Clinical epidemiology of central venous catheter–related bloodstream infections in an intensive care unit in China

Background

Central venous catheters (CVCs) are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk. At present, there are few studies on catheter-related bloodstream infections (CRBSIs) that are comparable with international similar research. The aim of this study was to determine the rate, risk factors, and outcomes of CRBSIs in patients of an intensive care unit (ICU) in China.

Methods

A prospective study was performed in the Affiliated Shengjing Hospital of China Medical University. All patients admitted to the ICU from June 2007 to May 2008 who had a central line placed were monitored for the development of BSI from insertion until 48 hours after removal. One hundred seventy-four patients with 178 admissions to the ICU, 219 CVCs and 1913 CVC days, 21 episodes of CRBSI in 21 patients were enrolled.

Results

The mean rate of CRBSI was 11.0 per 1000 CVC days with a catheter utilization rate of 72.8%. Analyses of the pathogens showed that gram-negative organisms were predominant. The univariate analysis showed that 3 things seemed to directly impact the occurrences of CRBSI. These were the number of lines insertion, the applications of antibiotics before CRBSI, and the duration of catheter. In a multiple logistic regression analysis of the risk factors, patients with multiple central lines (odds ratio = 5.981; 95% confidence intervals, 1.660-21.547; P = .006) and with the applications of multiple antibiotics before CRBSI (odds ratio = 6.335; 95% confidence interval, 2.001-20.054; P = .002) were more likely to develop CRBSI.

Conclusions

The CRBSI rate in our ICU is higher compared with that reported by the National Nosocomial Infection Surveillance and was associated with the applications of antibiotics before CRBSI and with the number of placed CVCs. Catheter-related bloodstream infections may be associated with a higher mortality rate and a higher incidence of ventilator-associated pulmonitis, which might lead to an increase in the total costs and medicine expenditures.     

Impact of a multidimensional approach on ventilator-associated pneumonia rates in a hospital of Shanghai: Findings of the International Nosocomial Infection Control Consortium

Purpose

The aim of this study was to analyze the impact of a multidimensional infection control approach on the reduction of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) patients of one hospital in China.

Materials and Methods

We conducted a before-after study from January 2005 to July 2009, which was divided into baseline (phase 1) and intervention (phase 2) periods. During phase 1, active prospective outcome surveillance of VAP was performed by applying the definitions of the Centers for Disease Control and Prevention/National Health Safety Network, and the methodology of the International Nosocomial Infection Control Consortium. During phase 2, the multidimensional approach was implemented. Ventilator-associated pneumonia rates obtained in phases 1 and 2 were compared in yearly periods.

Results

We recorded data from 16?429 patients hospitalized in 3 ICUs, for a total of 74?116 ICU bed days. The VAP baseline rate was 24.1 per 1000 ventilator-days. During phase 2, the VAP rate significantly decreased to 5.7 per 1000 ventilator-days in 2009 (2009 vs 2005: relative risk, 0.31; 95% confidence interval, 0.16-0.36; P = .0001), amounting to a 79% cumulative VAP rate reduction.

Conclusions

Implementing a multidimensional infection control intervention for VAP was associated with a significant cumulative reduction in the VAP rate in our ICUs.     

Injuries occurring in hospital staff attending medical emergency team (MET) calls—A prospective,observational study

Background

Clinical emergency response systems such as medical emergency teams (MET) have been implemented in many hospitals worldwide, but the effect that these systems have on injuries to hospital staff is unknown. The objective of this study was to determine the rate and nature of injuries occurring in hospital staff attending MET calls.

Methods

This study was a prospective, observational study, using a structured interview, of 1265 MET call participants, in a 650 bed urban, teaching hospital. Data was collected on the number and the nature of injuries occurring in hospital staff attending MET calls.

Results

Over 131 days, 248 MET calls were made. An average of 8.1 staff participated in each MET call. The overall injury rate was 13 (95% confidence interval (CI) 7–20) per 1000 MET participant attendances, and 70 (95% CI 38–102) per 1000 MET calls. One injured participant required time off-work, an injury requiring time off-work rate of 1 (95% CI 0–4) per 1000 MET participant attendances, or 4 (95% CI 0–27) per 1000 MET calls. The relative risk of sustaining an injury if the MET participant performed chest compressions, contacted patient body fluids on clothing or protective equipment, without direct contact to skin or mucosa, or lifted the patient or a patient body part was 11.0 (95% CI 4.2–28.6), 8.7 (95% CI 3.4–22.0) and 5.5 (95% CI 2.1–14.2), respectively.

Conclusion

The rate of injuries occurring to hospital staff attending MET calls is relatively low, and many injuries could be considered relatively minor.     

Predicting Bloodstream Infection via Systemic Inflammatory Response Syndrome or Biochemistry

Background

The yield of blood cultures is approximately 10%. This could be caused by inaccurate prediction of patients with bloodstream infection (BSI).

Objectives

To evaluate the usability of systemic inflammatory response syndrome (SIRS) or biochemical analyses as predictors for positive blood culture.

Methods

We conducted a prospective cohort study at a Danish regional hospital from February 1 to April 30, 2010. All adult patients were included on the first time blood cultures were sampled during admission. Data were obtained from medical records, databases on microbiology, biochemistry, and antibiotic treatment. Data included time of admission, date and result of blood culture, results of biochemical analyses, and clinical measurements on the day of blood culture. Prediction of BSI was analyzed according to both individual parameters and parameters combined in different sepsis score groups. Associations were calculated using multiple logistic regression.

Results

Patients with BSI (68 patients) were compared to patients without BSI (828 patients). Respiratory rate, body temperature, and C-reactive protein were strongest associated with BSI, with adjusted odds ratio (OR) 5.42, 95% confidence interval (CI) 1.13–25.9; OR 2.55, 95% CI 1.34–4.87; and OR 6.06, 95% CI 0.82–44.6, respectively. SIRS was associated with BSI, with crude OR 7.25, 95% CI 1.75–30.1. Neutrophil count and p-carbamide were not associated with BSI: adjusted OR 0.88, 95% CI 0.36–2.13 and OR 1.44, 95% CI 0.82–2.52, respectively. Only one of the sepsis score groups was associated with BSI: crude OR 2.13, 95% CI 1.08–4.19.

Conclusions

SIRS is an adequate predictor of BSI. By contrast, biochemical parameters were not useful as predictors of BSI.     

Diabetes mellitus and community-acquired bloodstream infections in the critically ill

Introduction

Community-acquired bloodstream infections have not been studied related to diabetes mellitus in the critically ill.

Hypothesis

We hypothesized that the diagnosis of diabetes mellitus and poor chronic glycemic control would increase the risk of community-acquired bloodstream infections (CA-BSIs) in the critically ill.

Methods

We performed an observational cohort study between 1998 and 2007 in 2 teaching hospitals in Boston, Massachusetts. We studied 2551 patients 18 years or older, who received critical care within 48 hours of admission and had blood cultures obtained within 48 hours of admission. The exposure of interest was diabetes mellitus defined by International Classification of Diseases, Ninth Revision, Clinical Modification, code 250.xx in outpatient or inpatient records. The primary end point was CA-BSI (< 48 hours of hospital admission). Patients with a single coagulase-negative Staphylococcus positive blood culture were not considered to have bloodstream infection. Associations between diabetes groups and bloodstream infection were estimated by bivariable and multivariable logistic regression models. Subanalyses included evaluation of the association between hemoglobin A1c (HbA1c) and bloodstream infection, diabetes and risk of sepsis, and the proportion of the association between diabetes and CA-BSI that was mediated by acute glycemic control.

Results

Diabetes is a predictor of CA-BSI. After adjustment for age, sex, race, patient type (medical vs surgical), and acute organ failure, the risk of bloodstream infection was significantly higher in patients with diabetes (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.10-1.82; P = .006) relative to patients without diabetes. The adjusted risk of bloodstream infection was increased in patients with HbA1c of 6.5% or higher (OR, 1.31; 95% CI, 1.04-1.65; P = .02) relative to patients with HbA1c less than 6.5%. Furthermore, the adjusted risk of sepsis was significantly higher in patients with diabetes (OR, 1.26; 95% CI, 1.04-1.54; P = .02) relative to patients without diabetes. Maximum glucose did not significantly mediate the relationship between diabetes mellitus diagnosis and CA-BSI.

Conclusions

A diagnosis of diabetes mellitus and HbA1c of 6.5% or higher is associated with the risk of CA-BSI in the critically ill.     

Incidence,risk factors and clinical outcomes of peripherally inserted central catheter spontaneous dislodgment in oncology patients: A prospective cohort study

Purpose

Peripherally inserted central catheter (PICC) spontaneous dislodgment is insidious in onset and prone to cause complications. We performed a prospective cohort study to examine the incidence, risk factors and clinical results of PICC spontaneous dislodgment in oncology patients to facilitate successful early diagnosis, prophylaxis and management.

Patients and methods

Consecutive oncology patients, undergoing placement of PICCs, were enrolled and prospectively followed up until their catheters were removed or PICC spontaneous dislodgment presented. The patients with PICC spontaneous dislodgment or catheter-associated thrombosis (CRT) were followed up for an extra three months from the date of diagnosis. The main endpoint was PICC spontaneous dislodgment, and the sub-endpoints were CRT and catheter in-place time. The PICC insertion team, nurses, interventional radiologists and oncology doctors collected longitudinal data.

Results

Over a total of 60,894 days of cumulative follow-up, 21 out of 510 PICCs presented spontaneous dislodgment, leading to an incidence rate of 4.12%. The CRT rate of the group with PICC spontaneous dislodgment was much higher than that of the group without PICC spontaneous dislodgment (RR = 17.46, 95% CI: 8.29–36.82, p = 1.09 × 10⁻¹⁷). Five baseline exposure factors, including primary lung cancer, metastatic lung cancer, chest radiotherapy, vigorous coughing and severe vomiting, were significant risk factors of PICC spontaneous dislodgment. Basilic vein access (odds ratio [OR] = 0.39, 95% CI: 0.16–0.95, P = 0.04) was a protective factor against PICCSD in univariate analysis. Among these factors, the independent significant risk factors were vigorous coughing (OR = 6.14, 95% CI: 1.70–22.16, P = 0.01) and severe vomiting (OR = 3.70, 95% CI: 1.28–10.68, P = 0.02).

Conclusion

The incidence rate of PICC spontaneous dislodgment is 4.12% (0.34 per 1000 catheter-days); PICC spontaneous dislodgment significantly increases the risk of CRT and shortens catheter in-place time. Vigorous coughing and severe vomiting were independent risk factors of PICC spontaneous dislodgment among oncology patients.     

A polyurethane cuffed endotracheal tube is associated with decreased rates of ventilator-associated pneumonia

Purpose

The aim of this study was to determine whether the use of a polyurethane-cuffed endotracheal tube would result in a decrease in ventilator-associated pneumonia rate.

Materials and Methods

We replaced conventional endotracheal tube with a polyurethane-cuff endotracheal tube (Microcuff, Kimberly-Clark Corporation, Rosewell, Ga) in all adult mechanically ventilated patients throughout our large academic hospital from July 2007 to June 2008. We retrospectively compared the rates of ventilator-associated pneumonia before, during, and after the intervention year by interrupted time-series analysis.

Results

Ventilator-associated pneumonia rates decreased from 5.3 per 1000 ventilator days before the use of the polyurethane-cuffed endotracheal tube to 2.8 per 1000 ventilator days during the intervention year (P = .0138). During the first 3 months after return to conventional tubes, the rate of ventilator-associated pneumonia was 3.5/1000 ventilator days. Use of the polyurethane-cuffed endotracheal tube was associated with an incidence risk ratio of ventilator-associated pneumonia of 0.572 (95% confidence interval, 0.340-0.963). In statistical regression analysis controlling for other possible alterations in the hospital environment, as measured by rate of tracheostomy-ventilator-associated pneumonia, the incidence risk ratio of ventilator-associated pneumonia in patients intubated with polyurethane-cuffed endotracheal tube was 0.565 (P = .032; 95% confidence interval, 0.335-0.953).

Conclusions

Use of a polyurethane-cuffed endotracheal tube was associated with a significant decrease in the rate of ventilator-associated pneumonia in our study.     

Survival benefit of the full selective digestive decontamination regimen

Purpose

We assessed the impact of the full protocol of selective decontamination of the digestive tract (SDD) using parenteral and enteral antimicrobials on mortality.

Materials and Methods

A systematic review was performed searching MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, previous meta-analyses, and conferences proceedings. We included all randomized controlled trials (RCTs) comparing the full protocol of SDD, including oropharyngeal and intestinal administration of antibiotics combined with the parenteral component, with no treatment or placebo. The primary end points were overall mortality, mortality attributable to infection, early, and late mortality.

Results

Twenty-one RCTs on 4902 patients were included. Overall mortality was significantly reduced (odds ratio [OR], 0.71; 95% confidence interval [CI]; 0.61-0.82; P < .001). There was a nonsignificant reduction in infection-related mortality (6 RCTs; OR, 0.40; 95% CI, 0.10-1.59; P = .19) and early mortality (4 RCTs; OR, 0.64; 95% CI, 0.34-1.19; P = 0.16), and a significant reduction in late mortality (5 RCTs; OR, 0.56; 95% CI, 0.40-0.77; P < .001). The subgroup analysis showed a significant mortality reduction in successfully decontaminated patients (OR, 0.58; 95% CI, 0.45-0.77; P < .001), and when parenteral and enteral antimicrobials were administered to every patient receiving treatment in the intensive care unit (OR, 0.59; 95% CI, 0.42-0.82; P < .001).

Conclusions

The findings strongly indicated that the full protocol of SDD reduces mortality in critically ill patients, in particular when successful decontamination is obtained. Eighteen patients should be treated with SDD to prevent one death.     

Accuracy of microscopic urine analysis and chest radiography in patients with severe sepsis and septic shock

Background

Diagnosis of source of infection in patients with septic shock and severe sepsis needs to be done rapidly and accurately to guide appropriate antibiotic therapy.

Objective

The purpose of this study is to evaluate the accuracy of two diagnostic studies used in the emergency department (ED) to guide diagnosis of source of infection in this patient population.

Methods

This was a retrospective review of ED patients admitted to an intensive care unit with the diagnosis of severe sepsis or septic shock over a 12-month period. We evaluated accuracy of initial microscopic urine analysis testing and chest radiography in the diagnosis of urinary tract infections and pneumonia, respectively.

Results

Of the 1400 patients admitted to intensive care units, 170 patients met criteria for severe sepsis and septic shock. There were a total of 47 patients diagnosed with urinary tract infection, and their initial microscopic urine analysis with counts > 10 white blood cells were 80% sensitive (95% confidence interval [CI] .66–.90) and 66% specific (95% CI .52–.77) for the positive final urine culture result. There were 85 patients with final diagnosis of pneumonia. The sensitivity and specificity of initial chest radiography were, respectively, 58% (95% CI .46–.68) and 91% (95% CI .81–.95) for the diagnosis of pneumonia.

Conclusion

In patients with severe sepsis and septic shock, the chest radiograph has low sensitivity of 58%, whereas urine analysis has a low specificity of 66%. Given the importance of appropriate antibiotic selection and optimal but not perfect test characteristics, this population may benefit from broad-spectrum antibiotics, rather than antibiotics tailored toward a particular source of infection.     

The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban Neonatal Intensive Care Unit: An intervention study with before and after comparison

Background

Nosocomial bloodstream infections are a major cause of morbidity and mortality in neonatal intensive care units. Appropriate hand hygiene is singled out as the most important measure in preventing these infections. However, hand hygiene compliance among healthcare professionals remains low despite the well-known effect on infection reduction.

Objectives

We studied the effectiveness of a hand hygiene education program on the incidence of nosocomial bloodstream infections.

Design

Observational study with two pretests and two posttest measurements and interrupted time series analysis.

Setting

A 27 bed level IIID neonatal intensive care unit in a teaching hospital in the Netherlands.

Participants

Healthcare professionals who had physical contact with very low birth weight (VLBW) infants.

Methods

The study was conducted during a period of 4 years. Medical and nursing staff followed a problem-based education program on hand hygiene. Hand hygiene practices before and after the education program were compared by guided observations. The incidence of nosocomial infections in VLBW infants was compared. In addition, numbers of nosocomial bloodstream infections per day-at-risk in very low birth weight infants were analyzed by a segmented loglinear regression analysis.

Results

During 1201 observations hand hygiene compliance before patient contact increased from 65% to 88% (p < 0.001). Median (interquartile range) drying time increased from 4 s (4-10) to 10 s (7-14) (p < 0.001).The proportion of very low birth weight infants with one or more bloodstream infections and the infection rate per 1000 patient days (relative risk reduction) before and after the education program on hand hygiene intervention decreased from 44.5% to 36.1% (18.9%, p = 0.03) and from 17.3% to 13.5% (22.0%, p = 0.03), respectively.At the baseline the nosocomial bloodstream infections per day-at-risk decreased by +0.07% (95% CI −1.41 to +1.60) per month and decreased with −1.25% (95% CI −4.67 to +2.44) after the intervention (p = 0.51). The level of instant change was −14.8% (p = 0.48).

Conclusions

The results are consistent with relevant improvement of hand hygiene practices among healthcare professionals due to an education program. Improved hand hygiene resulted in a reduction in nosocomial bloodstream infections.     

An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching,community medical center

OBJECTIVE: To evaluate the effectiveness of an evidence-based intervention to prevent catheter-associated bloodstream infections among intensive care unit patients at a nonteaching, community hospital. DESIGN: Nonrandomized pre/post observational trial. SETTING: Two intensive care units at Missouri Baptist Medical Center, Saint Louis, MO. PARTICIPANTS: Nurses and critical care physicians. INTERVENTION: A ten-page, self-study module on the prevention of catheter-associated bloodstream infections, lectures, and posters given between July and September 1999. MEASUREMENTS: The incidence of nosocomial catheter-associated bloodstream infection and patient demographics were measured for patients admitted between March 1998 and July 2000. MAIN RESULTS: Thirty cases of catheter-associated bloodstream infections during 6110 catheter-days were noted in the preintervention period (4.9 cases/1000 catheter-days) vs. 11 cases during the 5210 catheter-days in the postintervention period (2.1 cases/1000 catheter-days). The relative risk for catheter-associated infection in the postintervention period was 0.43 (95% confidence interval, 0.22-0.84). Among catheterized patients, Acute Physiology and Chronic Health Evaluation II score (25.2 preintervention vs. 25.1 postintervention; p =.86), hemodialysis (91 of 647 [14%] patients vs. 69 of 541 [13%]; p =.70), and the mean number of catheter days per patient (9.1 vs. 9.6 days; p =.46) did not differ between the pre- and postintervention periods. CONCLUSIONS: A focused, educational intervention among nurses and physicians in a nonteaching community hospital resulted in a significant, sustained reduction in the incidence of catheter-associated bloodstream infection.     

Peripherally inserted central catheters are associated with lower risk of bloodstream infection compared with central venous catheters in paediatric intensive care patients: a propensity-adjusted analysis

Purpose

Central line-associated bloodstream infection (CLABSI) is an important cause of complications in paediatric intensive care units (PICUs). Peripherally inserted central catheters (PICCs) could be an alternative to central venous catheters (CVCs) and the effect of PICCs compared with CVCs on CLABSI prevention is unknown in PICUs. Therefore, we aimed to evaluate whether PICCs were associated with a protective effect for CLABSI when compared to CVCs in critically ill children.

Methods

We have carried out a retrospective multicentre study in four PICUs in São Paulo, Brazil. We included patients aged 0–14 years, who needed a CVC or PICC during a PICU stay from January 2013 to December 2015. Our primary endpoint was CLABSI up to 30 days after catheter placement. We defined CLABSI based on the Center for Disease Control and Prevention’s National Healthcare Safety Networks (NHSN) 2015 surveillance definitions. To account for potential confounders, we used propensity scores with inverse probability weighting.

Results

A total of 1660 devices (922 PICCs and 738 CVCs) in 1255 children were included. The overall CLABSI incidence was 2.28 (95% CI 1.70–3.07)/1000 catheter-days. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR 2.20, 95% CI 1.05–4.61; p = 0.037) compared with PICCs. In a sensitivity analysis, CVCs remained associated with higher risk of CLABSI (adjHR 2.18, 95% CI 1.02–4.64; p = 0.044) after adding place of insertion and use of parenteral nutrition to the model as a time-dependent variable.

Conclusions

PICC should be an alternative to CVC in the paediatric intensive care setting for CLABSI prevention.

     

The safety and efficacy of midlines compared to peripherally inserted central catheters for adult cystic fibrosis patients: A retrospective,observational study

Background

Intravenous antibiotics are the cornerstone of treatment for patients with cystic fibrosis (CF). Midlines are a type of vascular access device (VAD) used exclusively in one treatment facility within Australia, most other centres use peripherally inserted central catheters (PICCs).

Objective

To ascertain the safety and efficacy of midlines for CF patients receiving intravenous antibiotics.

Design

Retrospective observational.

Setting

A large, major metropolitan teaching hospital in Adelaide, South Australia.

Participants

Adult patients with a diagnosis of CF, who had a PICC or midline inserted for the commencement of antibiotic therapy during the period 2004–2010 to treat a respiratory exacerbation.

Methods

Medical records and hospital reports were used to record rates of adverse events and unexpected removal of VADs. The primary outcome was a composite measure of adverse events (catheter-related blood stream infection, deep vein thrombosis, occlusion, pain, infiltration, bleeding, phlebitis, catheter leakage and dislodgement) and whether the VAD was removed unexpectedly.

Results

There were 231 midlines and 97 PICCs inserted into 64 patients (39 male and 25 female; age range 18–47 years old). Presented as per 1000 VAD days, patients with PICCs and midlines had similar rates of adverse events (14 and 11 adverse events per 1000 VAD days, respectively). Unexpected removal was higher for patients with midlines (6.90 per 1000 VAD days) than for PICCs (2.89 per 1000 VAD days). Incident rate ratios (IRRs) showed that patients with midlines and PICCs had similar rates of adverse events (IRR 1.18, P = 0.617, CI 0.62–2.22) although the removal rate of patients with midlines was twice that of patients with PICCs (IRR 2.24, P = 0.079, CI 0.91–5.56). As an absolute risk there were only 4.09 more cases of removal for patients with midlines per 1000 VAD days than those with PICCs.

Conclusions

Midlines may be an alternative to PICCs for adult CF patients although further research is required with a larger sample size to enable definitive conclusions.     

Antibiotic prophylaxis for ED patients with simple hand lacerations: a feasibility randomized controlled trial

Background

The benefit of antibiotic prophylaxis for simple hand lacerations (lacerations that do not involve special structures) has not been adequately studied.

Objective

To assess the feasibility of a randomized controlled trial to determine the role of antibiotic prophylaxis in emergency department (ED) patients with simple hand lacerations.

Methods

Randomized, double-blind, placebo-controlled pilot trial in 2 urban academic EDs. Adult (≥ 18 years old) patients with simple hand lacerations were randomized to cephalexin, 500 mg; clindamycin, 300 mg; or placebo (every 6 hours for 7 days, all in identical capsules). Outcomes: (1) feasibility determined by the number of patients who agreed to enroll and number of patients who completed follow-up, (2) infection rate (determined by 2 physicians at 10-14 days), (3) satisfaction with wound appearance (measured by a visual analogue scale at 30 days via phone). Medians, quartiles, and percentages with 95% confidence intervals (CI) were used to present data. Groups were compared with Kruskal-Wallis and Fisher exact tests, when appropriate.

Results

Over a 5-month period, 123 patients were approached, and 78 consented to enrollment (63%; 95% CI, 55-71%). Five were lost to follow-up (5/78, 6%; 95% CI, 2%-14%). Only one patient had infection on follow-up for an infection rate of 1% (95% CI, 0.01%-8%). Patient’s satisfaction with wound appearance did not differ among the groups.

Conclusion

The findings of this pilot study support the feasibility of a randomized, double-blind, controlled trial. The low rate of infection suggests the need of a large sample size for the trial.     

Cranial Computed Tomography Utilization for Suspected Ventriculoperitoneal Shunt Malfunction in a Pediatric Emergency Department

Background

Computed tomography (CT) scan, the largest medical source of ionizing radiation in the United States, is used to test for failure of ventricular peritoneal shunts.

Study Objectives

To quantify the exposure to cranial CT scans in pediatric patients presenting with symptoms of shunt malfunction, and to measure the association of signs and symptoms with clinical shunt malfunction and the need for neurosurgical intervention within 30 days of presentation.

Method

This was a quality improvement study evaluating a pathway used by providers in a tertiary care pediatric emergency department with 85,000 patient visits per year, by retrospective chart review of 223 patient visits for suspected shunt malfunction. We determined the median CT scan per patient per year and the association of signs and symptoms on the pathway with radiological signs of shunt failure and neurosurgical intervention within 30 days of scan.

Results

The median exposure was 2.6 (interquartile range 1.44–4.63) scans per patient per year. Among 11 signs and symptoms, none was associated with radiologic shunt failure. Neurosurgical intervention within 30 days was positively associated with bulging fontanelle (adjusted odds ratio [AOR] 11.78; 95% confidence interval [CI] 1.67–83.0) and behavioral change (AOR 3.01; 95% CI 1.14–7.93), and negatively associated with seizure (AOR 0.13; 95% CI 0.02–0.79) and fever (AOR 0.15; 95% CI 0.04–0.55).

Conclusions

Patients with ventricular peritoneal shunts underwent many cranial CT scans each year. None of the signs or symptoms included on the clinical pathway was predictive of changes on CT scan.     

Pitfalls in using serum C-reactive protein to predict bacteremia in febrile adults in the ED

Objectives

The diagnostic performance of serum C-reactive protein (CRP) in prediction of bacteremia among febrile patients visiting an emergency department (ED) was analyzed.

Methods

During randomly selected 96 days between August 2006 and July 2007, a prospective study of febrile adults visiting the ED of a medical center was conducted to analyze the clinical characters associated with bacteremia.

Results

Of the total 454 febrile adults enrolled, their mean age was 54.1 years, and 232 (54.6%) were women. Major comorbidities included cardiovascular disease (137 patients, or 30.1%) and diabetes mellitus (105, or 23.1%). Seventy-four patients (16.2%) had true bloodstream infections with the predominance of monomicrobial gram-negative bacteremia in 49 patients (10.7%). Four risk factors, including low platelet count (<100 000/mm³; odds ratio [OR], 4.19; 95% confidence interval [CI], 1.85-9.47; P = .001), high blood urea nitrogen (>20 mg/dL; OR, 4.61; 95% CI, 2.56-8.31; P < .001), high fever (>39.0°C; OR, 3.67; 95% CI, 2.05-6.59; P < .001), and high Pittsburg bacteremia scores (≧4 points; OR, 2.95; 95% CI, 1.01-8.57; P = .04) were independently associated with bacteremic episodes. Of note, high CRP (>150 mg/dL; OR, 1.75; 95% CI, 0.73-3.99; P = .21) was not an independent risk factor. In further analysis, the difference of serum CRP levels between bacteremic and nonbacteremic adults was significant only when the period from fever onset to ED arrival was more than 12 hours.

Conclusions

The CRP level was not reliable to distinguish the bacteremia from nonbacteremic infection, whereas duration after fever onset was less than 12 hours. Clinicians must consider the history of fever onset to improve the accuracy of early prediction of serum CRP before the microbiological results of blood cultures is available.     

Prone positioning in hypoxemic respiratory failure: Meta-analysis of randomized controlled trials

Purpose

Prone positioning is used to improve oxygenation in patients with hypoxemic respiratory failure (HRF). However, its role in clinical practice is not yet clearly defined. The aim of this meta-analysis was to assess the effect of prone positioning on relevant clinical outcomes, such as intensive care unit (ICU) and hospital mortality, days of mechanical ventilation, length of stay, incidence of ventilator-associated pneumonia (VAP) and pneumothorax, and associated complications.

Methods

We used literature search of MEDLINE, Current Contents, and Cochrane Central Register of Controlled Trials. We focused only on randomized controlled trials reporting clinical outcomes in adult patients with HRF. Four trials met our inclusion criteria, including 662 patients randomized to prone ventilation and 609 patients to supine ventilation.

Results

The pooled odds ratio (OR) for the ICU mortality in the intention-to-treat analysis was 0.97 (95% confidence interval [CI], 0.77-1.22), for the comparison between prone and supine ventilated patients. Interestingly, the pooled OR for the ICU mortality in the selected group of the more severely ill patients favored prone positioning (OR, 0.34; 95% CI, 0.18-0.66). The duration of mechanical ventilation and the incidence of pneumothorax were not different between the 2 groups. The incidence of VAP was lower but not statistically significant in patients treated with prone positioning (OR, 0.81; 95% CI, 0.61-1.10). However, prone positioning was associated with a higher risk of pressure sores (OR, 1.49; 95% CI, 1.17-1.89) and a trend for more complications related to the endotracheal tube (OR, 1.30; 95% CI, 0.94-1.80).

Conclusions

Despite the inherent limitations of the meta-analytic approach, it seems that prone positioning has no discernible effect on mortality in patients with HRF. It may decrease the incidence of VAP at the expense of more pressure sores and complications related to the endotracheal tube. However, a subgroup of the most severely ill patients may benefit most from this intervention.     

Expansion of a medical emergency team system to a mental health facility

Background

Clinical emergency response systems such as medical emergency teams (MET) are used in many hospitals worldwide, but the effect that these systems have in mental health facilities is unknown. This study examined the rate and nature of MET calls to a mental health facility that had relocated to the campus of a tertiary referral hospital.

Methods

This study was a prospective, observational study of MET calls to a newly constructed 170 bed mental health facility. Data were collected on the number and nature of MET calls to the facility.

Results

Over 24 months, there were 66 MET calls to the mental health facility, and 1217 MET calls at the main hospital. The mean MET call rate was 14.2 calls per 1000 admissions (95% confidence interval (CI) 10.8–17.7) at the mental health facility, and 14.7 calls per 1000 admissions (95% CI 13.9–15.5) at the main hospital. Neurological and cardiovascular problems were present in 61% and 41% of MET calls.

Conclusion

The rate of MET calls to a new mental health facility can be similar to that of a tertiary hospital. Staff attending MET calls need to be prepared to manage predominantly neurological and cardiovascular problems.     

Incidence and long-term outcomes of critically ill adult patients with moderate-to-severe diabetic ketoacidosis: Retrospective matched cohort study

Objective

The objective of this study was to describe the clinical outcomes and treatment intensity of adult intensive care unit (ICU) patients with moderate-to-severe diabetic ketoacidosis (DKA). We aimed also to compare their clinical course with matched non-DKA ICU controls and to identify prognostic factors for mortality and hospital readmission within 1 year.

Design

This is a retrospective matched cohort study.

Setting

The settings are 2 tertiary teaching hospitals in Edmonton, Canada.

Patients

Patients were adults with moderate-to-severe DKA admitted from January 2002 to December 2009. Control patients were defined as randomly selected age, sex, and Acute Physiology and Chronic Health Evaluation II score–matched nondiabetic ICU patients (1:4.5 matching ratio). Diabetic patients were stratified according to severity of exacerbation.

Interventions

None.

Measurements and main results

From 2002 to 2009, the incidence of DKA per 1000 admissions was 4.59 (95% confidence interval [CI], 3.64-5.71). Severe DKA was associated with higher Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores in the first 3 days of ICU stay as compared with moderate DKA. Mechanical ventilation was received in 39%, vasopressors in 17%, and renal replacement therapy in 12% of DKA patients, respectively. One-year mortality and readmission rates were 9% and 36%. By logistic regression, death and/or readmission occurring in 1 year was independently associated with insulin use (odds ratio, 4.79; 95% CI, 1.14-20.05) and treatment noncompliance (odds ratio, 3.33; 95% CI, 1.04-10.64). Compared with matched non-DKA patients, those with DKA had lower mortality and were more likely to be discharged home.

Conclusions

Diabetic ketoacidosis necessitating ICU admission is associated with considerable resource utilization and long-term risk for death. Interventions aimed to improve compliance with therapy may prevent readmissions and improve the long-term outcome.     

Short Versus Long Course of Antibiotics for Catheter-Associated Urinary Tract Infections in Patients With Spinal Cord Injury: A Randomized Controlled Noninferiority Trial

Objective

To assess the applicability of a short-course regimen of antibiotics for managing catheter-associated urinary tract infection (CA-UTI) in patients with spinal cord injury (SCI).

Design

Randomized, controlled, noninferiority trial.

Setting

Medical center.

Participants

Patients with SCI who had CA-UTI (N=61).

Interventions

Patients were randomized to receive either a 5-day regimen of antibiotics after catheter exchange (experimental group) or a 10-day regimen of antibiotics with catheter retention (control group). Noninferiority was prespecified with a margin of 10%.

Main Outcome Measure

Clinical cure at the end of therapy.

Results

Of the 61 patients enrolled in this study, 6 patients were excluded because of bacteremia or absence of urinary symptoms. All patients (100%) achieved clinical cure at the end of therapy. The rates of microbiologic response were 82.1% in the experimental group and 88.9% in the control group (upper boundary 95% confidence interval (CI) for difference, 26%). The rates of resolution of pyuria were 89.3% in the experimental group and 88.9% in the control group (upper boundary 95% CI for difference, 16%). Patients in the experimental group had higher rates of CA-UTI recurrence than the control group. The rates of new CA-UTI, diarrhea, and Clostridium difficile colitis were similar in the 2 treatment arms.

Conclusions

The primary endpoint of the study was met, indicating that the 5-day regimen with catheter exchange was noninferior to the 10-day regimen with catheter retention on the basis of clinical cure. Criteria for noninferiority on the basis of microbiologic response and resolution of pyuria were not met.