EPIC) was conducted in European intensive care units (ICUs) to determine the prevalence of nosocomial infection among ICU patients. Of the 10,038 patients included, 45% were infected and 21% had a nosocomial ICU-acquired infection. Many of the organisms responsible for these infections were resistant to commonly used antibiotics. For example, 60% of the Staphylococcus aureus isolated were resistant to methicillin and 46% of Pseudomonas aeruginosa were resistant to gentamicin. The incidence of nosocomial infection varied between countries as did the incidence of antibiotic resistance. Mortality rates were higher in countries with higher rates of nosocomial infection and higher again in those countries with higher rates of resistant organisms. Antibiotic resistance is rising and clearly efforts to contain its development and spread are vital. Basic infection control procedures such as hand-washing must be developed and implemented, and antibiotic prescribing needs to be rationalized. The international variations in resistance rates, even within Europe, highlight the importance of being familiar with local resistance patterns when prescribing. The assistance of an infectious diseases specialist can be invaluable in providing a global overview of the local microbial milieu and of antibiotic resistance patterns. Epidemiological studies of this sort can provide useful information which can be used to stimulate debate on the reasons behind regional differences in infection and help in the development of strategies to combat the rising tide of microbial antibiotic resistance.     

Intervention fidelity: lessons learned from an unsuccessful pilot study.

Although the design of the study we undertook was randomized, the groups were statistically similar, the intervention was based on evidence of previous efficacy, and the treatment was delivered exactly as planned, this pilot study on an intervention to promote motivation for weight loss in new mothers failed to produce an effect. A closer examination using criteria for intervention fidelity revealed a number of weaknesses. Both treatment integrity and differentiation merit careful consideration in intervention design.     

Renal dialysis abatement: lessons from a social study

AIM: This study aimed to examine the reasons why some people chose to abate (i.e., stop or not start) renal dialysis, together with the personal and social impact of this decision on the person concerned, and/or their families. METHOD: A qualitative design based on the principles of Grounded Theory was employed. Semi-structured interviews were conducted with sixteen patients and/or carers (depending on whether the patient was able to be interviewed) where the issue of dialysis abatement was being considered, or had recently been decided. RESULTS: Of 52 participants considered for entry into the study 41 were ineligible, with impaired cognition, rapid medical deterioration, and inability to speak sufficient English being the main reasons for exclusion. The desire not to burden others and the personal experience of a deteriorating quality of life were crucial elements in the decision to stop or decline dialysis. The problem of prognostic uncertainty and a sense of abandonment were also prominently expressed. CONCLUSIONS: From this small Australian sample, it appears that there would be considerable potential benefit from a more proactive and open approach to end-of-life issues, with incorporation of the clinical and health promoting principles of palliative care into renal dialysis practice. The high number of exclusions shows how sick and unstable this population of patients is, but the issue of data gathering from people whose main language is not English requires attention.     

Organization of intensive care units in Europe: lessons from the EPIC study

Objective: To study differences related to intensive care unit (ICU) structure and patient demography between the various countries of Western Europe. Design: Application of data collected by the European Prevalence of Infection in Intensive Care (EPIC) study, a one-day prevalence study. Setting: Voluntary participation of all Western European ICUs. A total of 1417 ICUs responded. Patients: All patients, older than 10 years of age, occupying a bed in the participating ICUs over a 24-h period. 10 038 patient case reports were submitted. Results: The study revealed important differences. In particular, there seems to be a north/south divide with fewer ICU beds and more severely ill patients in the south. The United Kingdom seemed more similar to southern European countries than to the north. Conclusion: While there are similarities between European countries, large differences still remain and are important to identify to enable us to work together to create a more uniform system of intensive care, which will in turn give more effective and efficient patient care. Received: 7 February 1997 Accepted 8 July 1997     

Influencing physician distribution in the South: lessons from a study in Texas

Analysis of recent and projected trends in the geographic distribution of Texas physicians indicates that maldistribution may continue to be a problem into the foreseeable future. A survey of manpower officials in other southern states and a review of research on the effectiveness of various policy interventions reveals that programs involving preferential medical school admissions and Medicaid reimbursement levels may hold the most promise for Texas and other southern states seeking to alleviate physician maldistribution.     

Moral lessons from the jury box

A decade ago a North Carolina jury awarded millions of dollars in damages because of a healthcare institution's failure to provide appropriate pain relief to a dying patient. In 2001, a California jury found a physician guilty of elder abuse for his failure to properly manage the pain of a cancer patient. In both instances, state licensing boards had failed to take any disciplinary action against those involved. These cases dramatically illustrate a significant and persistent gulf between the lay public and the health professions with regard to the moral significance they attach to the duty to relieve suffering. Measures to insure that all patients receive effective assessment and management of their pain must take into account this disparity, and endeavor to achieve congruence by reconnecting the health professions to their ancient and core value--the relief of suffering.