ABSTRACT
Our objective was to evaluate the impact of using an imipenem de-escalation protocol for empiric febrile neutropenia on the development of carbapenem resistance. A pre-post intervention design was used. The intervention was adopting the imipenem de-escalation approach, which began on January 1, 2012. A retrospective chart review of cases of febrile neutropenia bacteremia was performed one year before and one year after the intervention. We compared the development of carbapenem resistance between the two study periods. Seventy-five episodes of febrile neutropenia bacteremia were included in the study. They had similar demographics, clinical features and outcomes. There were 78 and 12 pathogens in the primary and follow-up blood cultures, respectively. Approximately 61% and 66% of the primary and follow-up blood cultures, respectively, were gram-negative bacteria with similar carbapenem resistance profiles in the two study periods. In our study population, 57% of the gram-negative bacteria were ESBL pathogens. The resistance of the gram-negative bacteria to piperacillin/tazobactam [72% versus 53%, p = 0.161], imipenem [16% versus 11%, p = 0.684], and meropenem [8% versus 16%, p = 0.638] did not significantly change after our policy change. In conclusion, the use of the carbapenem de-escalation approach for febrile neutropenia in our institution was not associated with an increase in carbepenem resistance. Future prospective multi-center studies are recommended to further confirm the current findings
ABSTRACT
Several guidelines base the empirical therapy of ventilator-associated pneumonia [VAP] on the time of onset. However, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. This study evaluated the characteristics and outcomes of VAP with different onset times. All of the mechanically ventilated patients admitted to the ICU of a 900-bed tertiary-care hospital between 01/08/2003 and 31/12/2010 were prospectively followed for VAP development according to the National Healthcare Safety Network criteria. The patients were categorized into four groups: EO if VAP occurred within 4 days of intubation and hospital admission; LO if VAP occurred after 4 days of admission; EL if VAP occurred within 4 days of intubation, but after the fourth hospitalization day; and LL if VAP occurred after the fourth day of intubation and hospitalization. Out of the 394 VAP episodes, 63 [16%] were EO episodes, 331 [84.0%] were LO episodes, 40 [10.1%] were EL episodes and 291 [73.1%] were LL episodes. The isolated microorganisms were comparable among the four groups, with a similar rate of potentially multidrug resistant organisms in the EO-VAP [31.7%], LO-VAP [40.8%], EL-VAP [37.5%] and LL-VAP [43.3%] samples. The hospital mortality was 24% for EO-VAP cases, 28% for LO-VAP cases, 40% for EL-VAP cases and 49% for LL-VAP cases. However, in the adjusted multivariate analysis, neither LO-VAP, EL-VAP nor LL-VAP was associated with an increased risk of hospital mortality compared with EO-VAP [OR, 0.86 95% CI, 0.34-2.19; 1.22; 95% CI, 0.41-3.68, and 0.95; 95% CI, 0.43-2.10, respectively]. In this study, the occurrence of potential multidrug resistant pathogens and the mortality risk were similar regardless of VAP timing from hospital admission and intubation. The bacterial isolates obtained from the VAP cases did not follow an early vs. late-onset pattern, and thus, these terms may not be clinically helpful
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Patient Outcome Assessment , Prospective Studies , Cohort Studies , Tertiary Care CentersABSTRACT
To assess the agreement between the tuberculin skin test [TST] and the QuantiFERON-TB Gold test [QFT-G] as pre-employment screening tests for latent tuberculosis infection [LTBI] among healthcare workers. A retrospective cross-sectional study was conducted among 1412 healthcare workers who were screened for LTBI during the period from August 2009 to May 2011 at a tertiary-care hospital in the Kingdom of Saudi Arabia [KSA]. The studied population was screened for LTBI using both TST and QFT-G simultaneously. The agreement between both tests was quantified using the Kappa coefficient [k]. Comparing the results of QFT-G with TST, the tests had a significant overall agreement of 73.7% [1040/1412; k = 0.33; p < 0.01]. Negative concordance comprised 60.1% of the results, and positive concordance comprised 13.5%. However, positive TST but negative QFT comprised 16.3% of the results, and negative TST but positive QFT-G comprised 10.1%. Concordance was significantly associated with young age, female gender, Saudi-born nationals, and early career but not job type [clinical versus non-clinical] nor status of Bacillus Calmette-Guerin [BCG] vaccination. This study demonstrated 73.7% overall agreement between TST and QFT-G results among healthcare workers during pre-employment screening for LTBI. The results need to be confirmed in future studies before recommending QFT-G as a pre-employment screening test for LTBI
Subject(s)
Humans , Male , Female , Tuberculin Test , Hospitals , Mass Screening , Health Personnel , Employment , Retrospective Studies , Cross-Sectional Studies , Tertiary Care CentersABSTRACT
Several studies showed that the implementation of the Institute for Healthcare Improvement [IHI] ventilator bundle alone or with other preventive measures are associated with reducing Ventilator-Associated Pneumonia [VAP] rates. However, the association with ventilator utilization was rarely examined and the findings were conflicting. The objectives were to validate the bundle association with VAP rate in a traditionally high VAP environment and to examine its association with ventilator utilization. The study was conducted at the adult medical-surgical intensive care unit [ICU] at King Abdulaziz Medical City, Saudi Arabia, between 2010 and 2013. VAP data were collected by a prospective targeted surveillance as per Centers for Disease Control and Prevention [CDC]/National Healthcare Safety Network [NHSN] methodology while bundle data were collected by a cross-sectional design as per IHI methodology. Ventilator bundle compliance significantly increased from 90% in 2010 to 97% in 2013 [P for trend < 0.001]. On the other hand, VAP rate decreased from 3.6 [per 1000 ventilator days] in 2010 to 1.0 in 2013 [P for trend = 0.054] and ventilator utilization ratio decreased from 0.73 in 2010 to 0.59 in 2013 [P for trend < 0.001]. There were negative significant correlations between the trends of ventilator bundle compliance and VAP rate [cross-correlation coefficients -0.63 to 0.07] and ventilator utilization [cross-correlation coefficients -0.18 to -0.63]. More than 70% improvement of VAP rates and approximately 20% improvement of ventilator utilization were observed during IHI ventilator bundle implementation among adult critical patients in a tertiary care center in Saudi Arabia. Replicating the current finding in multicenter randomized trials is required before establishing any causal link
ABSTRACT
There is a wide geographic and temporal variability of bacterial resistance among microbial causes of ventilator-associated pneumonia [VAP]. The contribution of multi-drug resistant [MDR] pathogens to the VAP etiology in Saudi Arabia was never studied. We sought to examine the extent of multiple-drug resistance among common microbial causes of VAP. We conducted a retrospective susceptibility study in the adult intensive care unit [ICU] of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Susceptibility results of isolates from patients diagnosed with VAP between October 2004 and June 2009 were examined. The US National Healthcare Safety Network definition of MDR was adopted. A total of 248 isolates including 9 different pathogens were included. Acinetobacter spp. was highly [60-89%] resistant to all tested antimicrobials, including carbapenems [three- and four-class MDR prevalence were 86% and 69%, respectively]. Pseudomonas aeruginosa was moderately [13-31%] resistant to all tested antimicrobials, including antipseudomonal penicillins [three- and four-class MDR prevalence were 13% and 10%, respectively]. With an exception of ampicillin [fully resistant], Klebsiella spp. had low [0-13%] resistance to other tested antimicrobials with no detected MDR. Staphylococcus aureus was fully susceptible to vancomycin with 42% resistance to oxacillin. There were significant increasing trends of MDR Acinetobacter spp. However not P. aeruginosa during the study. Resistant pathogens were associated with worse profile of ICU patients but not patients' outcomes. Acinetobacter in the current study was an increasingly resistant VAP-associated pathogen more than seen in many parts of the world. The current finding may impact local choice of initial empiric antibiotics.
Subject(s)
Humans , Male , Female , Tertiary Care Centers , Drug Resistance, Multiple , Acinetobacter , Retrospective Studies , Pseudomonas aeruginosa , Klebsiella , Staphylococcus aureusABSTRACT
Growing numbers of healthcare facilities are routinely collecting standardized data on healthcare-associated infection [HAI], which can be used not only to track internal performance but also to compare local data to national and international benchmarks. Benchmarking overall [crude] HAI surveillance metrics without accounting or adjusting for potential confounders can result in misleading conclusions. Methods commonly used to provide risk-adjusted metrics include multivariate logistic regression analysis, stratification, indirect standardization, and restrictions. The characteristics of recognized benchmarks worldwide, including the advantages and limitations are described. The choice of the right benchmark for the data from the Gulf Cooperation Council [GCC] states is challenging. The chosen benchmark should have similar data collection and presentation methods. Additionally, differences in surveillance environments including regulations should be taken into consideration when considering such a benchmark. The GCC center for infection control took some steps to unify HAI surveillance systems in the region. GCC hospitals still need to overcome legislative and logistic difficulties in sharing data to create their own benchmark. The availability of a regional GCC benchmark may better enable health care workers and researchers to obtain more accurate and realistic comparisons
ABSTRACT
To study the impact of educational activities on the rates and frequencies of percutaneous injuries [PIs] at a tertiary care hospital in Saudi Arabia. PI surveillance is a routine activity in King Abdulaziz Medical City [a 900-bed teaching tertiary health care hospital] in Riyadh using the Exposure Prevention Information Network [EPINet] data collection tool. From 2001 through 2003, educational activities were conducted for health care workers [HCWs] to prevent PIs. The education included lectures on the risk of unsafe practices that may lead to PIs and how to avoid them. Data from before [1997-2000] and after [2004-2008] the intervention were imported from our surveillance system and statistically analyzed. The total overall rate of PIs per 1000 HCWs was significantly lower in the post-intervention period than in the pre-intervention period [14 vs. 32.8/1000 HCWs, respectively]. The rates of PIs among nurses and housekeepers showed a significant decrease [15 vs. 37.6/1000 HCWs and 10 vs. 34.5/1000 HCWs, respectively]. The frequency of PIs in the emergency department [ED] and intensive care units [ICUs] showed a significant decrease [3.4% for both vs. 12.4% and 13.7%, respectively]. PIs associated with devices, such as needles on IV lines, IV catheters, lancets and suture needles, showed a significant decrease. PIs occurring during device disassembly and from inappropriately discarded devices also decreased significantly. The educational program reduced some categories of PIs, including the overall rate, the rate among nurses and housekeepers, the frequency in the ED and ICUs and the frequency among needles on IV lines, IV catheters, lancets and suture needles. Other PI categories did not change significantly
Subject(s)
Humans , Male , Female , Health Personnel , Hospitals , Influenza A virus , Influenza A Virus, H1N1 SubtypeABSTRACT
Breast carcinoma is most'y diagnosed beyond stage I in Egyptian patients. Here, we evakiate the use of preoperative ultrasonography to predict axillary lymph nodes involvement. We speculate that preoperative ultrasonographic evaluation may be of paramount importance in the era of sentinel node biopsy. Consecutive 110 clinically node-negative breast carcinomas were ultrasonographically examined for axillary nodes using 10 MHz linear transducer The images were recorded for analysis. Descriptive statistics of morphologic features of the examined lymph node in relation to final pathology were performed. Mean age was 47.5 years. Axillary lymph nodes were pathologically invaded in 80 patients [72.7%] with an average infiltration of 4.2 nodes per axilla. Compared to pathologic find ings, gray sca'e ultrasonography was highly significant in differentiating malignant from benign tumors [p<0.001], Gray sca'e examination had a sensitivity for detecting nodal metastases of 85.0%, specificity of 63.3% and overall accuracy of 79.1%. Surgeon-performed axillary ultrasonography is a helpful adjunct to clinical examination to improve preoperative staging in clinically node negative breast cancer especially in larger-sized tumors. However if sonography is negative sentinel node biopsy should be done due to considerable percentage of false negative results