Clinical features and risk factors of mortality for bacteremia due to community-onset healthcare-associated methicillin-resistant S. aureus

Studies comparing adult community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) and community-onset healthcare-associated MRSA (COHCA MRSA bacteremia have not been available. From 1 January 2010 through 30 October 2010, a prospective observational program was conducted among all patients aged >16 years with positive Staphylococcus aureus blood cultures within 48 h after their arrival at the emergency department of our hospital. Clinical course of infection and infection foci of bacteremia were evaluated. Resistance to oxacillin was confirmed with the presence of mecA gene examined by polymerase chain reaction. Presence of TSST-1, PVL gene, SCCmec elements (I–V), mecA gene, and multilocus sequence typing were identified through methods described elsewhere. Univariate and multivariate analysis revealed that chronic renal failure was significantly more common in COHCA-MRSA than in CA-MRSA. In addition, APACHE III score was significantly higher in COHCA-MRSA than in CA-MRSA. Both the 7-day and 30-day mortality rates in COHCA-MRSA, 14.6% (7/48) and 29.2% (14/48), respectively, were higher than those in CA-MRSA without a significant difference. SCCmec II was more common in COHCA-MRSA, but SCCmecV_T was more common in CA-MRSA. The majority of MRSA isolates belonged to ST59, ST239, and ST5. ST59 was significantly more common in CA-MRSA, while ST239 was nearly equally common in both CA-MRSA and COHCA-MRSA. SCCmec III and II isolates were the first and second most resistant to the antibiotics commonly used for S. aureus, whereas SCCmecV_T isolates were the most susceptible to these antibiotics. We conclude that, although both CA-MRSA and COHCA-MRSA bacteremia had community onset, these 2 MRSA infections were different in underlying diseases, risk of mortality, SCCmec types, sequence types, and antimicrobial susceptibility. It is more appropriate to understand the MRSA pathogen and clinical features based on etiology and ST types than based on the location of disease onset. CA-MRSA and HCA-MRSA should be differentiated also based on etiology and ST types, in addition to location of acquisition.     

菌血症患者病原菌耐药情况和临床特征分析

目的了解佛山市中医院菌血症患者的临床特征和病原菌耐药情况,探讨菌血症的相关因素,为临床预防、治疗菌血症、合理使用抗菌药物提供科学依据。方法对佛山市中医院2010年7月至2011年7月菌血症患者的临床资料进行回顾性分析,以Excel及SPSS统计分析病原菌种类和药物敏感情况。结果收集1 231例血培养标本,共分离病原菌174株,革兰阴性(G-)杆菌105株(60.34%),革兰阳性(G+)球菌59株(33.91%),真菌10株(5.75%);G-杆菌以大肠埃希菌和肺炎克雷伯菌为主,对亚胺培南和阿米卡星高度敏感,对氨苄西林高度耐药;G+球菌以溶血葡萄球菌和金黄色葡萄球菌为主,对万古霉素、替考拉宁、利奈唑胺、呋喃妥因、喹奴普汀-达福普汀、米诺环素全敏感,对青霉素高度耐药。医院获得性感染率39.0%,社区获得性感染率61.0%;有基础疾病者81.8%;科室主要分布于肿瘤科、重症监护病房。经过抗生素治疗,治愈及好转占87.0%、死亡占7.8%、未愈占5.2%。住院期间进行过手术或侵入性操作、插管占45.5%;临床上97.4%有发热,常伴寒战症状。结论应根据药敏分析结果选用最佳抗生素治疗菌血症患者,缩短治疗时间,减少细菌耐药性发生,提高菌血症的救治成功率;菌血症患者多伴有基础疾病,临床常见发热、寒战等症状。减少手术、侵入性操作、插管,合理使用广谱抗菌药物可以减少医院菌血症的发生率。     

Staphylococcal bacteremia in cancer patients: Risk factors and outcome in 134 episodes prior to and after introduction of quinolones into infection prevention in neutropenia

A total of 134 episodes of staphylococcal bacteremia (SBE) appearing among 9987 admissions, and 979 episodes of bacteremia in cancer patients within 5 years, were analyzed for risk factors, clinical course and outcome; 64 were monomicrobial and 70 polymicrobial. The most frequent risk factors were acute leukemia, catheter insertion, long-lasting neutropenia, and prior prophylaxis with quinolones. There was no significant difference between polymicrobial and monomicrobial SBE in risk factors. The two groups differed only in the source of bacteremia (gastrointestinal and respiratory-tract infections were more common in monomicrobial SBE) and etiology —Staphylococcus aureus appeared more frequently in monomicrobial than in polymicrobial bacteremia (20.3% compared to 4.3%,P<0.05). More complications (14.3%) such as abscesses, endocarditis, etc. appeared in the group of polymicrobial SBE (P < 0.05). No difference was observed in clinical course and outcome between monomicrobial and polymicrobial SBE. The incidence of SBE has increased since 1991, when quinolones were first used in prophylaxis in afebrile neutropenia at our center; however, the infection-associated mortality in monomicrobial SBE was low (4.3%).     

Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients

Objective To determine the incidence, risk factors, and outcome of barotrauma in a cohort of mechanically ventilated patients where limited tidal volumes and airway pressures were used.Design and setting Prospective cohort of 361 intensive care units from 20 countries.Patients and participants A total of 5183 patients mechanically ventilated for more than 12 h.Measurements and results Baseline demographic data, primary indication for mechanical ventilation, daily ventilator settings, multiple-organ failure over the course of mechanical ventilation and outcome were collected. Barotrauma was present in 154 patients (2.9%). The incidence varied according to the reason for mechanical ventilation: 2.9% of patients with chronic obstructive pulmonary disease; 6.3% of patients with asthma; 10.0% of patients with chronic interstitial lung disease (ILD); 6.5% of patients with acute respiratory distress syndrome (ARDS); and 4.2% of patients with pneumonia. Patients with and without barotrauma did not differ in any ventilator parameter. Logistic regression analysis identified as factors independently associated with barotrauma: asthma [RR 2.58 (1.05–6.50)], ILD [RR 4.23 (95%CI 1.78–10.03)]; ARDS as primary reason for mechanical ventilation [RR 2.70 (95%CI 1.55–4.70)]; and ARDS as a complication during the course of mechanical ventilation [RR 2.53 (95%CI 1.40–4.57)]. Case-control analysis showed increased mortality in patients with barotrauma (51.4 vs 39.2%; p=0.04) and prolonged ICU stay.Conclusions In a cohort of patients in whom airway pressures and tidal volume are limited, barotrauma is more likely in patients ventilated due to underlying lung disease (acute or chronic). Barotrauma was also associated with a significant increased in the ICU length of stay and mortality.Electronic Supplementary Material Supplementary Material is available in the online version of this article at     

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

Objective To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors.Design Retrospective cohort study.Setting Medical ICU of an academic tertiary care hospital.Patients A total of 273 consecutive overdose admissions.Measurements and results Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in a patient with a localised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with a higher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1–3) vs 1 (1–2), p = 0.025; and median 2 (1–7) vs 1 (1–3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7–0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7–11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 10⁹/l 1.05; 95% CI 1.0–1.19; p = 0.049) were identified as independent risk factors.Conclusions Clinically relevant aspiration pneumonitis is a frequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with a higher incidence of cardiac arrest and increased ICU and total in-hospital stay.     

Day-of-the-week variations in myocardial infarction onset over a 27-year period: the importance of age and other risk factors

Introduction

The aim of this study was to analyze the day-of-the-week variations of acute myocardial infarction (AMI) over a 27-year period. The effects of sex, age, history of AMI, hypertension, fatality, and temporal changes over the 27-year period were also investigated.

Methods

The Charleroi register of ischemic cardiopathies is the oldest register of infarctions in the French-speaking community of Belgium and is one of the very rare registers that can track trends over 27 years. The analyses presented in our study relate only to patients in the 25- to 69-year age range over time from 1983 to 2009. The χ² test for goodness of fit was used to test the difference among the frequencies of AMI events over 7 days during the week.

Results

Data from 9732 cases of AMI were analyzed. Overall, there was a significant day-of-the-week variation (P < .001), with an excess of AMI observed on Mondays (n = 1495) and a minimum on Saturdays (n = 1259), corresponding to a relative increase in AMI of 18.2% over the 2 days. The Monday peak is more pronounced for the 35- to 44-year (P = .045) age bracket than for the 45- to 54-year (P = .27) and the 55- to 64-year (P = .032) brackets. The cases with (n = 2713) and without (n = 4931) arterial hypertension exhibited the same day-of-the-week variation. In contrast, the cases with antecedent AMI (n = 1888) exhibited a less pronounced excess of MI incidence on Mondays compared with the cases without antecedent (n = 5970).

Conclusions

The present study demonstrates that there is a marked incidence peak in AMI on Mondays. This peak is similar for men and women but varies according to age. The Monday peak is not observed in subjects previously admitted for AMI or in fatal cases. The organization of the emergency medical services could take into account the day-of-the-week pattern of AMI to adapt emergency medical service capacity to needs.     

Improvements in glycaemic control and cardiovascular risk factors in a cohort of patients with type 1 diabetes over a 5-year period

Background: Management of patients with type 1 diabetes in theUK has changed over the past 20 years. The targets for glycaemiccontrol, blood pressure and cholesterol are lower. We examineda cohort of patients with type 1 diabetes who have been throughthese changes to assess their effects. Design and Methods: A cohort of patients with type 1 diabeteswho attended a secondary care outpatient diabetes clinic between1991 and 1996 were reviewed in 2001and 2006. Comparison is madebetween current biophysical markers and those obtained in 2001. Results: Only 81.9% (n = 214) of the original cohort attendedin 2006. These patients had an average duration of diabetesof 23.46 (SD ± 8.06) years. There were 134 male patients(62.62%). In these patients HbA1c had reduced by 0.4% (absolutereduction); a relative reduction of 4.41% (P = 0.0001). Statisticallysignificant reductions in diastolic blood pressure (74–68mmHg) and total cholesterol (5.37–4.62 mmol/l) occurred.However, weight (75.04–82.31 kg) and BMI (25.32–27.72kg/m²) significantly increased. There was no statistically significantchange in insulin dose (units/kg), serum creatinine, urinaryACR or systolic blood pressure. Conclusions: An urban setting, mobile population and patientnon-attendance can complicate modern diabetes care. Despitethese difficulties, input by the diabetes team working withthe patients can achieve small improvements in Hba1c and cardiovascularrisk factors by increased use of long acing insulins, metformin,statins and blood pressure medication.     

497例子宫内膜癌的临床诊断治疗以及预后因素分析

目的评价国际大样本数据库子宫内膜癌的临床诊治和预后因素分析。方法选取1995年6月—2013年12月国际TCGA组织诊断治疗的子宫内膜癌患者连续病例,分析临床诊疗的特征,评价临床客观疗效和生存时间。结合lncRNA RP11-350N15.6基因的表达和相关性分析,评价患者的预后指标。结果共497例子宫内膜癌入选。71.6%的患者为Ⅰ~Ⅱ期,白种人为72.6%,子宫内膜腺癌为75.9%,81.1%患者为绝经后患者。RP11-350N15.6基因表达与肿瘤组织病理和分级以及7个重要的肿瘤驱动基因具有明显相关性,高表达组总生存时间明显延长。结论国际TCGA子宫内膜癌研究的诊断治疗符合临床规范,高表达RP11-350N15.6是患者具有良好预后的重要指标。     

老年非小细胞肺癌合并肺部感染的临床特点及危险因素分析

目的 探讨老年非小细胞肺癌合并肺部感染的临床特点及危险因素.方法 分析2017年12月至2020年12月我院收治的111例非小细胞肺癌患者的临床资料.以细菌培养鉴定计算感染率,根据是否合并肺部感染分为合并组、未合并组,分析临床特点以及影响非小细胞肺癌合并肺部感染的独立危险因素.结果 111例非小细胞肺癌患者中,合并肺部...     

Risk factors and clinical outcome of unsuspected pulmonary embolism in cancer patients: a case‐control study

Summary. Background: Little is known about the risk factors and outcome of unsuspected pulmonary embolism (UPE) in cancer patients. Objectives: To assess the risk factors and outcome of UPE in cancer patients. Methods: The charts of 66 patients diagnosed with UPE were reviewed. Two control groups were selected: 132 cancer patients without pulmonary embolism (PE) and 65 cancer patients with clinically suspected PE. Variables associated with UPE were identified by multivariable analysis. Six‐month survival and recurrent venous thromboembolism were compared by use of Cox proportional analysis. Results: Twenty‐seven (40.9%) patients with UPE had symptoms suggesting PE. Adenocarcinoma (odds ratio [OR] 4.45; 95% confidence interval [CI] 1.98–9.97), advanced age (OR 1.18; 95% CI 1.02–1.38), recent chemotherapy (OR 4.62; 95% CI 2.26–9.44), performance status > 2 (OR 7.31; 95% CI 1.90–28.15) and previous venous thromboembolism (OR 4.47; 95% CI 1.16–17.13) were associated with UPE. When adjusted for tumor stage and performance status, 6‐month mortality did not differ between patients with UPE and patients without PE (hazard ratio 1.40; 95% CI 0.53–3.66; P = 0.50). Patients with UPE were more likely to have central venous catheters and chemotherapy and less likely to have proximal clots than patients with clinically suspected PE. Recurrent venous thromboembolism occurred in 6.1% and 7.7% of patients with UPE and symptomatic PE, respectively. Conclusion: UPE is not associated with an increased risk of death. Patients with clinically suspected PE and those with UPE have similar risks of recurrent venous thromboembolism.     

Incidence,risk factors,and predictors of outcome of candidemia. Survey in 2 Italian university hospitals

In recent decades, Candida spp. emerged as the fourth most common cause of nosocomial bloodstream infections. The incidence of candidemia was 0.13 per 100 persons. Eighty-three cases (61%) of candidemia were due to Candida albicans and 53 (39%) to nonalbicans Candida spp. Twelve strains of Candida (9%) had shown in vitro resistance to fluconazole, 5 (4%) to itraconazole, 2 (1.5%) to voriconazole, 12 (9%) to 5-flucytosine, and 1 (0.7%) to amphotericin B. Multivariate logistic regression analysis of risk factors showed that length of hospitalization, presence of a central venous catheter, previous episodes of candidemia or bacteremia, parenteral nutrition, and chronic renal failure were variables independently associated with the development of candidemia. Multivariate logistic regression analysis of prognostic indicators showed that the independent variables associated with poor prognosis were inadequate initial therapy (P < .001) and high APACHE III score (P = .004). The inadequate initial therapy associated with mortality indicates the need for additional investigations to define high-risk patients for beneficial antifungal prophylaxis.     

Epidemiologic features,risk factors,and outcome of sepsis in stroke patients treated on a neurologic intensive care unit

Purpose

Because of the immune-suppressive effect of cerebral damage, stroke patients are at high risk for infections. These might result in sepsis, which is the major contributor to intensive care unit (ICU) mortality. Although there are numerous studies on infections in stroke patients, the role of sepsis as a poststroke complication is unknown.

Methods

We retrospectively analyzed incidence of and risk factors for sepsis acquisition as well as outcome parameters of 238 patients with ischemic or hemorrhagic strokes consecutively admitted to the neurologic ICU in a tertiary university hospital between January 1, 2009, and December 31, 2010. Basic demographic and clinical data including microbiological parameters as well as factors describing stroke severity (eg, lesion volume and National Institute of Health stroke scale score) were recorded and included into the analysis. The diagnosis of sepsis was based on the criteria of the German Sepsis Society.

Results

We identified 30 patients (12.6%) with sepsis within the first 7 days from stroke onset. The lungs were the most frequent source of infection (93.3%), and gram-positive organisms were dominating the microbiologic spectrum (52.4%). Comorbidities (chronic obstructive pulmonary disease and immunosuppressive disorders) and Simplified Acute Physiology Score II but none of the factors describing stroke severity were independent predictors of sepsis acquisition. Sepsis was associated with a significantly worse prognosis, leading to a 2-fold increased mortality rate during in-hospital care (36.7% vs 18.8%) and after 3 months (56.5% vs 28.5%), but only in the subgroup of supratentorial hemorrhages, it was an independent predictor of in-hospital and 3-month mortality. Other factors significantly associated with death in a multivariate analysis were chronic obstructive pulmonary disease, malignancies (in-hospital mortality only), and Simplified Acute Physiology Score II (3-month mortality only) for ischemia and heart failure (in-hospital mortality only), National Institute of Health stroke scale score (in-hospital mortality only), and stroke volume for hemorrhages, respectively.

Conclusions

Sepsis seems to be a frequent complication of stroke patients requiring neurologic ICU treatment. Predictors of sepsis acquisition in our study were comorbidities and severity of deterioration of physiological status, but not stroke severity. A better understanding of risk factors is important for prevention and early recognition, whereas knowledge of outcome may help in prognosis prediction. Further studies are needed to clarify the optimal preventive treatment for these patients.     

成人体外膜肺氧合支持过程中高胆红素血症的发生率、危险因素及结局

目的探讨成人体外膜肺氧合(ECMO)患者高胆红素血症的发生率、危险因素及结局。方法回顾分析阜外医院89例接受ECMO辅助支持的成人心脏病患者。所有患者分成正常组、高胆红素组、严重高胆红素组。进行多元线性回归分析时,非正态分布变量需要进行对数转换。结果高胆红素血症的发生率为73%,其中高胆红素组30例,严重高胆红素组35例。多元线性回归模型显示,lg(最高TBIL+1)和lg(最高天冬氨酸转氨酶+1)(P=0.001)、lg(最高游离血红蛋白+1)(P=0.003)、ECMO支持前TBIL(P=0.009)有相关性。二元相关系数分析显示,最高TBIL和ECMO支持前TBIL(P=0.011)、最高天冬氨酸转氨酶(P=0.004)、最高游离血红蛋白(P0.001)具有线性相关。严重高胆红素组在ECMO辅助期间血小板数量低,且院内存活率低于其他2组。结论高胆红素血症在ECMO辅助期间比较常见。严重高胆红素血症与血小板数量下降和高院内死亡率有关。溶血、肝功能障碍、ECMO前高TBIL是ECMO辅助期间高胆红素血症的危险因素。     

Analysis of risk factors for surgical-site infections in 276 oral cancer surgeries with microvascular free-flap reconstructions at a single university hospital

The purpose of this study was to elucidate the risk factors for surgical-site infection (SSI) in oral cancer surgery with microvascular free-flap reconstructions and to propose appropriate SSI prevention. There were 276 patients who underwent oral cancer surgery with microvascular free-flap reconstructions at the Department of Oral and Maxillo-facial Surgery of Tokai University Hospital. The following variables were assessed as risk factors for SSIs: preoperative variables, including age, sex, body mass index, American Society of Anesthesiologist’s (ASA) score, debilitating comorbidities, smoking, alcohol consumption, and Union Internationale Contre le Cancer Tumor Node Metastasis (UICC-TNM) classification; and operative variables, including duration of surgery, amount of blood loss, quantity of blood transfusion, tracheostomy, area of neck dissection, and previous chemotherapy. Statistical analysis was conducted to determine whether these factors constitute risks for SSI. Total overall SSI rate was 40.6% (112/276). When the occurrence of SSI was compared with the variables, ASA score (P = 0.036), T stage (P = 0.013), duration of surgery (P < 0.001), blood loss (P = 0.001), blood transfusion (P = 0.01), and area of neck dissection (P = 0.009) showed statistical significance. Analysis of these variables with a logistic regression model yielded ASA score and duration of surgery as significant factors. There was a tendency for blood loss and duration of surgery to increase in patients with a high T stage. A high T stage not only broadens the resection area and increases surgical invasiveness, it also increases susceptibility to dead space after microvascular reconstruction for oral cancer. Particular care in treating the wound should be taken in surgical patients with high T-stage scores. The occurrence of SSI is of particular concern in oral cancer surgery in patients with high ASA scores.     

The influence of prognostic factors on neck pain intensity, disability, anxiety and depression over a 2-year period in subjects with acute whiplash injury

The influence of potential prognostic factors (occupant- and crash-related factors, initial neck pain intensity and headache, whiplash injury severity, helplessness, locus of control, socioeconomic status) on neck pain intensity (VAS), disability (DRI), anxiety and depression (HADS) was estimated in a cohort of 3704 subjects with whiplash injury following a motor vehicle crash. Questionnaires were administered (baseline, 1-, 6-, 12-, 24-month follow-ups). VAS was trichotomized; "low" (0-30), "moderate" (31-54), "severe" (55-100). A cumulative logit model with a proportional odds assumption was applied. Results regarding depression differed somewhat from the other outcomes. Overall, initial neck pain intensity was an important prognostic factor, but acted also as an evident effect modifier. Females had slightly increased odds for all outcomes but depression, for which no gender differences were shown. Injury severity was associated with all outcomes, but was most pronounced regarding disability among those who perceived numbness/pain in arms/hands and also had severe initial neck pain (proportional odds ratio [OR] 6.5; 95% confidence interval [CI] 2.5-17.0). Initial headache influenced all outcomes. Income was not related to any of the outcomes, whereas a lower level of education was associated with all outcomes but depression. Locus of control was not a factor of importance. In contrast, helplessness was related to all outcomes, but was most pronounced regarding neck pain intensity and depression for subjects with severe initial neck pain (OR 4.8; 95% CI 2.9-7.8; OR 6.6; 95% CI 2.6-17.0). Associations seem to be established early, and then to be relatively constant over time.