A real-world assessment of procalcitonin combined with antimicrobial stewardship in a community ICU.

PURPOSE: We evaluated the feasibility and impact of PCT-guided antibiotic duration combined with an established antibiotic stewardship program (ASP) in a community hospital intensive care unit (ICU). METHODS: We implemented daily PCT levels for ICU patients receiving antibiotics. Our protocol recommended stopping antibiotic therapy if PCT met an absolute or relative stopping threshold. We evaluated the adherence to stopping criteria within 48 h, antibiotic use [days of therapy (DOT) per 1000 patient-days (PD)], length of stay and ICU-mortality. We performed interrupted time series analysis to compare 24 months before and 12 months after implementation. RESULTS: A total of 297 antibiotic courses were monitored with PCT in 217 patients. Protocol adherence was 34% (absolute threshold: 39%, relative threshold: 12%). Antibiotic use pre-PCT was 935 DOTs/1000 PDs and post-PCT was 817 DOTs/1000 PDs (RRadj 0.73, 95% CI: 0.62 to 0.86). No statistically significant changes in clinical outcomes were noted. CONCLUSION: In the context of an established ASP in a community hospital ICU, PCT monitoring was feasible and associated with an adjusted overall decrease of 27% in antibiotic use with no adverse impact on clinical outcomes. Incorporating PCT testing to guide antibiotic duration can be successful if integrated into workflow and paired with ASP guidance.

The second-hand effects of antibiotics: communicating the public health risks of drug resistance.

Antimicrobial resistance (AMR) poses a threat to modern medicine, but there are challenges in communicating its urgency and scope and potential solutions to this growing problem. It is recognized that AMR has a 'language problem' and the way in which healthcare professionals communicate about AMR may not always resonate with patients. Many patients are unaware that antibiotics can have detrimental effects to those beyond the recipient, due to transmission of drug-resistant organisms. The overestimation of benefits and underestimation of risks helps to fuel demand for antibiotic use in situations where they may be of little or no benefit. To better communicate risks, clinicians may borrow the term 'second-hand' from efforts to reduce smoking cessation. We present several examples where antibiotics themselves have second-hand effects beyond the individual recipient in hospitals, long-term care homes and the community. Incorporation of the concept of the second-hand effects of antibiotics into patient counselling, mass messaging and future research may help facilitate a more balanced discussion about the benefits and risks of antibiotic use in order to use these agents more appropriately.

Bringing home unwelcome souvenirs: Travel and drug-resistant bacteria.

Antimicrobial resistance poses a significant threat to public health globally and in Canada. Wide regional variability in antimicrobial resistance and ongoing increases in global travel present an important risk for the acquisition and transmission of drug-resistant organisms. Travel from high-income to low- and middle-income countries, particularly the Indian subcontinent, present the greatest risks for acquiring a drug-resistant Enterobacteriaceae. Risk factors for returning from travel with drug-resistant organisms include seeking medical care while abroad, travellers' diarrhea and antibiotic use. Health care professionals can play an important role in preventing harm for travellers by counselling patients on the risks of acquiring drug-resistant organisms, appropriate antibiotic prescribing for travellers' diarrhea and tailored empiric therapy for patients presenting with infection after travel.

Meat-cooking mutagens and risk of renal cell carcinoma.

BACKGROUND: High-temperature cooked meat contains two families of carcinogens, heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs). Given the kidneys' role in metabolism and urinary excretion of these compounds, we investigated meat-derived mutagens, as well as meat intake and cooking methods, in a population-based case-control study conducted in metropolitan Detroit and Chicago. METHODS: Newly diagnosed, histologically confirmed adenocarcinoma of the renal parenchyma (renal cell carcinoma (RCC)) cases (n=1192) were frequency matched on age, sex, and race to controls (n=1175). The interviewer-administered Diet History Questionnaire (DHQ) included queries for meat-cooking methods and doneness with photographic aids. Levels of meat mutagens were estimated using the DHQ in conjunction with the CHARRED database. RESULTS: The risk of RCC increased with intake of barbecued meat (P(trend)=0.04) and the PAH, benzo(a)pyrene (BaP) (multivariable-adjusted odds ratio and 95% confidence interval, highest vs lowest quartile: 1.50 (1.14, 1.95), P(trend)=0.001). With increasing BaP intake, the risk of RCC was more than twofold in African Americans and current smokers (P(interaction)<0.05). We found no association for HCAs or overall meat intake. CONCLUSION: BaP intake, a PAH in barbecued meat, was positively associated with RCC. These biologically plausible findings advocate further epidemiological investigation into dietary intake of BaP and risk of RCC.

Use of a template to improve documentation and coding.

BACKGROUND AND OBJECTIVES: Accurate assignment of evaluation and management (E&M) codes is a challenge for physicians. Having guidelines close at hand during patient visits might improve appropriateness and accuracy of E&M coding. We developed a template based on a clinical prediction rule for group A beta-hemolytic streptococcal (GABHS) pharyngitis to improve documentation and coding decisions. METHODS: Fifty office visits for sore throat were documented using templates and were compared with 50 sore throat visits that were documented using progress notes. We counted history and physical examination items and compared the level of service charged to the level of service supported by the note. RESULTS: Significantly more history of present illness and physical examination items were recorded on templates. Decisions related to treatment for patients with a low probability of GABHS were also improved by the templates. Templates had no effect on billing and coding errors. CONCLUSIONS: The template resulted in more-thorough documentation but had no effect on coding and billing errors relative to progress notes.

Prostate cancer histologic trends in the metropolitan Detroit area, 1982 to 1996.

OBJECTIVES: One of the concerns regarding the widespread use of serum prostate-specific antigen (PSA) as a screening tool for prostate cancer is the possibility that it may detect latent or clinically insignificant cancers. One indicator of clinical importance is thought to be histologic grade, with clinically unimportant cancers more likely to be well differentiated and clinically important tumors more likely to be moderately or poorly differentiated. METHODS: Data from the metropolitan Detroit population-based Surveillance, Epidemiology, and End Results Program were examined to determine trends in prostate cancer histologic grading before and after the introduction of PSA screening. RESULTS: From 1989 through 1996, the most recent year for which data are available, a dramatic increase in the incidence of prostate cancer occurred in the Detroit area, corresponding to the routine use of PSA as a screening test for prostate cancer. Local stage cancer demonstrated the largest increase in incidence. The incidence of moderately differentiated cancers also rose substantially during the same period; the incidence of poorly differentiated tumors remained about the same, and the incidence of well differentiated tumors decreased. Coincident with the increasing proportion of moderately differentiated cancers was a significant increase in the proportion of prostate biopsies performed (P = 0.001). CONCLUSIONS: These population-based data add important evidence that prostate cancers identified with PSA are more likely to be moderately than well differentiated. Additionally, if the definition of clinical significance depends on histopathologic grade, this finding could further be interpreted as evidence that PSA is more likely to detect clinically significant prostate cancer.

Trends in the stage specific incidence of prostate carcinoma in the Detroit metropolitan area, 1973-1994.

BACKGROUND: Much of the recent increase in prostate carcinoma incidence has been attributed to screening with prostate specific antigen (PSA). Controversy exists as to whether this screening will ultimately impact prostate carcinoma mortality. Until adequate time elapses since PSA screening became widespread, or a randomized trial of PSA screening is completed, the effect of PSA screening on prostate carcinoma mortality cannot be determined. In the interim, stage specific prostate carcinoma incidence rates may provide an indication of the effect of PSA screening. METHODS: Annual stage specific age-adjusted prostate carcinoma incidence rates for the years 1973 through 1994 were obtained from the Metropolitan Detroit Cancer Surveillance System (MDCSS), a member of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program. These incidence rates were analyzed for trends using Poisson regression analysis. RESULTS: There were 10,801 cases of prostate carcinoma in black men and 31,501 in white men during the 22-year period. Incidence rates for stages of local and regional prostate carcinoma reached a maximum in 1992 and 1993. Distant stage prostate carcinoma incidence has steadily declined since 1989 (P < 0.001), the year in which the increasing trend in the incidence rates for local and regional stage prostate carcinoma were first noted. CONCLUSIONS: These findings suggest that a substantial proportion of early stage prostate carcinoma detected by PSA is in fact clinically important and that early detection of these carcinomas has resulted in a continuous decline in the stage of metastatic prostate carcinoma since 1989.

Prostate-specific antigen in a community screening program.

BACKGROUND: This study was designed to determine who participates in community-based prostate-specific antigen (PSA) screening programs and what serum PSA levels can be expected. METHODS: A descriptive analysis of men who participated in an annual community health screening program was used to compare men who chose PSA screening with those who did not. The relationship of demographic variables to PSA level was evaluated by multivariate regression analysis. Data were available on 5548 men, 6% of whom were black. RESULTS: The population of PSA screening participants included proportionately more middle-aged white men with higher median income, as compared with men who did not participate. Those who did not participate in the screening were more likely to be either very old or very young. PSA levels increased with age, and the percentage of men with elevated PSA levels increased with age. One tenth (9.6%) of all participants had PSAs between 4 ng/mL and 10 ng/mL, and 1.9% had levels greater than 10 ng/mL. Within 1 year of the screening, 1.7% of the screened participants had a diagnosis of prostate cancer. The mean PSA in this group was 15.9 ng/mL. CONCLUSIONS: These data confirm the need for age-specific PSA reference ranges. It is likely that the same reference range can be used for all racial ethnic populations.