Reducing the incidence of nosocomial pneumonia in cardiovascular surgery patients

Outcomes management provides a mechanism to foster development of patient-driven services through revision of practice and measurement of outcomes. Because nosocomial pneumonia is the most common hospital-acquired infection in intensive care units, reducing the rate of nosocomial pneumonia became on area of intense scrutiny at our institution. This article shares an outcome initiative that focused on reducing the incidence of nosocomial pneumonia in a hospital setting. Strategies used such as multidisciplinary team formation, case/control study, quality improvement activities, risk tool development, and protocol implementation, are discussed. Process and outcome data are provided to demonstrate the initiative's positive impact. The benefits of this outcome effort are easily identified and well-illustrated. The backbone of the initiative--proactive identification of problems and the methodical, reasoned search for answers--is universally applicable.     

Intrauterine device use does not increase the incidence of anti-hepatitis C seropositivity among monogamous women in Turkey

Background

The relationship between intrauterine device (IUD) use and anti-hepatitis C virus (HCV) status has not been investigated yet. The aims of this study were to compare anti-HCV seropositivity between IUD users and nonusers and to determine whether IUD use is an independent risk factor for anti-HCV seropositivity.

Study Design

This cross-sectional study included 302 married women who used either an IUD (n=164) or did not use any form of modern contraception (n=138). Statistical analysis was carried out using multiple logistic regression models.

Results

Most women were housewives and all indicated their husbands as the one and only lifetime sexual partner. None of the women have ever used intravenous drugs. There were no statistically significant differences between groups in any of the major risk factors for HCV exposure such as invasive dental procedures, parenteral injections, surgery and blood or blood product transfusions. Twenty-seven (8.9%) of the participants were anti-HCV-positive. Of these, 14 were IUD users and 13 were nonusers and there were no statistically significant differences between the two groups (p=.472). The most important risk factors for anti-HCV seropositivity were the number of deliveries (OR=1.41; 95% CI 1.07-1.86) and invasive dental procedures (OR=2.39; 95% CI 1.07-5.39).

Conclusions

IUD use is not associated with an increased incidence of anti-HCV seropositivity among monogamous women. The IUD may be an appropriate contraceptive option for women in stable monogamous partnership with HCV carriers and condom use should not be specifically recommended in this situation.     

Periodically changing ventilator circuits is not necessary to prevent ventilator-associated pneumonia when a heat and moisture exchanger is used.

OBJECTIVE: To analyze the efficacy of periodically changing ventilator circuits for decreasing the rate of ventilator-associated pneumonia when a heat and moisture exchanger (HME) is used for humidification. The Centers for Disease Control and Prevention recommended not changing the circuits periodically. DESIGN: Randomized, controlled trial conducted between April 2001 and August 2002. SETTING: A 24-bed, medical-surgical intensive care unit in a 650-bed, tertiary-care hospital. PATIENTS: All patients requiring mechanical ventilation during more than 72 hours from April 2001 to August 2002. INTERVENTIONS: Patients were randomized into two groups: (1) ventilation with change of ventilator circuits every 48 hours and (2) ventilation with no change of circuits. Throat swabs were taken on admission and twice weekly until discharge to classify pneumonia as endogenous or exogenous. RESULTS: Three hundred four patients (143 from group 1 and 161 from group 2) with similar characteristics (age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic group, and mortality) were analyzed. There was no significant difference in the rate of pneumonia between the groups (23.1% vs 23.0% and 15.5 vs 14.8 per 1,000 ventilator-days). There was no significant difference in the incidence of exogenous pneumonia per 1,000 days of mechanical ventilation (1.71 vs 1.25). There was no difference in the distribution of microorganisms causing pneumonia. CONCLUSIONS: Circuit change using an HME for humidification does not decrease pneumonia and represents an unnecessary cost.     

H. pylori eradication does not reduce gastric cancer incidence in a high-risk area of China

QuestionDoes treating H. Pylori reduce the incidence of gastric cancer?StudyRandomised placebo-controlled trial.Main resultsAt 7.5 years, incidence of gastric cancer was not significantly different between groups (treatment: 0.86%, n=7; placebo: 1.35%, n=11; p=0.33). In people without precancerous lesions at baseline, risk of gastric cancer was significantly lower for treatment compared with placebo (incidence of gastric cancer: treatment n=0; placebo n=6; p=0.02) but there was no difference among people with precancerous lesions (n=7 and 5, respectively). Smoking (hazard ratio [HR] 6.2, 95% CI 2.3 to 16.5) and older age (HR per 1 year 1.10, 95% CI 1.05 to 1.15) were independent predictors of gastric cancer risk.Authors’ conclusionsIncidence of gastric cancer was similar between H. pylori eradication and placebo groups over 7.5 years of follow-up. However, it was significantly reduced in a subgroup of people without precancerous lesions at baseline.     

Vaccination of koalas with a prototype chlamydial vaccine is safe,does not increase the incidence of lymphoma-related disease and maybe associated with increased lifespan in captive koalas

ObjectivesTo assess the impact of Chlamydia vaccination on survival of captive koalas, and to compare the incidence of lymphomas and neoplasias between vaccinated and unvaccinated koalas.MethodsSurvival analysis using Cox and Weibull regressions on 54 vaccinated and 52 matched unvaccinated koalas, and chi-square contingency table for incidence of lymphomas/neoplasias.ResultsVaccination was found to have a significant positive effect on koala lifespan (P = 0.03), with vaccinated koalas having a median lifespan of 12.25 years compared to 8.8 years for unvaccinated ones. The effect of sex on lifespan was not significant (P = 0.31). The risk ratio of unvaccinated over vaccinated koalas was 2.2 with both Cox and Weibull regressions. There was no association between the incidence of lymphoma/neoplasias and vaccination status (P = 0.33).ConclusionsKoalas vaccinated with a prototype Chlamydia vaccine may live longer than unvaccinated ones. There was no known Chlamydia infection among koalas, so our interpretation is that vaccination may have boosted the innate and adaptive immune systems to protect against a wide spectrum of bacteria, fungi and parasites. Vaccinated koalas did not show negative physiological effects of the vaccine, for example, the frequency of deaths due to lymphomas/neoplasias was the same in both vaccinated and unvaccinated animals.     

Ethanol exposure of neonatal rats does not increase biomarkers of oxidative stress in isolated cerebellar granule neurons.

Oxidative stress is a candidate mechanism for ethanol neuropathology in fetal alcohol spectrum disorders. Oxidative stress often involves production of reactive oxygen species (ROS), deterioration of the mitochondrial membrane potential (MMP), and cell death. Previous studies have produced conflicting results regarding the role of oxidative stress and the benefit of antioxidants in ethanol neuropathology in the developing brain. This study investigated the hypothesis that ethanol neurotoxicity involves production of ROS with negative downstream consequences for MMP and neuron survival. This was modeled in neonatal rats at postnatal day 4 (P4) and P14. It is well established that granule neurons in the rat cerebellar cortex are more vulnerable to ethanol neurotoxicity on P4 than at later ages. Thus, it was hypothesized that ethanol produces more oxidative stress and its negative consequences on P4 than on P14. A novel experimental approach was used in which ethanol was administered to animals in vivo (gavage 6g/kg), granule neurons were isolated 2-24h post-treatment, and ROS production and relative MMP were immediately assessed in the viable cells. Cells were also placed in culture and survival was measured 24h later. The results revealed that ethanol did not induce granule cells to produce ROS, cause deterioration of neuronal MMP, or cause neuron death when compared to vehicle controls. Further, granule neurons from neither P4 nor P14 animals mounted an oxidative response to ethanol. These findings do not support the hypothesis that oxidative stress is obligate to granule neuron death after ethanol exposure in the neonatal rat brain. Other investigators have reached a similar conclusion using either brain homogenates or cell cultures. In this context, it is likely that oxidative stress is not the sole and perhaps not the principal mechanism of ethanol neurotoxicity for cerebellar granule neurons during this stage of brain development.     

Publicity does not increase recruitment to falls prevention trials: the results of two quasi-randomized trials

ObjectiveTo test the effect of publicity on recruitment to a randomized trial. Recruitment is often poor in trials. Publicity within recruitment packs might be an inexpensive method of increasing recruitment. We tested this in two quasi-randomized trials.Study DesignIn a primary care setting, within the context of a randomized trial of falls prevention, we allocated participants to receive a newspaper article about the study with their information sheet. The first trial compared one newspaper article against no article; the second compared a more favorably written article against the original.ResultsIn the first study 4,488 participants were allocated into two groups. The response rate was 102 and 97 in the intervention and control groups, respectively (4.55% vs. 4.32%, 95% confidence interval [CI]: ?0.98, 1.43); the recruitment rate was 73 and 71, respectively, the difference not being statistically significant. In the second study 2,745 were allocated into two groups with a response rate of 75 and 69 for the control and intervention groups, respectively (5.46% vs. 5.03%, 95% CI: ?1.24, 2.09); the recruitment rate was 57 and 54, respectively, the difference not being statistically significant.ConclusionThese two large experiments revealed no evidence of effect of publicity on recruitment rates.     

老年人院内获得性肺炎的危险因素及其预防

[目的 ]　分析老年人院内获得性肺炎的危险因素 ,提出预防对策。 [方法 ]　回顾性调查三级医院的住院病例。 [结果 ]　 92例老年NP中 ,男 71例 ,女 2 1例 ,最常见的基础疾病为慢性心脑血管疾病 (33 .7% ) ,慢性阻塞性肺病 (2 8.3 % ) ,恶性肿瘤和外科手术后 (各 13 .8% ) ,主要诱发因素为长期使用抗生素、激素或其他免疫抑制剂、气管插管或气管切开 ,使用H2 受体阻滞剂或抑酸剂、鼻胃留管等。住院时间越长 ,感染的机会越高 ,病死率为 2 9.3 %。[结论 ]　老年人NP病死率高 ,应针对其危险因素 ,早防早治。     

A study of the etiologies and treatment of nosocomial pneumonia in a community-based teaching hospital.

OBJECTIVE: To compare the frequency of the pathogens of nosocomial pneumonia in a community-based teaching hospital to the frequencies previously published, and to evaluate recommendations for the therapy of nosocomial pneumonia in this setting. DESIGN: Retrospective review of prospectively acquired data accrued during 9 randomized single-blinded and 4 single-agent investigational antibiotic studies for the therapy of pneumonia in hospitalized patients between 1981 and 1989. SETTING: The study was performed at a university affiliated, community-based teaching Department of Veterans Affairs Medical Center. PATIENTS: Patients were hospitalized on the acute medical/surgical and intermediate medicine wards. Informed consent was obtained prior to enrolling patients into the respective antimicrobial studies. Pneumonia was documented radiographically and clinically for each patient. RESULTS: Two hundred thirty-one episodes of nosocomial pneumonia were treated. Overall, 51% of pneumonias were caused by Streptococcus pneumoniae or Hemophilus influenzae with or without other organisms that were not gram-negative bacilli. Gram-negative bacilli, with or without other organisms, accounted for only 26% of all nosocomial pneumonias. Overall, monotherapy with a cephalosporin (usually a broad-spectrum agent) was equally efficacious compared with combination therapy (87% versus 81%, respectively). Cure rates for nosocomial pneumonias from gram-negative bacilli treated with these 2 therapies also were similar (70% versus 60%, respectively). CONCLUSIONS: In nontertiary care settings, gram-negative bacilli may cause fewer episodes of nosocomial pneumonia (26% in this study) than noted by previously published reports, which indicated that these organisms account for 50% of nosocomial pneumonias. Further, S pneumoniae and H influenzae may account etiologically for many of these nosocomial pneumonias. Monotherapy with an extended-spectrum cephalosporin may be more appropriate than combined treatment with a beta-lactam and an aminoglycoside in a nontertiary care setting, thereby reducing potential toxicity in an older, hospitalized patient population.     

Disinfection of the skin prior to injections does not influence the incidence of infections; a literature study

OBJECTIVE: To assess the incidence of infections after subcutaneous, intramuscular or intravenous injections--using sterile needles--with or without prior disinfection of the skin. METHOD: Literature searches were made in the database Medline from 1966-June 2001, in the databases Picarta, Embase and the Cochrane Library, as well as manually in the reference lists of the collected articles. Original papers in English, Dutch or German were selected. RESULTS: Four relevant studies were found, generally of poor quality. In these two infections were reported after disinfecting the skin prior to over 2300 injections in 156 patients, and none were reported after not disinfecting the skin prior to over 7000 injections in more than 700 patients. CONCLUSION: Both disinfection prior to skin injections and omission of disinfection were followed by (almost) no infections.     

Study of the incidence and cost of nosocomial infections in general surgery

Nosocomial infection incidence and its cost were study. We have identified 61 infected patients and 75 infectious episodes, is an incidence of 9.4% infected for 100 hospitalized by trimester. Operative site infections are the most frequent (60%), operative site infection (9.1%), inferior respiratory ways infections (2.2%). Incriminated germs are represented essentially by negative gram Bacillus (77.3%) with predominance of enterobacterias (59%). Invasive technique usage, surgery types and contamination classes have been identified as risk factors of nosocomial infection occurrence. The supplementary stay duration estimated by simple comparison between infected group and no-infected one is 9.3% days, responsible of an over cost of 336 TD by infected patient and 273 TD by infectious episode. The curative antibiotic costs have been estimated at 70 TD by infected patient being equivalent to two hospitalization days and to 57 TD by infectious episode.     

Converting incidence and prevalence data of nosocomial infections: results from eight hospitals.

OBJECTIVE: To investigate the use of the formula of Rhame and Sudderth for the interconversion of prevalence and incidence data on the frequency of nosocomial infections. DESIGN: Comparison of observed and calculated incidence data and prevalence data. SETTING: One 8-week incidence investigation in the surgical and intensive care units of eight medium-sized hospitals; three separate point-prevalence studies in the same units. RESULTS: The overall prevalence observed after the three prevalence studies in 2,169 patients was 6.8% (95% confidence interval [CI95], 5.7-8.0). In 2,882 discharged patients observed during the incidence study, the mean hospitalization was 9.8 days; patients with one or more nosocomial infection had a mean hospitalization time of 22.3 days and a mean interval of 8.2 days from admission to the first day of infection. Based on these data, the overall calculated incidence was 4.7%, whereas the observed incidence was 4.3% (CI95, 3.6-5.2). Vice versa, an overall prevalence of 6.2% was found when calculated from the observed incidence data. The incidence data calculated from prevalence data also were within the confidence interval of the incidences observed for urinary tract infections and surgical-site infections. (However, it was not possible to convert the data for two of the eight hospitals.) CONCLUSION: The approximate mathematical relationship between the prevalence and incidence data of nosocomial infection is confirmed by this study. However, although it is theoretically possible, we would not recommend the conversion of prevalence into incidence data or vice versa.     

Surgical masks do not increase the risk of heat stroke during mild exercise in hot and humid environment

Surgical masks are widely used for the prevention of respiratory infections. However, the risk of heat stroke during intense work or exercise in hot and humid environment is a concern. This study aimed to examine whether wearing a surgical mask increases the risk of heat stroke during mild exercise in such environment. Twelve participants conducted treadmill exercise for 30 min at 6 km/h, with 5% slope, 35°C ambient temperature, and 65% relative humidity, while wearing or not a surgical mask (mask and control trials, respectively). Rectal temperature (T_rec), ear canal temperature (T_ear), and mean skin temperature (mean T_skin) were assessed. Skin temperature and humidity of the perioral area of the face (T_face and RH_face) were also estimated. Thermal sensation and discomfort, sensation of humidity, fatigue, and thirst were rated using the visual analogue scale. T_rec, T_ear, mean T_skin, and T_face increased during the exercise, without any difference between the two trials. RH_face during the exercise was greater in the mask trial. Hot sensation was greater in the mask trial, but no influence on fatigue and thirst was found. These results suggest that wearing a surgical mask does not increase the risk of heat stroke during mild exercise in moist heat.     

Changing drinking pattern does not influence health perception: a longitudinal study of the atherosclerosis risk in communities study

OBJECTIVE: To investigate if dynamic changes in the pattern of alcoholic beverages consumption are associated with modifications in health perception. Design, setting, and PARTICIPANTS: This study investigated 12 332 middle aged men and women from the atherosclerosis risk in communities study who reported drinking status and perceived health triennially from 1987 to 1995. Crude and adjusted risks for change in health perception between visits two and three by change in drinking status between visits one and two were computed. In the multivariate analysis the sample was restricted to participants with stable drinking status between visit two and three and stable health perception between visits one and two, to assure that exposure and outcome were not temporary. Covariates included age, sex, race, income, smoking status, educational level, and obesity. RESULTS: Health for persons who stopped or started drinking, or continued to abstain was more likely to decline than was health for persons who continued to drink even after adjustment and restrictions (drinking cessation: OR = 1.6, 95% CI = 1.1, 2.3; started drinking; OR = 1.4, 95% CI = 0.9, 2.2; continued abstaining from alcohol: OR = 1.5, 95% CI = 1.3, 1.9). Among participants with poor perceived health, starting, stopping, or continuing to abstain from alcohol did not improve health in relation to participants that continued to drink. CONCLUSION: Increasing and decreasing drinking patterns and continuous abstinence were associated with declining health perception in comparison with continuous drinking, while starting or stopping drinking did not improve health perception of persons with poor perceived health. These findings suggest that change in health perception was not biologically related to alcohol consumption.