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2.
Introduction: Community-acquired pneumonia (CAP) continues to be associated with significant mortality and morbidity. As with other infectious diseases, in recent years there has been a marked increase in resistance to the antibiotics commonly used against the pathogens that cause CAP. Antimicrobial stewardship denotes coordinated interventions to improve and measure the appropriate use of antibiotics by encouraging the selection of optimal drug regimens. Areas covered: Several elements can be applied to antibiotic stewardship strategies for CAP in order to maintain or improve patient outcomes. In this regard, antibiotic de-escalation, duration of antibiotic treatment, adherence to CAP guidelines recommendations about empirical treatment, and switching from intravenous to oral antibiotic therapy may each be relevant in this context. Antimicrobial stewardship strategies, such as prospective audit with intervention and feedback, clinical pathways, and dedicated multidisciplinary teams, that have included some of these elements have demonstrated improvements in antimicrobial use for CAP without negatively affecting clinical outcomes. Expert commentary: Although there are a limited number of randomized clinical studies addressing antimicrobial stewardship strategies in CAP, there is evidence that antibiotic stewardship initiatives can be securely applied, providing benefits to both healthcare systems and patients. 相似文献
6.
BACKGROUND: Most defibrillator (ICD) trials have excluded patients on hemodialysis (HD). It is therefore not known whether the ICD, when indicated, confers the same mortality benefit to HD and non-HD patients. METHOD: HD patients implanted with an ICD from July 2001 to June 2004 were matched by age, gender, left ventricular ejection fraction (LVEF), and class of heart failure to non-HD ICD recipients. RESULTS: Forty-six (16 on HD) patients (age = 65 +/- 15 yrs, LVEF = 30 +/- 14%, 44% in class III-IV HF) were followed for a mean of 30 +/- 16 months (range, 4-61 months) after ICD implantation. During this period, 12/16 HD versus 9/30 non-HD patients died (P = 0.006). The two-year mortality rates were 54% and 29% in the HD and non-HD groups, respectively (P = 0.01). After correcting for age, gender, race, LVEF, class of HF, and ICD indication (primary vs. secondary prevention) in a Cox regression model, HD remained a significant predictor of the time to death (HR = 2.9, adjusted P = 0.023). CONCLUSION: Despite having an ICD, HD patients have approximately a three-fold increase in total mortality and may therefore not extract the same survival benefits from the ICD as their non-HD counterparts. If duplicated in larger randomized trials, these results may demonstrate the futility of implanting defibrillators in HD patients. 相似文献
7.
Background: To determine the utility of computed tomography (CT) in the detection and correction of malpositioned nephrostomy catheters
after contrast spillage during nephrostograms.
Methods: CT was performed in nine patients after an abnormal (contrast spillage) tube nephrostogram performed during or after nephrostomy
tube placement. CT was used to locate the nephrostomy catheter position in relation to the renal collecting system. If possible,
CT was also used for guidance and repositioning of the nephrostomy catheters into the intrarenal collecting system.
Results: In all nine cases, CT was successful in detecting the position of the suspected malpositioned catheter. In seven of nine
cases, CT demonstrated the catheter outside the renal collecting system and effectively helped reposition the catheters into
the intrarenal collecting system. In one case, the malpositioned nephrostomy catheter was within the intraperitoneal cavity
and required surgical correction. Another case required fluoroscopic-guided repositioning for the initial nephrostomy catheter,
which was partly posterior to the kidney and partly within the kidney. The catheter in this latter case was successfully advanced
over a guidewire into the collecting system.
Conclusions: CT may be used to detect possible catheter malposition associated with nephrostomy tube placement. CT may also be used to
successfully guide catheter repositioning in the renal collecting system.
Received: 29 May 1998/Accepted: 20 July 1998 相似文献
9.
Objectives: The objectives were to assess emergency physician (EP) understanding of the Centers for Medicare and Medicaid Services (CMS) core measures for community‐acquired pneumonia (CAP) guidelines and to determine their self‐reported effect on antibiotic prescribing patterns. Methods: A convenience sample of EPs from five medical centers in North Carolina was anonymously surveyed via a Web‐based instrument. Participants indicated their level of understanding of the CMS CAP guidelines and the effects on their prescribing patterns for antibiotics. Results: A total of 121 EPs completed the study instrument (81%). All respondents were aware of the CMS CAP guidelines. Of these, 95% (95% confidence interval [CI] = 92% to 98%) correctly understood the time‐based guidelines for antibiotic administration, although 24% (95% CI = 17% to 31%) incorrectly identified the onset of this time period. Nearly all physicians (96%; 95% CI = 93% to 99%) reported institutional commitment to meet these core measures, and 84% (95% CI = 78% to 90%) stated that they had a department‐based CAP protocol. More than half of the respondents (55%; 95% CI = 47% to 70%) reported prescribing antibiotics to patients they did not believe had pneumonia in an effort to comply with the CMS guidelines, and 42% (95% CI = 34% to 50%) of these stated that they did so more than three times per month. Only 40% (95% CI = 32% to 48%) of respondents indicated a belief that the guidelines improve patient care. Of those, this was believed to occur by increasing pneumonia awareness (60%; 95% CI = 52% to 68%) and improving hospital processes when pneumonia is suspected (86%; 95% CI = 80% to 92%). Conclusions: Emergency physicians demonstrate awareness of the current CMS CAP guidelines. Most physicians surveyed reported the presence of institutional protocols to increase compliance. More than half of EPs reported that they feel the guidelines led to unnecessary antibiotic usage for patients who are not suspected to have pneumonia. Only 40% of EPs believe that CAP awareness and expedient care resulting from these guidelines has improved overall pneumonia‐related patient care. Outcome‐based data for non–intensive care unit CAP patients are lacking, and EPs report that they prescribe antibiotics when they may not be necessary to comply with existing guidelines. 相似文献
11.
Objective: Early antibiotic administration has been associated with a significant decrease in infection following open fractures. However, antibiotics are most effective at a time when many patients are still being transported for care. There is limited evidence that antibiotics may be safely administered for open fractures when being transported by life-flight personnel. No such data exists for ground ambulance transport of patients with open fractures. The purpose of the study was to assess the safety and feasibility of prophylactic antibiotic delivery in the prehospital setting. Methods: We performed a prospective observational study between January 1, 2014 and May 31, 2015 of all trauma patients transferred to a level 1 trauma center by a single affiliated ground ambulance transport service. If open fracture was suspected, the patient was indicated for antibiotic prophylaxis with 2?g IV Cefazolin. Exclusion criteria included penicillin allergy, higher priority patient care tasks, and remaining transport time insufficient for administration of antibiotics. The administration of antibiotics was recorded. Patient demographics, associated injuries, priority level (1?=?life threatening injury, 2?=?potentially life threatening injury, 3?=?non-life threatening injury), and timing of transport and antibiotic administration were recorded as well. Results: EMTs identified 70 patients during the study period with suspected open fractures. Eight reported penicillin allergy and were not eligible for prophylaxis. The patient’s clinical status and transport time allowed for administration of antibiotic prophylaxis for 32 patients (51.6%). Total prehospital time was the only variable assessed that had a significant impact on administration of prehospital antibiotics (<30?minutes?=?29% vs. >30?minutes?=?66%; p?<?0.001). There were no allergic reactions among patients and no needle sticks or other injuries to EMT personnel related to antibiotic administration. Conclusions: EMT personnel were able to administer prehospital antibiotic prophylaxis for a substantial portion of the identified patients without any complications for patients or providers. Given the limited training provided to EMTs prior to implementation of the antibiotic prophylaxis protocol, it is likely that further development of this initial training will lead to even higher rates of prehospital antibiotic administration for open fractures. 相似文献
13.
The purpose of this project was to determine if evidence-based practice change related to antibiotic administration criteria for outpatients receiving percutaneous nephrostomy tube exchanges implemented by a medical center's Vascular and Interventional Radiology department impacted hospital admission rates for infection in these patients. The 2017 practice change was based on 2010 guidelines from the Society of Interventional Radiology (SIR), stating that outpatients with a low risk of acquiring infection did not need to receive a perioperative antibiotic, as evidence has shown prophylactic therapy has no significant effect on infection rates for this population. Using a retrospective review design, 1 year of data before and after the practice change were collected and analyzed using the repeated measures generalized estimating equation (GEE) model with a binomial output by Liang & Zeger. Fisher's exact test was used to evaluate demographic variables by level of risk of infection. Data included 493 procedural events for 126 outpatients. The mean number of events per patient was 3.91 (SD: 4.15; median: 2; interquartile range: 3). Admission and infection criteria within thirty days of the event and infection risk factors were collected for each patient. Age, sex, and race were the variables that had a significant relationship with risk level of infection. Due to sample size, the GEE model could not be run using risk level (high/low) to predict admissions before or after the practice change. The relationship between the number of risk factors (0-5) and the odds of admission for infection was the same regardless of the practice change (before: odds ratio [OR] = 2.17, 95% confidence interval [CI] = 1.19-3.95; after: OR = 1.9, 95% CI = 1.12-3.22, p interaction = .67). For every increase in a patient's number of risk factors, the odds of developing an infection would be expected to increase by almost 90% (OR = 1.9, 95% CI = 1.27-2.84). Although it was not possible to determine efficacy of the practice change, the predictive analysis indicated that risk level is a significant predictor of admission for infection regardless of antibiotic therapy. The results suggest that demographic indicators should be considered when determining appropriate therapies for this procedure; however, research studies should evaluate this relationship with larger samples to design specific recommendations. Our project results support the 2010 SIR antibiotic prophylaxis guidelines and their more recently updated antibiotic parameter guidelines from 2018. 相似文献
14.
目的 总结超声引导经皮穿刺肾造瘘对肾结核孤立肾肾盂积水治疗的效果.方法 选取2011年1月至2019年7月在解放军总医院第八医学中心收治的27例肾结核孤立肾肾积水患者,行超声引导下经皮造瘘置管留置,统计置管及换管成功率、并发症,采用t检验比较置管前后血清肌酐变化差异,调查长期带管对患者生活的影响.结果 27例患者共行置... 相似文献
15.
ObjectiveTo describe emergency department (ED) antibiotic prescribing for urinary tract infections (UTIs) and asymptomatic bacteriuria (ASB) and to identify improvement opportunities. MethodsPatients treated for UTI in 16 community hospital EDs were reviewed to identify prescribing that was unnecessary (any treatment for ASB, duration >7 days for cystitis or >14 days for pyelonephritis) or suboptimal [ineffective antibiotics (nitrofurantoin/fosfomycin) or duration <7 days for pyelonephritis]. Duration criteria were based on recommendations for complicated UTI since criteria for uncomplicated UTI were not reviewed. 14-day repeat ED visits were evaluated. ResultsOf 250,788 ED visits, UTI was diagnosed in 13,466 patients (5%), and 1427 of these (11%) were manually reviewed. 286/1427 [20%, 95% CI: 18–22%] met criteria for ASB and received 2068 unnecessary antibiotic days [mean (±SD) 7 (2) days]. Mean treatment duration was 7 (2) days for cystitis and 9 (2) days for pyelonephritis. Of 446 patients with cystitis, 128 (29%) were prescribed >7 days (total 396 unnecessary). Of 422 pyelonephritis patients, 0 (0%) were prescribed >14 days, 20 (5%) were prescribed <7 days, and 9 (2%) were given ineffective antibiotics. Overall, prescribing was unnecessary or suboptimal in 443/1427 [31%, 95% CI: 29–33%] resulting in 2464/11,192 (22%) unnecessary antibiotic days and 8 (0.5%) preventable ED visits. ConclusionsAmong reviewed patients, poor UTI prescribing in 16 EDs resulted in unnecessary antibiotic days and preventable readmissions. Key areas for improvement include non-treatment of ASB and shorter durations for cystitis. 相似文献
17.
Hemodialysis (HD) catheters are associated with blood stream infections, and catheter use continues to be high among incident and prevalent patients on maintenance HD. Migration of micro-organism along the external surface of the catheter is probably the most common route of infection, followed by the endoluminal route of contamination. Almost all HD catheters have biofilm formation on their surfaces and this serves as a good reservoir for micro-organisms. These active but protected microorganisms have been implicated in local and systemic infections associated with HD catheters. Good personal hygiene, exit-site care with topical antibiotics and antibiotic lock solution in the dialysis catheter reduce the incidence of catheter infection. In selected subgroup of patients, HD catheter is promptly removed after the diagnosis of blood stream infection. However, catheter guidewire exchange is an acceptable alternate strategy in some patients. The most important goal should be to increase the rate of incident arteriovenous fistula use in the HD population. 相似文献
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