Antibiotic prescribing practices for catheter urine culture results.

BACKGROUND: The literature suggests that positive results of catheter urine cultures frequently lead to unnecessary antimicrobial prescribing, which therefore represents an important target for stewardship. OBJECTIVE: To assess the appropriateness of antibiotic prescribing in response to the results of urine cultures from patients with indwelling urinary catheters. METHODS: This retrospective study was conducted at a tertiary care centre and involved adults with indwelling urinary catheters from whom urine specimens were obtained for culture. Patients with positive or negative culture results were identified from microbiology laboratory reports. The medical records of consecutive patients were screened to select a sample of 80 inpatients (40 per group). Abstracted patient histories were independently evaluated by an expert panel of 3 infectious diseases consultants blinded to the decisions of prescribers and of fellow panelists. The primary end point was concordance of each patient's treatment decision (with respect to the indication) between the expert panel (based on majority agreement, i.e., at least 2 of the 3 expert panelists) and the prescriber. The secondary end points were unnecessary days of therapy and selected outcomes over a predefined period after urine was obtained for culture. RESULTS: A total of 591 charts were screened to generate the targeted number of patients. Baseline demographic characteristics were comparable for the 2 groups, except antibiotic exposure before urine collection was significantly more frequent for the group with negative culture results. The treatment decision was concordant in 40% (16/40) of the patients with a positive culture result and 85% (34/40) of those with a negative culture result (p < 0.001). The most common reason for discordance was administration of antibiotics when not indicated (23 of 24 patients with a positive result and 5 of 6 patients with a negative result), which accounted for 165 and 32 unnecessary days of therapy per 1000 inpatient-days, respectively (p < 0.001). Adverse effects occurred in 2 of the 23 patients with a positive result who received antibiotics that were not indicated. CONCLUSIONS: Appropriateness of antibiotic prescribing, as measured by concordance of decisions between the expert panel and prescribers, was more common among patients with negative urine culture results than among those with positive results. However, there is an opportunity to improve prescribing for both groups through antimicrobial stewardship initiatives. Unnecessary days of therapy and adverse effects were more common in patients with a positive culture result.

CONTEXTE: Selon la littérature, des résultats positifs à des cultures d'échantillons d'urine prélevés à partir d'une sonde vésicale entraînent souvent la prescription inutile d'antibiotiques; par conséquent, cette situation représente un objet important de gestion responsable des antimicrobiens. OBJECTIF: Évaluer la pertinence de la prescription d'antibiotiques sur la base de résultats des cultures d'échantillons d'urine prélevés chez les patients porteurs d'une sonde vésicale à demeure. MÉTHODES: La présente étude rétrospective a été menée dans un établissement de soins tertiaires auprès de patients adultes porteurs d'une sonde vésicale à demeure chez qui on a prélevé des échantillons d'urine à des fins de culture. Les patients avec des résultats de culture positifs ou négatifs ont été repérés à partir des rapports de microbiologie. Les dossiers médicaux d'une série consécutive de patients ont été examinés afin de choisir un échantillon de 80 patients hospitalisés (40 par groupe). Les historiques abrégés des patients ont été évalués indépendamment par un panel d'experts composé de trois consultants en maladies infectieuses qui ignoraient la décision des prescripteurs et les résultats des évaluations de leurs collègues panélistes. Le paramètre d'évaluation principal était la concordance de la décision thérapeutique (quant à l'indication) pour chaque patient entre le panel d'experts (selon un accord majoritaire, c.-à-d. au moins deux des trois panélistes experts) et le prescripteur. Les paramètres d'évaluation secondaires étaient le nombre de jours de traitement inutiles et certains résultats cliniques sur une période prédéterminée après l'obtention d'un échantillon d'urine à des fins de culture. RÉSULTATS: Un total de 591 dossiers de patients ont été analysés afin d'obtenir le nombre cible de patients pour l'étude. Les caractéristiques démographiques initiales étaient comparables dans les deux groupes, sauf l'exposition aux antibiotiques avant le prélèvement d'urine qui était significativement plus fréquente dans le groupe de patients ayant obtenu des résultats de culture négatifs. La décision thérapeutique concordait pour 40 % (16/40) des patients ayant obtenu des résultats positifs à la culture d'urine et pour 85 % (34/40) de ceux qui avaient obtenu des résultats négatifs (p < 0,001). La raison la plus fréquente expliquant la discordance entre les décisions thérapeutiques était l'administration non indiquée d'antibiotiques, une circonstance observée chez 23 patients sur 24 ayant obtenu des résultats positifs et 5 patients sur 6 ayant obtenu des résultats négatifs. Ces cas ont contribué respectivement à un total de 165 et de 32 jours de traitement inutiles par 1000 journées-patients hospitalisés (p < 0,001). Des effets indésirables sont survenus chez deux des 23 patients ayant obtenu un résultat positif et reçu des antibiotiques non indiqués. CONCLUSIONS: La pertinence de la prescription d'antibiotiques, telle qu'elle a été mesurée en fonction de la concordance des décisions entre le panel d'experts et les prescripteurs, était plus fréquente dans le cas des patients ayant obtenu des résultats négatifs à la culture d'urine que chez ceux dont ces résultats étaient positifs. Cependant, des mesures pour la gestion responsable des antimicrobiens pourraient améliorer la prescription dans les deux groupes. Le nombre de jours de traitement inutiles et les effets indésirables étaient plus fréquents chez les patients ayant obtenu des résultats positifs à la culture. [Traduction par l'éditeur].

Methicillin-resistant/methicillin-sensitive Staphylococcus aureus bacteremia.

OBJECTIVE: To examine the differences between the clinical presentation, management and outcome of persons bacteremic with methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA), after controlling for age, sex and primary diagnosis. METHODS: A review of the clinical records and laboratory data of all MRSA and MSSA bacteremic patients. Fifty matched case-control pairs were further analyzed looking for differences between the 2 populations. The study was carried out in a 500-bed adult tertiary care institution in southwestern Ontario, Canada, between 1994 and 1999. RESULTS: On univariate analysis a) duration of hospitalization prior to bacteremia, b) concomitant polymicrobial bacteremia, c) time to appropriate treatment, were significantly greater in the MRSA infected population. Attributable mortality was also higher, 36%-20%, but this did not achieve significance (p=0.1). On multiple logistic regression analysis, a), b) and c) remained significantly different. CONCLUSION: In a 1:1 matched case-control study of Staphylococcus aureus bacteremia, those infected with MRSA became bacteremic later in their hospital stay, more often had a polymicrobial bacteremia and were appropriately treated later. Although mortality attributable to the MRSA bacteremia was greater, this difference did not achieve significance.

MRSA prevalence in a teaching hospital in Western Saudi Arabia.

OBJECTIVE: To determine the prevalence of Methicillin Resistant Staphylococcus aureus (MRSA) colonization in our institution. METHODS: A 5-day period prevalence study of all adult and pediatric patients. Excluded areas were the adult intensive care unit (screened on admission and weekly thereafter), the outpatient hemodialysis population (screened monthly), and newborns. Our facility is a referral/teaching hospital for the National Guard population and their dependants in Western Saudi Arabia. A total of 240 patients were screened. Nasal sampling was carried out and isolation/identification of MRSA was performed using standard microbiological methods. RESULTS: The total number of patients sampled was 240 and of those 10 (4%) were colonized. The 10 positives were found in 4 patient care areas; adult male medicine 5, adult male oncology 3, adult female medicine one, adult high dependency unit one. These patients care areas had 69 patients (42 males and 27 females). Ten (14%) were colonized by MRSA; 9 males (21%) and one female (3%). Statistical analysis Chi Square for discontinuous variables, "F" test for continuous variables found that one), male gender (p=0.04), 2) the presence of a long term invasive device (p=0.04), 3), length of stay (p=0.004) were predictive of MRSA colonization. CONCLUSION: The overall prevalence of MRSA colonization in our hospital was low, however a sub-segment of the population identified as male, having long term invasive devices, and hospitalized more than 2 weeks, were frequently colonized. Any strategy, in our hospital, to control the spread of MRSA should include the testing of this population.

A prospective randomized trial of endoscopic versus conventional harvesting of the saphenous vein in coronary artery bypass surgery.

OBJECTIVES: Our objectives were (1) to determine whether minimally invasive endoscopic harvesting of the saphenous vein reduces morbidity due to postoperative wound infection and pain with improved cosmetic results and mobilization as compared with the conventional technique and (2) to compare the histologic properties of the saphenous veins harvested conventionally and endoscopically. METHODS: One hundred forty-four patients undergoing coronary artery bypass grafting were randomized to have vein harvesting performed by either the conventional (n = 72) or an endoscopic (n = 72) minimally invasive technique. RESULTS: Vein harvest time (open leg wound time) was significantly reduced in the endoscopic group (27.6 vs 64.4 minutes; P <.0001). The rate of leg wound infection was significantly reduced in the endoscopic group (4.3%) as compared with the conventional group (24.6%), a relative risk reduction of 83% (95% confidence interval: 36%-129%; P =.0006). The majority of infections (84.2%) occurred after hospital discharge. Postoperative leg pain, mobilization, and overall patient satisfaction were also significantly improved in the endoscopic group. Double blinded histologic assessment of harvested vein (n = 28) showed no evidence of any clinically important significant damage to the specimens in either group. CONCLUSIONS: In this prospective randomized trial, endoscopic harvesting of the saphenous vein significantly reduced postoperative leg wound complications, including infection, and improved patient satisfaction as compared with the conventional harvesting technique. There were no significant histologic differences between the conventional and endoscopically harvested saphenous veins.