Epidemiology and genetic characteristics of extended-spectrum ß-lactamase-producing Gram-negative bacteria causing urinary tract infections in long-term care facilities.

OBJECTIVES: To assess risk factors for acquiring extended-spectrum ß-lactamase-producing Gram-negative bacteria (ESBL+ GN) causing urinary tract infections (UTIs) in long-term care facilities (LTCFs). METHODS: A prospective case-case-control study was carried out. In the first study, cases were defined as patients harbouring ESBL+ GN, while, in the second study, cases were defined as patients harbouring ESBL-negative (ESBL-) GN. Controls were selected by simple random sampling from patients without GN infection. ESBL determinants were characterized by hybridization, and confirmed by PCR and sequencing. RESULTS: The study involved 297 LTCF patients (99 with ESBL+ GN UTI, 99 with ESBL- GN UTI and 99 without GN infection). ESBL+ GN UTIs were due to Escherichia coli (64%), Proteus mirabilis (25%) and Klebsiella pneumoniae (11%). The CTX-M-type enzymes were the most prevalent (73% of isolates), whereas TEM- and SHV-type ESBLs and AmpC-type enzymes were less prevalent (10%, 2% and 15% of isolates, respectively). Patients with ESBL+ GN UTI were more likely to have a permanent urinary catheter (OR 15, 95% CI 6.9-30.5) and to have received antimicrobial therapy in the previous 30 days (OR 4, 95% CI 1.2-10.9). After adjusting for type, dosage and duration of antibiotic, exposure to ≥7 days of quinolones and third-generation cephalosporins was associated with the highest risk of ESBL+ GN UTI development (OR 7, 95% CI 1.2-40). Independent risk factors for acquiring ESBL- GN UTIs were previous surgical procedures (OR 2, 95% CI 1.1-4) and the presence of a urinary catheter (OR 8, 95% CI 4-16). No specific antibiotics remained a significant risk for ESBL- GN UTI after adjusting for demographic and clinical risk factors. CONCLUSIONS: Exposure to ≥7 days of quinolones and third-generation cephalosporins significantly increases the risk of ESBL+ GN UTI. Interventions aimed at improving compliance with antimicrobial stewardship principles should be further developed and implemented in LTCFs.

Ten years' activity of the first Italian public hospice for terminally ill patients.

We present a review of the first 10 years of the hospice at the Geriatric Institute Pio Albergo Trivulzio of Milan, Italy's first public hospice for the admission of terminally ill patients. Over 1200 patients were admitted to the nine-bed hospice between October 1991 and December 2001, most of whom (63%) were referred by the Home Palliative Care Units operating in Milan. The hospice patients are elderly (nearly 60% are 70 or more years of age, median 72 years). Admission to the hospice was until the patient's death (74% of patients) after a brief time (4 weeks on average). From the very outset, we have striven to focus our attention on the daily application of the programmes of care inspired by the philosophy and practice of palliative medicine, i.e. the holistic approach and attention devoted to quality of life, multidimensional assessment, and the services of a multiprofessional team to provide, alongside medical and nursing assistance, psychosocial and spiritual support, bereavement support, etc. The continuing education of health workers and the systematic use of a clinical audit tool specifically designed for palliative care, are the two key elements which, in our judgement, have proved to be the most fruitful in reaching the objectives described above. These 10 years of the Pio Albergo Trivulzio Hospice have made a significant contribution towards defining a concrete Italian model which can be applied to the care of the terminally ill inpatient.

Distortion of iron status indices by acute inflammation in older hospitalized patients.

The relation between acute inflammation and biochemical indices of iron and nutritional status in older in-patients have been investigated. Thirty-nine consecutive patients (25 men and 14 women; median age 79 years) with acute inflammation episode were evaluated. C-reactive protein (CRP) > or = 3 mg/dl was considered to indicate acute inflammation. Iron and nutritional status were explored measuring hemoglobin (Hb), hematocrit (Ht), red blood cell (RBC), white blood cell (WBC), mean erythrocyte volume (MCV), mean corpuscular hemoglobin (MCH), and serum levels of iron (Fe), transferrin (T), percentage transferrin saturation (%TS), ferritin (SF), albumin (Alb) and pre-albumin (pre-Alb), the day after admission (T-basal), the day of onset of inflammation (T0), and successively (T5, T8-15, and T-final). CRP and WBC were significantly higher at T0 than T-basal (CRP: +1014%, P < 0.01; WBC: +30%, P < 0.01) but had reduced on days T8-15 compared to T0 (CRP: -90%, P < 0.01; WBC: -26%, P < 0.01). Fe serum levels fell at the beginning of the acute phase (T0: -24% versus T-basal; P < 0.01), but had recovered at T-final (+36% versus T5; P < 0.01). T levels also varied significantly (P < 0.01) (T0: -16% versus T-basal; T-final: +18% versus T5). SF was slightly higher than normal at T-basal and increased further during inflammation (+41% at T5 versus T-basal) to reduce at T-final (-36% versus T5; P < 0.01). At T-final, pre-Alb and Alb were significantly higher than at T5 (pre-Alb +63%, P < 0.01; Alb +20%, P < 0.05). The indices of iron status are disrupted in elderly patients during acute inflammation, just as they are in chronic inflammation, and cannot therefore be used to diagnose sideropenic anemia. The only variables not influenced by inflammation are MCV and %TS. Low values of these, associated with other symptoms of anemia, suggest sideropenic anemia, irrespective of the values of the other indices of iron status. With the appearance of inflammation, nutritional indices tend to decline as liver activity shifts to the production of acute phase proteins.