Knowledge and awareness of infection control practices among nursing professionals: A cross-sectional survey from South Asia and the Middle East.

BACKGROUND: The proficiency of nursing professionals in the infection prevention and control (IPC) practices is a core component of the strategy to mitigate the challenge of healthcare associated infections. AIM: To test knowledge of nurses working in intensive care units (ICU) in South Asia and Middle East countries on IPC practices. METHODS: An online self-assessment questionnaire based on various aspects of IPC practices was conducted among nurses over three weeks. RESULTS: A total of 1333 nurses from 13 countries completed the survey. The average score was 72.8% and 36% of nurses were proficient (mean score > 80%). 43% and 68.3% of respondents were from government and teaching hospitals, respectively. 79.2% of respondents worked in < 25 bedded ICUs and 46.5% in closed ICUs. Statistically, a significant association was found between the knowledge and expertise of nurses, the country's per-capita income, type of hospitals, accreditation and teaching status of hospitals and type of ICUs. Working in high- and upper-middle-income countries (ß = 4.89, 95%CI: 3.55 to 6.22) was positively associated, and the teaching status of the hospital (ß = -4.58, 95%CI: -6.81 to -2.36) was negatively associated with the knowledge score among respondents. CONCLUSION: There is considerable variation in knowledge among nurses working in ICU. Factors like income status of countries, public vs private and teaching status of hospitals and experience are independently associated with nurses' knowledge of IPC practices.

The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis.

This is the first guideline developed by the Saudi Thoracic Society for the diagnosis and management of noncystic fibrosis bronchiectasis. Local experts including pulmonologists, infectious disease specialists, thoracic surgeons, respiratory therapists, and others from adult and pediatric departments provided the best practice evidence recommendations based on the available international and local literature. The main objective of this guideline is to utilize the current published evidence to develop recommendations about management of bronchiectasis suitable to our local health-care system and available resources. We aim to provide clinicians with tools to standardize the diagnosis and management of bronchiectasis. This guideline targets primary care physicians, family medicine practitioners, practicing internists and respiratory physicians, and all other health-care providers involved in the care of the patients with bronchiectasis.

Antimicrobial therapeutic determinants of outcomes from septic shock among patients with cirrhosis.

UNLABELLED: It is unclear whether practice-related aspects of antimicrobial therapy contribute to the high mortality from septic shock among patients with cirrhosis. We examined the relationship between aspects of initial empiric antimicrobial therapy and mortality in patients with cirrhosis and septic shock. This was a nested cohort study within a large retrospective database of septic shock from 28 medical centers in Canada, the United States, and Saudi Arabia by the Cooperative Antimicrobial Therapy of Septic Shock Database Research Group between 1996 and 2008. We examined the impact of initial empiric antimicrobial therapeutic variables on the hospital mortality of patients with cirrhosis and septic shock. Among 635 patients with cirrhosis and septic shock, the hospital mortality was 75.6%. Inappropriate initial empiric antimicrobial therapy was administered in 155 (24.4%) patients. The median time to appropriate antimicrobial administration was 7.3 hours (interquartile range, 3.2-18.3 hours). The use of inappropriate initial antimicrobials was associated with increased mortality (adjusted odds ratio [aOR], 9.5; 95% confidence interval [CI], 4.3-20.7], as was the delay in appropriate antimicrobials (aOR for each 1 hour increase, 1.1; 95% CI, 1.1-1.2). Among patients with eligible bacterial septic shock, a single rather than two or more appropriate antimicrobials was used in 226 (72.9%) patients and was also associated with higher mortality (aOR, 1.8; 95% CI, 1.0-3.3). These findings were consistent across various clinically relevant subgroups. CONCLUSION: In patients with cirrhosis and septic shock, inappropriate and delayed appropriate initial empiric antimicrobial therapy is associated with increased mortality. Monotherapy of bacterial septic shock is also associated with increased mortality. The process of selection and implementation of empiric antimicrobial therapy in this high-risk group should be restructured.

Ventilator-associated pneumonia in adults in developing countries: a systematic review.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a leading cause of death in hospitalized patients, but there has been no systematic analysis of the incidence, microbiology, and outcome of VAP in developing countries or of the interventions most applicable in that setting. METHODS: We reviewed MEDLINE (January 1966-April 2007) and bibliographies of the retrieved articles for all observational or interventional studies that examined the incidence, microbiology, outcome, and prevention of VAP in ventilated adults in developing countries. We evaluated the rates of VAP using the National Healthcare Safety Network (NHSN) definitions and the impact of VAP on the intensive care unit (ICU) length of stay (LOS) and mortality, and the impact of interventions used to reduce VAP rates. RESULTS: The rates of VAP varied from 10 to 41.7 per 1000 ventilator-days and were generally higher than NHSN benchmark rates. Gram-negative bacilli were the most common pathogens (41-92%), followed by Gram-positive cocci (6-58%). VAP was associated with a crude mortality that ranged from 16% to 94% and with increased ICU LOS. Only a small number of VAP intervention studies were performed; these found that staff education programs, implementation of hand hygiene, and VAP prevention practice guidelines, and/or implementation of sedation protocol were associated with a significant reduction in VAP rates. Only one interventional study was a randomized controlled trial comparing two technologies, the rest were sequential observational. This study compared a heat and moisture exchanger (HME) to a heated humidifying system (HHS) and found no difference in VAP rates. CONCLUSIONS: Based on the existing literature, the rate of VAP in developing countries is higher than NHSN benchmark rates and is associated with a significant impact on patient outcome. Only a few studies reported successful interventions to reduce VAP. There is a clear need for additional epidemiologic studies to better understand the scope of the problem. Additionally, more work needs to be done on strategies to prevent VAP, probably with emphasis on practical, low-cost, low technology, easily implemented measures.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman's Disease) as cause of isolated hilar lymphadenopathy and complete remission after high dose steroid.

Rosai-Dorfman's Disease, also known as sinus histiocytosis with massive lymphadenopathy (SHML), is a rare histiocytic proliferative disorder and a distinct clinico-pathological feature of unknown origin. Painless cervical lymphadenopathy is the most common clinical presentation. Different treatment modalities have been tried with variable responses, however, there is no consensus on the best modality of treatment. Here, we present a case report of SHML causing isolated hilar lymphadenopathy with complete remission for more than 6 years, after a short course of high dose steroid (dexamethasone 20 mg daily for 3 days).

Awake anaesthesia for major thoracic surgical procedures: an observational study.

OBJECTIVE: Major thoracic surgical procedures are rarely performed under awake anaesthesia. The purpose of this study is to review the experience of a tertiary center in major thoracic surgical procedures done under awake anaesthesia. METHODS: This single center, single operator, retrospective review of cases of thoracic surgery were done under awake anaesthesia, which included all patients operated on from September 2002 to September 2006. Patients were pre-medicated with intravenous fentanyl 50 microg and midazolam 3mg. Thoracic epidural anaesthesia was done either between T1-T3 and T4-T6 depending on the type of procedure. The block level was verified using warm-cold discrimination. In addition, stellate ganglion block was performed in some patients to achieve cough control. The following data were documented: patients' demographics, the type and approach of procedure, operative time, intraoperative complications, conversion to general anaesthesia, mortality, the need for intensive care unit (ICU) admission and postoperative hospital length of stay. RESULTS: A total of 79 cases were performed over the study period. The mean age was 37+/-18 years (59% male). Twenty-five patients (32%) underwent thymectomy, 11 patients (13%) lung resection and 8 patients (11%) sympathectomy. The most common approach was thoracoscopy in 61 patients (77%), followed by thoracotomy in 11 patients (14%) and median sternotomy in 3 patients (4%). The median postoperative hospital stay was 1.5 days, with 33% of cases discharged on the same day of operation (day surgery). Only five patients (6%) required ICU admission; three of these patients in 2002 did not need ICU, but epidural policy at that time mandated ICU admission - only 2/79 (2.5% required ICU). One patient died as a result of his underlying metastatic hepatocellular carcinoma 9 days postoperatively. Another patient was converted early to general anaesthesia prior to pneumonectomy after discovery of left upper lobe involvement and he died 3 months later. There was no anaesthesia related mortality. CONCLUSIONS: We conclude that major thoracic procedure can be safely performed under awake anaesthesia. The technique avoids general anaesthesia and endotracheal intubation, reduces postoperative hospital stay and minimizes intensive care unit admission. This study strongly suggests awake anaesthesia can improve outcomes and reduce cost. A proper multi-center trial to further evaluate this technique is needed.

Assessment of six mortality prediction models in patients admitted with severe sepsis and septic shock to the intensive care unit: a prospective cohort study.

INTRODUCTION: We conducted the present study to assess the validity of mortality prediction systems in patients admitted to the intensive care unit (ICU) with severe sepsis and septic shock. We included Acute Physiology and Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Mortality Probability Model (MPM) II0 and MPM II24 in our evaluation. In addition, SAPS II and MPM II24 were customized for septic patients in a previous study, and the customized versions were included in this evaluation. MATERIALS AND METHOD: This cohort, prospective, observational study was conducted in a tertiary care medical/surgical ICU. Consecutive patients meeting the diagnostic criteria for severe sepsis and septic shock during the first 24 hours of ICU admission between March 1999 and August 2001 were included. The data necessary for mortality prediction were collected prospectively as part of the ongoing ICU database. Predicted and actual mortality rates, and standardized mortality ratio were calculated. Calibration was assessed using Lemeshow-Hosmer goodness of fit C-statistic. Discrimination was assessed using receiver operating characteristic curves. RESULTS: The overall mortality prediction was adequate for all six systems because none of the standardized mortality ratios differed significantly from 1. Calibration was inadequate for APACHE II, SAPS II, MPM II0 and MPM II24. However, the customized version of SAPS II exhibited significantly improved calibration (C-statistic for SAPS II 23.6 [P = 0.003] and for customized SAPS II 11.5 [P = 0.18]). Discrimination was best for customized MPM II24 (area under the receiver operating characteristic curve 0.826), followed by MPM II24 and customized SAPS II. CONCLUSION: Although general ICU mortality system models had accurate overall mortality prediction, they had poor calibration. Customization of SAPS II and, to a lesser extent, MPM II24 improved calibration. The customized model may be a useful tool when evaluating outcomes in patients with sepsis.