Appropriateness of the dialysis modality selection process: A cross-sectional study.

Studies that specifically quantify the appropriateness of the process of dialysis modality selection are lacking. Peritoneal dialysis (PD) offers clinical and social advantages over hemodialysis (HD), but may be underused. We aimed to determine the appropriateness of the process of dialysis modality selection and quantify the percentage of patients who could potentially have been PD candidates. We performed a cross-sectional study that included adult patients from a hospital Nephrology Department in Barcelona who started dialysis between 2014 and 2015. We assessed the appropriateness of dialysis modalities selection by defining 3 sequential domains based on 3 critical steps in choosing a dialysis modality: eligibility for either treatment, information about modalities, and shared decision-making. We obtained data using medical records and a patient questionnaire. The dialysis modality selection process was considered appropriate when patients had no contraindications for the selected option, received complete information about both modalities, and voluntarily chose the selected option. A total of 141 patients were included in this study. The median age was 72 years (interquartile range 63-82 years), and 65% of the patients were men. The dialysis modality selection process was potentially inappropriate in 22% of the participants because of problems related to information about dialysis modalities (15%) or shared decision-making (7%). Appropriate PD use can potentially increase from 17% to 38%. Patient age and lack of information regarding dialysis options were independently associated with the potential degree of inappropriate dialysis modality selection. Our findings indicate areas for improvement in the selection of dialysis modalities. With better education and shared decision-making, the number of patients with PD could potentially double. The analysis of appropriateness is a helpful approach for studying renal replacement treatment patterns and identifying strategies to optimize their use.

Impact of a Stewardship-Initiated Restriction on Empirical Use of Ciprofloxacin on Nonsusceptibility of Escherichia coli Urinary Isolates to Ciprofloxacin.

STUDY OBJECTIVE: To evaluate the impact of a stewardship-initiated restriction on empirical use of ciprofloxacin on the nonsusceptibility of Escherichia coli urinary isolates to ciprofloxacin over time while controlling for the use of other key antibiotics with gram-negative activity. DESIGN: Retrospective single-center study. SETTING: Large tertiary and quaternary care academic medical center. ISOLATES: Of 3714 E. coli urinary isolates. MEASUREMENTS AND MAIN RESULTS: The susceptibilities of the E. coli urinary isolates to ciprofloxacin, ceftriaxone, cefepime, piperacillin-tazobactam, meropenem, trimethoprim-sulfamethoxazole, and nitrofurantoin obtained over a 7-year period (January 1, 2006-December 31, 2012) from adult inpatients were evaluated for potential relationships with antibiotic use over time by using multiple variable regression analysis. After introduction of the restriction on empirical use of ciprofloxacin in the first quarter of 2011, ciprofloxacin use declined from 141.1-39.8 defined daily doses/1000 patient-days, and the percentage of E. coli isolates that were not susceptible to ciprofloxacin decreased from 41.5-32.8%. With all antibiotics evaluated included in the model, no apparent relationships were found between the percentage of E. coli isolates nonsusceptible to ciprofloxacin and antibiotic use. However, when nonsignificant variables were eliminated (p>0.20), ciprofloxacin use was found to be positively associated with the percentage of E. coli isolates nonsusceptible to ciprofloxacin (p=0.037), whereas ceftriaxone use was negatively associated (p=0.045). CONCLUSION: The restriction and subsequent reduction of ciprofloxacin use was found to have a positive effect on the susceptibility of E. coli urinary isolates to ciprofloxacin.

Evaluación de la inmunofijación sérica frente al cociente de cadenas ligeras libres Kappa/Lambda en la confirmación de componentes monoclonales de baja concentración / Evaluation of serum immunofixation compared to the free Kappa/Lambda light chains ratio for confirming low monoclonal component concentrations

Introducción. La electroforesis de proteínas séricas (EFs) constituye, por norma general, el primer paso en la búsqueda de componentes monoclonales (CM). Una baja concentración de CM dará lugar a pequeños picos en la EFs que pueden hacer sospechar la existencia de una gammapatía monoclonal de significado incierto (GMSI). Para confirmar estas GMSI se ha utilizado la inmunofijación sérica (IFs) y un cociente de cadenas ligeras libres séricas (CLLs) Kappa (K)/Lambda (λ) alterado. Materiales y métodos. De 3.683 EFs realizadas en nuestro laboratorio durante los meses de febrero a noviembre de 2011, se observaron 165 con pequeños picos en las fracciones β1, β2 o gamma. La confirmación del CM se realizó mediante la IFs y la existencia de un cociente de CLLs K/ λ alterado. Resultados. De las 165 EFs seleccionadas para el estudio, la IFs fue positiva en 82, mientras que un cociente de CLLs K/λ alterado solo se observó en 11 de los 82. El cociente de CLLs K/λ de las 71 EFs restantes con IFs positivas, estuvo dentro del intervalo de normalidad para sujetos sanos (0.25-1.65). Conclusiones. La EFs constituye el primer paso en la búsqueda del CM, aunque esta interpretación está ligada a un cierto grado de subjetividad cuando estos CM están a baja concentración. Al valorar la utilidad de la IFs frente al cociente de CLLs K/λ en la confirmación de estos CM, se observó que la confirmación debe realizarse por IFs ya que la cuantificación del cociente de CLLs K/λno resultó útil (AU)

Introduction. Serum protein electrophoresis (SPE) is the first step in the search for a monoclonal component (MC). A low concentration of MC will give small spikes in the SPE, which may lead to the suspicion of a monoclonal gammopathy of undetermined significance (MGUS). To confirm these MGUS, serum immunofixation (sIFE) and abnormal serum free light chains (sFLC) Kappa/Lambda ratio have been used. Material and methods. Of 3683 SPE carried out in our laboratory during the months from February to November of 2011, we observed 165 small spikes in the SPE in β1, β2 or gamma region. The confirmation of these MGUS was made using sIFE and abnormal sFLC Kappa (K)/Lambda (λ) ratio. Results. Of 165 SPE selected for the study, sIFE was positive in 82, while an abnormal sFLC K/λ ratio alone was observed in 11 of the 82. The sFLC K/λ ratio of the 71 SPE remaining with positive sIFE was inside the interval of normality for healthy people (0.25-1.65). Conclusion. SPE is the first step in the search for a MC. When there is a low concentration of MC, this interpretation has a certain grade of subjectivity. When we evaluated the utility of sIFE versus sFLC K/λ ratio in the confirmation of these MC, it was observed that the confirmation should be carried out by means of sIFE since the quantification of the sFLC K/λ ratio was not useful (AU)

Stable susceptibility to aminoglycosides in an age of low level, institutional use.

INTRODUCTION: The use of aminoglycosides has decreased dramatically over several decades in the United States due to the introduction of safer Gram-negative agents. This study was conducted to assess possibly changing aminoglycoside susceptibility rates between 2006 and 2012 and in reference to 1992 use in the context of aminoglycoside use volume. METHODS: Quarterly adult use of amikacin, gentamicin and tobramycin were determined from the Medical University of South Carolina Medical Center, Charleston, South Carolina, USA, pharmacy drug use database and expressed as total aminoglycoside defined daily doses per 1,000 patient days for the years 1992 and 2006 through 2012. Annual susceptibility of Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae, for the years 1992, 2006, and 2008 through 2012 were retrieved from our hospital's clinical microbiology database (duplicate isolates were excluded). Quarterly and annualized aminoglycoside usage rates were compared to the other years of interest. Likewise, susceptibility rates of the target organisms to each aminoglycoside were also compared across the same timeframe. RESULTS: While total use of aminoglycosides decreased slightly from 1992 to 2006, it increased by about 40% between 2006 and 2008 and then stabilized. Changes in susceptibility rates between 1992 and 2006 were all ≤±9% with the exception of K. pneumoniae susceptibility to amikacin (-17%). Changes in susceptibility from 1992 to 2012 were also all ≤±9%. Tobramycin remained the most active versus P. aeruginosa (% susceptible = 90), while amikacin remained most active versus E. coli and K. pneumoniae (% susceptible = 98 and 98, respectively). CONCLUSION: With low level use of aminoglycosides in our institution over the past 2 decades, the susceptibility of key Gram-negative pathogens has remained relatively stable, preserving these agents as potential alternative therapies as resistance arises to other frequently used antibiotics.

Impact of regional comorbidity on infective endocarditis in a southeastern United States medical center.

INTRODUCTION: Recent reports differ regarding microbiologic and epidemiologic characteristics of infectious endocarditis (IE). The authors studied cases presenting to our institution from 2001 to 2006, hypothesizing regional variation in patient populations and comorbidity (especially end-stage renal disease) significantly impact IE causative factors and presentation, which may account for conflicting reports in the literature. METHODS: Consecutive IE cases were prospectively identified and characterized. Multivariate logistic regression analysis identified factors associated with Staphylococcus aureus IE. Incidence of IE in populations on and not on hemodialysis (HD) was estimated, and relative frequency of IE in the population requiring HD was calculated. RESULTS: Of 160 cases, infection was community acquired in 48.8%, nonnosocomial healthcare-associated in 35.6% and nosocomial in 15%. S aureus caused infection in 47.5%. No contribution of referral bias to the predominance of S aureus infection was detected. Factors significantly associated with S aureus infection included symptom duration <1 month, HD and persistent bacteremia. Transthoracic echocardiography was less sensitive in detecting IE in community-acquired infection in comparison with nosocomial infection (P = 0.0383). Estimation of IE incidence in the population on HD relative to the population not on HD revealed a 129- to 174-fold increased incidence of IE in this population. S aureus caused IE in 76.2% of patients on HD. CONCLUSION: S aureus is the most frequent cause of IE at our Southeastern institution. Healthcare-associated acquisition, particularly HD, influenced this epidemiological trend. In populations with a high prevalence of HD, the epidemiology of IE may reflect the increased incidence of HD-associated IE caused by S aureus.