Persuasive antimicrobial stewardship intervention in the context of a KPC outbreak: a controlled interrupted time series analysis.

INTRODUCTION: Antimicrobial resistance is a major public health threat. Antimicrobial stewardship (AMS) is one of the key strategies to overcome resistance, but robust evidence on the effect of specific interventions is lacking. We report an interrupted time series (ITS) analysis of a persuasive AMS intervention implemented during a KPC producing Klebsiella pneumoniae outbreak. METHODS: A controlled ITS for carbapenem consumption, total antibiotic consumption and antibiotic-free days, between January 2012 and May 2018 was performed, using segmented regression analysis. The AMS intervention was implemented in the Vascular Surgery ward starting on April 2016 in the context of a KPC outbreak. The General Surgery ward was taken as a control group. Data were aggregated by month for both wards, including 51 pre-intervention and 26 intervention points. RESULTS: The AMS intervention produced a level change in carbapenem consumption of - 11.14 DDDs/100 patient-days accompanied by a decreasing trend of total antibiotic consumption and stable rate of antibiotic-free days in Vascular Surgery ward. These differences were not apparent in the control group. No differences in mortality or readmission rates between pre-intervention and intervention periods were noticed in any of the groups. CONCLUSION: Persuasive AMS interventions on top of previously implemented restrictive interventions can reduce carbapenem consumption without increasing total antibiotic consumption. Starting persuasive AMS interventions in an outbreak setting does not compromise the sustainability of the intervention.

Severe Tuberculosis Requiring Intensive Care: A Descriptive Analysis.

Background. This study aims to describe the characteristics of tuberculosis (TB) patients requiring intensive care and to determine the in-hospital mortality and the associated predictive factors. Methods. Retrospective cohort study of all TB patients admitted to the ICU of the Infectious Diseases Department of Centro Hospitalar de São João (Porto, Portugal) between January 2007 and July 2014. Comorbid diagnoses, clinical features, radiological and laboratory investigations, and outcomes were reviewed. Univariate analysis was performed to identify risk factors for death. Results. We included 39 patients: median age was 52.0 years and 74.4% were male. Twenty-one patients (53.8%) died during hospital stay (15 in the ICU). The diagnosis of isolated pulmonary TB, a positive smear for acid-fast-bacilli and a positive PCR for Mycobacterium tuberculosis in patients of pulmonary disease, severe sepsis/septic shock, acute renal failure and Multiple Organ Dysfunction Syndrome on admission, the need for mechanical ventilation or vasopressor support, hospital acquired infection, use of adjunctive corticotherapy, smoking, and alcohol abuse were significantly associated with mortality (p < 0.05). Conclusion. This cohort of TB patients requiring intensive care presented a high mortality rate. Most risk factors for mortality were related to organ failure, but others could be attributed to delay in the diagnostic and therapeutic approach, important targets for intervention.

[Leukemoid reaction and fever after polyvalent polysaccharide pneumococcal vaccination]. / Reacção leucemóide e febre após vacinação anti-pneumocócica polissacarídica 23-valente.

Streptococcus pneumoniae is one of the leading causes of pneumonia and several other invasive diseases as well as upper respiratory tract infections. They are more prevalent and serious in elderly and in those with chronic diseases and with high morbidity and mortality. Invasive pneumococcal diseases can most effectively be prevented by vaccination. The vaccine is effective and safe, even after revaccination. Nevertheless, some adverse events can occur, the most frequent being local, mild and self-limited. Although unusual, serious systemic reactions can eventually have a great impact in the individual health. The authors report a clinical case of a 66 years old man who was vaccinated with polyvalent polysaccharide pneumococcal vaccine and who developed a serious local and systemic reaction, including leukemoid reaction and respiratory insufficiency. In this respect they make some comments regarding the value of this vaccine.