Infectious disease consultations and antibiotic usage in a Turkish university hospital.

OBJECTIVES: The aim of this study was to investigate the various features of infectious disease (ID) consultations and the usage of antibiotics in a Turkish university hospital. METHODS: A total of 395 consultation requests were recorded during a three-year period. RESULTS: The departments most frequently requesting the consultation services of the ID department were Orthopedics (29.6%), Neurology (18.5%), Cardiology (11.8%) and Internal Medicine (10.4%). The main reasons were for diagnosis of unexplained fever (42.3%) and for antibiotic modification according to culture results (18%). Diagnoses made by the ID consultant were pneumonia (16.7%), urinary tract infections (9.3%), bone and joint prosthesis infections (9.1%) and in 15.7% of the investigated patients, no infectious focus was determined. It was recognized that the use of antibiotics had already been initiated in the great majority of patients (67.1%) before the consultation request. While the current therapy was changed in 57.4% of these patients, antibiotics were not necessary for 9.8%. CONCLUSIONS: Since the most common diagnoses were respiratory and urinary tract or bone and joint prosthesis infections, the ID specialists should have detailed knowledge of these problems. Usage of antibiotics without ID consultation was prevalent, therefore a continuous educational program is a necessity for healthcare workers in the hospital.     

Appropriate antibiotic use according to diagnoses and bacteriological findings: report of 12 point-prevalence studies on antibiotic use in a university hospital

The objective of this study was to evaluate antibiotic use in relation to diagnoses and bacteriological findings in a 600-bed Norwegian university hospital. Twelve point-prevalence studies of antibiotic use were conducted between 1996 and 1999. In the point-prevalence studies, 1,096 of 6,588 adult patients (16.6%) used on average 1.25 antibiotics each. Of the patients who received antibiotics, 35% were treated for hospital-acquired infections. Lower respiratory tract and urinary tract infections accounted for more than half of all antibiotic use. Pencillins represented 54% of antibiotic use, cephalosporins 9%, quinolones 6% and antifungal agents 0.7%. The prescribed daily doses for the penicillins were 2-3 times higher than the defined daily doses. Bacteriological samples were obtained from 929 (85%) patients. Compliance with the guidelines was > 90% and was highest when the results of bacteriological samples were positive. Good compliance led to low prevalence of antibiotic use and the use of narrow-spectrum antibiotics.     

Systemic antibiotic use in nursing homes. A quality assessment

In this evaluation of the prevalence and quality of systemic antibiotic use in nursing homes, 42 skilled nursing facilities (SNFs) and their 11 attached intermediate care facilities (ICFs) were surveyed. A random sample of 2238 patients (51%) from the total of 4378 beds was selected and of these, 7.7% of the total (8.6% of the SNF and 4.5% of the ICF) patients were on systemic antibiotics on the day of the survey. The most common suspected sites of infection were urinary tract (58.4%), lower respiratory tract (19.1%), and skin or subcutaneous tissue (4.6%). Criteria for appropriateness of initiating systemic antibiotics, for adequacy of initial diagnostic workup, and for appropriate specific antibiotics were developed by the authors, with input from a group of medical directors of nursing homes, based on Centers for Disease Control and Federal Drug Administration guidelines. Evidence to start an antibiotic was judged adequate in 62.4% of cases. Workups were considered inadequate in a high proportion of cases. For example, urinalysis was ordered in only 23.8% and urine culture in 57.4% of suspected urinary tract infections; chest x-ray was ordered in 24.2% and sputum culture in 3.0% of suspected lower respiratory infections. Recommendations are made as to minimum adequate workup for suspected infections and appropriate evidence to justify start of a systemic antibiotic, recognizing the limitations in diagnostic modalities in the nursing home setting and the special problems of their resident populations.     

Antibiotic prescribing for patients with colds, upper respiratory tract infections, and bronchitis: A national study of hospital-based emergency departments

STUDY OBJECTIVE: Antibiotics are often used to treat viral upper respiratory tract infections, even though they are usually ineffective. However, frequent inappropriate antibiotic use contributes to the emergence of drug-resistant bacterial pathogens. This study used a national database to evaluate antibiotic use in treating upper respiratory tract infections in emergency departments. METHODS: Data were obtained from the 1996 National Hospital Ambulatory Medical Care Survey. Antibiotic prescribing rates were examined for colds, upper respiratory tract infections, and acute bronchitis. Patients with comorbid conditions or secondary diagnoses, such as chronic obstructive pulmonary disease, pneumonia, sinusitis, and HIV, were excluded. Bivariate and multivariate analyses were used to assess predictors of antibiotic use. RESULTS: Overall, there were an estimated 2.7 million ED visits for colds, upper respiratory tract infections, and bronchitis by children and adults in 1996. Antibiotics were prescribed for 24.2% (95% CI 18.9, 29.5) of patients with common colds and upper respiratory tract infections and for 42.2% (95% CI 35.2, 49.2) of patients with bronchitis. There were no significant associations between antibiotic use and patient race, sex, Hispanic ethnicity, geographic location, or source of payment. Antibiotics were prescribed less often by interns or residents than by staff or other physicians (odds ratio 0.43; 95% CI 0.19, 0.98), and patients younger than 18 years were less likely to receive antibiotics than adults (odds ratio 0.32; 95% CI 0.20, 0.52). Smokers were 4.3 (95% CI 2.2, 8.3) times more likely to receive antibiotics than nonsmokers. CONCLUSION: Antibiotics are commonly prescribed for ED patients with upper respiratory tract infections even though they are usually ineffective in otherwise healthy adults. Efforts should be made to reduce inappropriate antibiotic use for the sake of containing costs, preventing side effects, and limiting the spread of antibiotic resistance.     

Desire for antibiotics and antibiotic prescribing for adults with upper respiratory tract infections

OBJECTIVE: Prior studies have shown that 60% to 75% of adults with upper respiratory tract infections want antibiotics. More recent research indicates declines in antibiotic prescribing for upper respiratory tract infections. To investigate whether there has been a comparable decrease in patients' desire for antibiotics, we measured the proportion of adults with upper respiratory tract infections who wanted antibiotics in the winter of 2001-2002. We also sought to identify factors independently associated with wanting antibiotics and antibiotic prescribing. DESIGN: Prospective survey of adults with upper respiratory tract infections prior to visiting an acute care clinic from November 2001 to February 2002. MEASUREMENTS AND MAIN RESULTS: Thirty-nine percent of 310 patients wanted antibiotics. Many patients wanted relief from symptoms (43%) or pain (24%) and many patients expected to receive a diagnosis (49%) or reassurance during the visit (13%). In multivariable modeling, independent predictors of wanting antibiotics were prior antibiotic use (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3 to 4.7) and current smoking (OR, 3.1; 95% CI, 1.3 to 7.3). Physicians prescribed antibiotics to 46% of patients who wanted antibiotics and 29% of patients who did not want antibiotics (P=.01). In multivariable modeling, wanting antibiotics was an independent predictor of antibiotic prescribing (OR, 2.1; 95% CI, 1.1 to 4.4). CONCLUSIONS: Only 39% of adults seeking care for upper respiratory tract infections wanted antibiotics, less than in previous studies. In continuing efforts to break the cycle of inappropriate antibiotic use, physicians should not assume that most patients with upper respiratory tract infections want antibiotics.     

Infectious aetiologies in elderly patients hospitalised with non-pneumonic lower respiratory tract infection

OBJECTIVE: to identify the infectious aetiologies of non-pneumonic lower respiratory tract infections in hospitalised elderly patients, and to characterise the patients in terms of demographic, clinical and therapeutic variables. DESIGN:a prospective, non-interventional, purely serologically based diagnostic study. SETTING: a tertiary university hospital in southern Israel. SUBJECTS:133 elderly patients hospitalised for non-pneumonic lower respiratory tract infections. METHODS: paired sera were obtained for each of the hospitalisations and were tested using immunofluorescence or enzyme immunoassay methods to identify 13 different pathogens. Only significant changes in antibody titers or levels between the paired sera were considered diagnostic. RESULTS: at least one infectious aetiology was identified in 77 patients (58%). At least one of seven viral aetiologies was identified in 52 patients (39%). A bacterial aetiology was identified in 27 patients (20%) including Streptococcus pneumoniae in 24 (18%). An atypical bacterium was found in 27 patients (20%) including Mycoplasma pneumoniae in 15 (11%) and Legionella spp. in nine (7%). More than one aetiology was found in 23 patients (17%). One hundred and twenty nine patients (96%) suffered from serious chronic co-morbidity. One hundred and twenty one patients received antibiotics during their hospitalisation, 106 (80%) with a beta-lactam and 42 (31%) with another antibiotic. CONCLUSIONS: non-pneumonic lower respiratory tract infection is caused in hospitalised elderly patients by a broad spectrum of aetiological agents, primarily respiratory viruses with a significant, though lesser, prevalence of classical and atypical bacteria. Despite this distribution of aetiologies, most patients are treated with beta-lactam antibiotics. The indication for antibiotic therapy in these patients and the choice of antibiotic preparation should be addressed in further studies.     

Effects of respiratory tract infections and antibiotic therapy on NADPH oxidase activity]

The superoxide generation of neutrophil NADPH oxidase was investigated in healthy subjects, patients with respiratory tract infections, and patients receiving effective antibiotic therapy. In adults, oxidase activity significantly increased during respiratory tract infections and decreased after treatment with effective antibiotics. In the elderly, no significant increase in oxidase activity was observed during respiratory tract infections, while the activity significantly decreased after therapy. Increases in white blood cell counts, neutrophil counts and C-reactive protein values in the elderly during respiratory tract infections were less marked than those in adults. These abnormalities in both adults and the elderly were restored to within normal limits after antibiotic therapy. In in vitro experiments, antibiotics, such as imipenem, ceftazidime and cefoperazone, at each therapeutic dose did not inhibit the superoxide generation of NADPH oxidase. These results suggest that in the elderly, defense activity against infections may be suppressed, and that these antibiotics may normalize neutrophil NADPH oxidase activity as a result of their bactericidal action and a possible biological action to normalize the peri-neutrophil environment of the body.     

Regional community-acquired urinary tract infections in Israel: diagnosis, pathogens, and antibiotic guidelines adherence: a prospective study.

INTRODUCTION: The identification and treatment of hospitalized patients with community-acquired urinary tract infections (CAUTI) may be a challenge. The pathogens causing the infection and their relative proportions vary geographically and with time. This observational prospective study had three primary goals: (1) to estimate the likelihood of diagnosis of CAUTI upon admission; (2) to evaluate adherence to the institutional recommendations; (3) to assess the compatibility of the current local antibiotic recommendations with a pathogen's distribution and with its drug sensitivities. METHODS AND RESULTS: Two hundred and twenty-three patients with positive urinary cultures fulfilling criteria for CAUTI were studied. Only 54 (24.2%) were diagnosed as having a urinary tract infection upon admission. Approximately 90% of the patients, who were correctly diagnosed, received the institutional recommended antibiotic therapy (ofloxacin or cefuroxime). Gram-negative intestinal flora comprised 86.1% (192 patients) of the causative microorganisms. Of these, 20.3% of the pathogens demonstrated resistance to ofloxacin and 19.8% to cefuroxime. The prevalence of Escherichia coli, the most common pathogen of UTI, significantly declined in the current study, from 70.5% in 1991 to 56% in 2000. CONCLUSIONS: We observed a low sensitivity in diagnosing community-acquired urinary tract infections upon admission. In patients correctly diagnosed, the use of recommended antibiotics was high. A substantial percentage of the pathogens were resistant to the recommended antibiotics. This study stresses the need for frequent re-evaluation of the prevalence of pathogens involved in regional community-acquired urinary tract infections and the adjustment of the empirical first-line treatment accordingly.     

老年慢性肺心病患者下呼吸道不动杆菌感染34例临床分析

目的了解老年慢性肺心病患者下呼吸道不动杆菌感染的致病特点和对抗生素的敏感性。方法对３４例老年慢性肺心病患者的临床特点、痰细菌培养及药敏试验进行回顾性分析。结果老年慢性肺心病下呼吸道不动杆菌感染居同期１３６例肺心病下呼吸道感染的首位，老年、有较严重基础病和并存症、有多种抗生素、激素或免疫抑制剂的应用史是引起不动杆菌下呼吸道感染的危险因素，其临床症状严重，混合感染率高（５２．９％），院内感染率高（２９．４％），病死率高（２６．５％）。不动杆菌对多种抗生素有不同程度的耐药性，硝酸盐阴性不动杆菌比洛菲不动杆菌的致病性强。结论老年肺心病患者下呼吸道不动杆菌感染的预后不良，治疗的关键应根据细菌培养和药敏试验选择敏感抗生素     

What's the basis for treating infections your way? Quality assessment of review articles on the treatment of urinary and respiratory tract infections in older people

OBJECTIVE: To assess the quality of readily available review articles on urinary and respiratory tract infections in older people. METHODS: Data sources were articles identified by MEDLINE search (1988-1998), review of the bibliographies of identified publications, textbooks from the library of a geriatric university hospital, and booklets with general guidelines on antibiotic therapy. Selection was made of review articles or book chapters about urinary and/or respiratory tract infections in older people that were readily available, ie, in Swiss medical libraries. Quality was assessed according to clinical applicability of the recommendations, methodology of the review, type of literature cited in the bibliography, and age of the population included in these reference articles. RESULTS: Only 13 of 29 (45%) review articles about urinary tract infections and seven of 29 (24%) articles about respiratory tract infections satisfied our criteria of applicability. Specifically, dosage, route of administration, and treatment duration were often not described. The overall methodological quality was low (mean score 1.9 +/- 1.0 on a scale of 9). No review specified the methods used to identify, select, and validate included information. Authors of the review articles quoted an important number of other review articles and only a small number of clinical trials. Less than one-quarter of these clinical trials actually comprised primarily an older population. CONCLUSIONS: Review articles on treatment of common infectious diseases in older people are often neither clinically applicable nor of good methodological quality. Therefore, more systematic review articles regarding treatment of older patients, as well as evidence-based practice guidelines, are needed.     

Profile and prognosis of febrile elderly patients with bacteremic urinary tract infection

OBJECTIVE: To describe the profile of elderly patients with bacteremic urinary tract infections (UTI) and correlate clinical and laboratory findings with the outcome in order to identify independent predictors of mortality. METHODS: This retrospective study took place in a large community-based, geriatric hospital and included 191 patients aged 75-105 years with urine and blood cultures simultaneously positive for bacterial organisms. Records were analysed for demographic information, clinical and laboratory data over a 29 month period. Mortality was assessed and was correlated with these findings. RESULTS: Most of the patients (80.1%) had community-acquired infection. Gram-negative organisms accounted for 87.6% of bacterial isolates, with Escherichia coli accounting for 46.1% of cases. Non-Escherichia coli Gram-negative organisms were highly resistant to two common urinary tract antibiotics (gentamicin and ceftriaxone). Patients with chronic urinary catheter had Gram-negative bacteria significantly less sensitive to ciprofloxacin, gentamycin, ampicillin and ceftriaxon than patients without catheter (p<0.05). In-hospital mortality was 33%. Multiple logistic regression analysis revealed that mortality was significantly related to the number of underlying diagnoses (p<0.0203), cognitive status (p<0.0003), length of hospitalization (p<0.0397), low level of serum albumin (p<0.0021), high neutrophil count (p<0.0001) and high level of lactate dehydrogenase (p<0.0351). Fatality was not associated with advanced age in the very old. CONCLUSION: Bacteremic UTI in the elderly has a high mortality rate. In frail elderly patients with age-associated multiple severe underlying disorders and cognitive impairment, early recognition of bacteremic UTI and prompt, appropriate treatment are critical in reducing the mortality.     

Urinary tract infection.

Urinary tract infections are the most common bacterial infections experienced by elderly patients. These infections are often asymptomatic, although on occasion they produce discomfort for selective older patients (particularly those with obstructive uropathy), and present a risk for bacteremia, septic shock, adult respiratory distress syndrome, and death. The limited available data suggest that there are major differences with regard to pathogenesis, microbiology, clinical features, laboratory abnormalities, and therapy between young and elderly women who develop symptomatic pyelonephritis. There is a need to provide a standard antibiotic prophylaxis program to those elderly patients with specific cardiac conditions who are scheduled to undergo urinary procedures.     

Clinical and economic evaluation of oral ciprofloxacin after an abbreviated course of intravenous antibiotics

PURPOSE: Oral ciprofloxacin has the requisite pharmacokinetic and antibacterial properties to rival the potency of intravenous antibiotics. This study was designed to determine whether oral ciprofloxacin could abbreviate the course of intravenous antibiotics in the treatment of serious infections. PATIENTS AND METHODS: Hospitalized adult patients were eligible for enrollment if they had a serious infection that was expected to require 8 or more days of intravenous antibiotic treatment. After conventional intravenous antibiotics were administered for 3 days, informed consent was obtained and patients were randomly assigned to either continue parenteral antibiotics (n = 53) or switch to oral ciprofloxacin 750 mg taken twice daily (n = 52). Ninety-nine of the 105 patients were evaluable for the assessment of efficacy. Clinical and bacteriologic efficacy, adverse events, and costs of the two treatments were compared. RESULTS: The two treatment groups were comparable for demographic characteristics, types of infections, bacteria isolated, initial intravenous antibiotic regimens, and duration of antibiotic treatment. The most common infections were of the skin and skin structure; bacteremia and infections of the lower respiratory tract, urinary tract, and bone and joint were also represented. The most commonly isolated pathogens were Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli. The most frequently prescribed intravenous antibiotics before randomization included aminoglycosides, cephalosporins, vancomycin, and nafcillin; 52 evaluable patients were treated with combination therapy while 47 received monotherapy. The clinical and bacteriologic outcomes and adverse reaction frequency with oral ciprofloxacin were comparable to those of the continued intravenous antibiotic regimens. Ciprofloxacin was associated with an average cost savings of $293 per patient. CONCLUSION: When used after 3 days of intravenous antibiotics, oral ciprofloxacin was as safe and effective as full courses of intravenous antibiotics and provided substantial cost savings.     

继发性血流感染108例病原学特点分析

目的 研究感染来源明确的血流感染患者的病原学特点. 方法 收集四川省人民医院2011年1月—2013年6月实验室确诊、感染来源明确的血流感染患者临床资料,回顾性分析其病原学特点. 结果 共计108例诊断为有明确感染来源的血流感染患者纳入研究,其中93例为单一菌感染,15例为复数菌感染. 常见的感染来源为泌尿系统、腹腔和呼吸道. 泌尿系统和腹腔来源血流感染患者中,大肠埃希菌分别占75.8%和42.4%;下呼吸道来源血流感染者中,鲍曼不动杆菌占62.5%,且对碳青霉烯类抗生素耐药率为100%. 108例30 d死亡21例(19.4%),其中泌尿系统来源血流感染者病死率最低(3.0%),而下呼吸道来源血流感染者病死率最高(45.8%),非发酵革兰阴性杆菌和真菌血流感染患者的病死率分别为55.0%和50.0%. 结论 不同感染来源的血流感染患者病原菌分布差异较大,抗生素治疗应密切结合感染来源、菌种及细菌耐药情况.     

Antibiotic prophylaxis for haematogenous bacterial arthritis in patients with joint disease: a cost effectiveness analysis

OBJECTIVE: To assess the cost effectiveness of antibiotic prophylaxis for haematogenous bacterial arthritis in patients with joint disease. METHODS: In a decision analysis, data from a prospective study on bacterial arthritis in 4907 patients with joint disease were combined with literature data to assess risks and benefits of antibiotic prophylaxis. Effectiveness and cost effectiveness calculations were performed on antibiotic prophylaxis for various patient groups. Grouping was based on (a) type of event leading to transient bacteraemia-that is, infections (dermal, respiratory/urinary tract) and invasive medical procedures-and (b) the patient's susceptibility to bacterial arthritis which was increased in the presence of rheumatoid arthritis, large joint prostheses, comorbidity, and old age. RESULTS: Of the patients with joint disease, 59% had no characteristics that increased susceptibility to bacterial arthritis, and 31% had one. For dermal infections, the effectiveness of antibiotic prophylaxis was maximally 35 quality adjusted life days (QALDs) and the cost effectiveness maximally $52 000 per quality adjusted life year (QALY). For other infections, the effectiveness of prophylaxis was lower and the cost effectiveness higher. Prophylaxis for invasive medical procedures seemed to be acceptable only in patients with high susceptibility: 1 QALD at a cost of $1300/QALY; however, the results were influenced substantially when the level of efficacy of the prophylaxis or cost of prophylactic antibiotics was changed. CONCLUSION: Prophylaxis seems to be indicated only for dermal infections, and for infections of the urinary and respiratory tract in patients with increased susceptibility to bacterial arthritis. Prophylaxis for invasive medical procedures, such as dental treatment, may only be indicated for patients with joint disease who are highly susceptible.