Selective digestive and oropharyngeal decontamination in medical and surgical ICU patients: individual patient data meta-analysis.

OBJECTIVES: Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) improved intensive care unit (ICU), hospital and 28-day survival in ICUs with low levels of antibiotic resistance. Yet it is unclear whether the effect differs between medical and surgical ICU patients. METHODS: In an individual patient data meta-analysis, we systematically searched PubMed and included all randomized controlled studies published since 2000. We performed a two-stage meta-analysis with separate logistic regression models per study and per outcome (hospital survival and ICU survival) and subsequent pooling of main and interaction effects. RESULTS: Six studies, all performed in countries with low levels of antibiotic resistance, yielded 16 528 hospital admissions and 17 884 ICU admissions for complete case analysis. Compared to standard care or placebo, the pooled adjusted odds ratios for hospital mortality was 0.82 (95% confidence interval (CI) 0.72-0.93) for SDD and 0.84 (95% CI 0.73-0.97) for SOD. Compared to SOD, the adjusted odds ratio for hospital mortality was 0.90 (95% CI 0.82-0.97) for SDD. The effects on hospital mortality were not modified by type of ICU admission (p values for interaction terms were 0.66 for SDD and control, 0.87 for SOD and control and 0.47 for SDD and SOD). Similar results were found for ICU mortality. CONCLUSIONS: In ICUs with low levels of antibiotic resistance, the effectiveness of SDD and SOD was not modified by type of ICU admission. SDD and SOD improved hospital and ICU survival compared to standard care in both patient populations, with SDD being more effective than SOD.

Self-Reported Acute Health Effects and Exposure to Companion Animals.

To understand the etiological burden of disease associated with acute health symptoms [e.g. gastrointestinal (GI), respiratory, dermatological], it is important to understand how common exposures influence these symptoms. Exposures to familiar and unfamiliar animals can result in a variety of health symptoms related to infection, irritation and allergy; however, few studies have examined this association in a large-scale cohort setting. Cross-sectional data collected from 50 507 participants in the United States enrolled from 2003 to 2009 were used to examine associations between animal contact and acute health symptoms during a 10-12 day period. Fixed-effects multivariable logistic regression estimated adjusted odds ratios (AORs) and 95% confident intervals (CI) for associations between animal exposures and outcomes of GI illness, respiratory illness and skin/eye symptoms. Two-thirds of the study population (63.2%) reported direct contact with animals, of which 7.7% had contact with at least one unfamiliar animal. Participants exposed to unfamiliar animals had significantly higher odds of self-reporting all three acute health symptoms, when compared to non-animal-exposed participants (GI: AOR = 1.4, CI = 1.2-1.7; respiratory: AOR = 1.5, CI = 1.2-1.8; and skin/eye: AOR = 1.9, CI = 1.6-2.3), as well as when compared to participants who only had contact with familiar animals. Specific contact with dogs, cats or pet birds was also significantly associated with at least one acute health symptom; AORs ranged from 1.1 to 1.5, when compared to participants not exposed to each animal. These results indicate that contact with animals, especially unfamiliar animals, was significantly associated with GI, respiratory and skin/eye symptoms. Such associations could be attributable to zoonotic infections and allergic reactions. Etiological models for acute health symptoms should consider contact with companion animals, particularly exposure to unfamiliar animals. Prevention of pet-associated zoonotic diseases includes commonsense measures such as hand-washing, but are often overlooked by pet owners and non-pet owners alike.

Environmental risk factors associated with Helicobacter pylori seroprevalence in the United States: a cross-sectional analysis of NHANES data.

Helicobacter pylori imparts a considerable burden to public health. Infections are mainly acquired in childhood and can lead to chronic diseases, including gastric ulcers and cancer. The bacterium subsists in water, but the environment's role in transmission remains poorly understood. The nationally representative National Health and Nutrition Examination Survey (NHANES) was examined for environmental risk factors associated with H. pylori seroprevalence. Data from 1999-2000 were examined and weighted to represent the US population. Multivariable logistic regression estimated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for associations with seropositivity. Self-reported general health condition was inversely associated with seropositivity. Of participants aged <20 years, seropositivity was significantly associated with having a well as the source of home tap water (aOR 1·7, 95% CI 1·1-2·6) and living in a more crowded home (aOR 2·3, 95% CI 1·5-3·7). Of adults aged ⩾20 years, seropositivity was not associated with well water or crowded living conditions, but adults in soil-related occupations had significantly higher odds of seropositivity compared to those in non-soil-related occupations (aOR 1·9, 95% CI 1·2-2·9). Exposures to both well water and occupationally related soil increased the effect size of adults' odds of seropositivity compared to non-exposed adults (aOR 2·7, 95% CI 1·3-5·6). Environmental exposures (well-water usage and occupational contact with soil) play a role in H. pylori transmission. A disproportionate burden of infection is associated with poor health and crowded living conditions, but risks vary by age and race/ethnicity. These findings could help inform interventions to reduce the burden of infections in the United States.

Evidence for unapparent Brucella canis infections among adults with occupational exposure to dogs.

Human serological assays designed to detect brucellosis will miss infections caused by Brucella canis, and low levels of periodic bacteremia limit diagnosis by blood culture. Recent B. canis outbreaks in dogs and concomitant illnesses in caretakers suggest that unapparent human infections may be occurring. With more than a quarter of a million persons in occupations involving dogs, and nearly 80 million dog owners in the United States, this pathogen is an under-recognized human health threat. To investigate occupational exposure to B. canis, we adapted a commercial canine serological assay and present the first controlled seroepidemiological study of human B. canis infections in recent years. 306 adults with occupational exposure to dogs and 101 non-matched, non-canine-exposed subjects were enrolled. Antibodies were detected using the canine D-Tec(®) CB rapid slide agglutination test (RSAT) kit with a secondary 2-mercaptoethanol (ME)-RSAT. Results were validated on a blinded subset of sera with an additional RSAT and indirect enzyme-linked immunoassay at the National Administration of Laboratories and Health Institutes (ANLIS) in Argentina. Seroprevalence ranged from 10.8% (RSAT) to 3.6% (ME-RSAT) among canine-exposed subjects. Kennel employees were more likely to test RSAT seropositive compared with other canine exposures (OR = 2.7; 95% CI, 1.3-5.8); however, low seroprevalence limited meaningful occupational risk factor analyses. Two seropositive participants reported experiencing symptoms consistent with brucellosis and having exposure to B. canis-infected dogs; however, temporality of symptom onset with reported exposure could not be determined. D-Tec(®) CB results had substantial agreement with ANLIS assays (Cohen's kappa = 0.60-0.68). These data add to a growing body of literature suggesting that people occupationally exposed to dogs may be at risk of unapparent B. canis infection. It seems prudent to consider B. canis as an occupational public health concern and encourage the development of serological assays to detect human B. canis infections.

No serologic evidence for zoonotic canine respiratory coronavirus infections among immunocompetent adults.

Zoonotic diseases continue to emerge and threaten both human and animal health. Overcrowded shelters and breeding kennels create the perfect environment for amplified infectious disease transmission among dogs and present a critical opportunity for zoonotic pathogens to emerge and infect people who work in close contact with dogs. Coronaviruses' widespread prevalence, extensive host range, various disease manifestations and increased frequency of recombination events all underline their potential for interspecies transmission (Methods Mol. Biol. 2008, 454, 43). The objectives of this study were to determine whether people with occupational contact with dogs were more likely to have antibodies against canine respiratory coronavirus (CRCoV) compared to persons with no dog exposure. A seroepidemiological cohort study was completed, for which 302 canine-exposed and 99 non-canine-exposed study subjects enrolled in the study by providing a serum sample and completing a self-administered questionnaire. A competitive enzyme-linked immunosorbent assay (ELISA) was developed to detect human antibodies against CRCoV while controlling for cross-reacting antibodies against the human coronavirus OC43. All study subjects were negative for antibodies against CRCoV by this competitive ELISA. This study supports the premise that humans are not at risk for CRCoV infections; however, infrequent cross-species transmission of CRCoV cannot be ruled out.

Olive Twig and Branch Dieback: Etiology, Incidence, and Distribution in California.

Eighteen different fungal species were isolated from symptomatic wood of olive trees (Olea europaea) affected by twig and branch dieback in California and identified by means of morphological characters and multigene sequence analyses of the internal transcribed spacer (ITS) region (ITS1-5.8S-ITS2), a partial sequence of the ß-tubulin gene, and part of the translation elongation factor 1-α gene (EF1-α). These species included Diaporthe viticola, Diatrype oregonensis, Diatrype stigma, Diplodia mutila, Dothiorella iberica, Lasiodiplodia theobromae, Phaeomoniella chlamydospora, Phomopsis sp. group 1, Phomopsis sp. group 2, and Schizophyllum commune, which are for the first time reported to occur in olive trees; Eutypa lata, Neofusicoccum luteum, Neofusicoccum vitifusiforme, and Phaeoacremonium aleophilum, which are for the first time reported to occur in olive trees in the United States; and Botryosphaeria dothidea, Diplodia seriata, Neofusicoccum mediterraneum, and Trametes versicolor, which have been previously reported in olive trees in California. Pathogenicity studies conducted in olive cultivars Manzanillo and Sevillano showed N. mediterraneum and Diplodia mutila to be the most virulent species and Diatrype stigma and D. oregonensis the least virulent when inoculated in olive branches. Intermediate virulence was shown for the rest of the taxa. This study demystifies the cause of olive twig and branch dieback and elucidates most of the fungal pathogens responsible for this disease in California.

Cost-effectiveness of linezolid vs vancomycin in suspected methicillin-resistant Staphylococcus aureus nosocomial pneumonia in Germany.

BACKGROUND: The oxazolidinone antibiotic linezolid has demonstrated efficacy in treating infections caused by methicillin-resistant Staphylococcus aureus (MRSA). In a retrospective analysis of two prospective randomized clinical trials in patients with nosocomial pneumonia (NP), initial therapy with linezolid produced significantly better clinical cure and survival rates than vancomycin in the subset of patients with documented MRSA infection. This study was designed to evaluate the economic impact of these clinical outcomes from the perspective of the German health care system to determine the use of these regimens in the light of limited resources and rising costs. METHODS: A decision-analytic model using clinical trial data was developed to examine the costs and outcomes of treatment with linezolid or vancomycin in hospitalized patients with NP caused by suspected MRSA. The model followed an average patient from initiation of empiric treatment until treatment success, death, or second-line treatment failure. Local treatment patterns and resource use were obtained from a Delphi panel. Costs were taken from published sources. Outcomes included total cost per patient, cost per additional cure, cost per death avoided, and cost per life-year gained. RESULTS: The model calculated that linezolid was associated with an 8.7% higher cure rate compared with vancomycin (73.6% vs 64.9%, respectively). Average total costs per episode for linezolid- and vancomycin-treated patients were 12,829 and 12,409, respectively. Death rates were 13.2% lower with linezolid than with vancomycin (20.7% vs 33.9%), resulting in an average of 2.3 life-years gained per linezolid-treated patient in a 65-year-old cohort (14.0 life-years vs 11.7 life-years). With linezolid, incremental costs per death avoided and per patient cured were 3,171 and 4,813, respectively. The base case estimated a similar mean length of stay for both drugs (11.2 vs 10.8 days). One-way sensitivity analyses did not change the overall results. CONCLUSION: The model estimated a higher clinical cure (+8.7%) and survival (+13.2%) for linezolid compared with vancomycin at an incremental cost of 420 per treatment episode. The cost-benefit profile suggests that linezolid could be considered a cost-effective alternative to vancomycin in the treatment of patients with NP caused by suspected MRSA in Germany.

Audit of motor weakness and premature catheter dislodgement after epidural analgesia in major abdominal surgery.

In a quality improvement audit on epidural analgesia in 300 patients after major abdominal surgery, we identified postoperative lower leg weakness and premature catheter dislodgement as the most frequent causes of premature discontinuation of postoperative epidural infusion. Lower limb motor weakness occurred in more than half of the patients with lumbar epidural analgesia. In a second period monitoring 177 patients, lumbar catheter insertion was abandoned in favour of exclusive thoracic placement for epidural catheters. Additionally, to prevent outward movement, the catheters were inserted deeper into the epidural space (mean (SD) 5.2 (1.5) cm in Period Two vs 4.6 (1.3) cm in Period One). Lower leg motor weakness declined from 14.7% to 5.1% (odds ratio 0.35; 95% confidence interval 0.16-0.74) between the two periods. Similarly, the frequency of premature catheter dislodgement was reduced from 14.5% to 5.7% (odds ratio 0.35; 95% confidence interval 0.17-0.72). With a stepwise logistic regression model we demonstrated that the odds of premature catheter dislodgement was reduced by 43% for each centimetre of additional catheter advancement in Period Two. We conclude that careful audit of specific complications can usefully guide changes in practice that improve success of epidural analgesia regimens.

Monocyte phagocytosis of viable Staphylococcus aureus is impaired by barbiturates, but not by propofol.

BACKGROUND: Barbiturates and propofol are used for deep sedation of patients with elevated intracranial pressure refractory to standard therapeutic regimens. Such patients often suffer from bacterial infections, which are most commonly caused by Staphylococcus aureus. Various interactions of anesthetics with components of the host defense have been documented, but very little is known about the influence on monocytes, which are a first-line defense against bacterial invasion. Therefore, we studied the effects of thiopental, methohexital, and propofol on monocyte phagocytosis using an in vitro whole blood model of viable S. aureus. MATERIALS AND METHODS: Whole blood samples were preincubated with different concentrations of thiopental, methohexital, and propofol. Phagocytosis was stopped at different time points after addition of viable S. aureus. Monocytes then were stained with monoclonal antibodies for flow cytometric analysis of monocyte recruitment (ratio of ingesting monocytes). Furthermore, the fluorescence intensity of ingested bacteria served as semiquantitative measurement of phagocytosis activity. RESULTS: Both barbiturates inhibited monocyte recruitment and phagocytosis activity concentration-dependently, whereas propofol did not affect any of the investigated parameters. At concentrations of 7.6 x10(-3) M thiopental or 1.1 x 10(-3) M methohexital and greater, monocyte recruitment and phagocytosis activity were significantly inhibited. The calculated half-maximum inhibitory concentration (IC50) of thiopental was 8.4 x 10(-3) M for monocyte recruitment and 8.6 x 10(-3) M for phagocytosis activity. The corresponding values for methohexital were 4.1 x 10(-3) M and 1.1 x 10(-3) M, respectively. CONCLUSION: The two barbiturates induce concentration-dependent inhibition of monocyte phagocytosis, whereas propofol is without effect. In combination with previously described effects on granulocyte function, these findings suggest that defense against bacterial infection might be reduced by barbiturates.

Effect of method of applying fibrolytic enzymes or ammonia to Bermudagrass hay on feed intake, digestion, and growth of beef steers.

This study examined how different methods of applying a fibrolytic enzyme or ammonia affect the nutritive value of Bermudagrass hay and the performance of beef cattle. Fifty Angus x Brangus crossbred steers (mean initial BW 244 +/- 26 kg) were individually fed for ad libitum intake of a 5-wk regrowth of a mixture of Florakirk and Tifton 44 Bermudagrass [Cynodon dactylon (L.) Pers] hay for 84 d with a concentrate supplement (77% soybean hull pellets, 23% cottonseed meal (DM basis) fed at 1% of BW daily. The Bermudagrass was conserved as hay without treatment (control), with NH(3) (30 g/kg of DM), or with a fibrolytic enzyme (16.5 g/t, air-dry basis) that was applied immediately after cutting (Ec), at baling (Eb), or at feeding. Chromic oxide was dosed to steers for 10 consecutive days, and fecal Cr concentrations from the last 5 d were used to estimate apparent total tract digestibility. In situ ruminal DM degradability was measured by incubating ground (4-mm) hay samples in duplicate in each of 2 ruminally cannulated cows having ad libitum access to Bermudagrass hay and 500 g/d of soybean meal. Unlike the enzyme treatment, ammoniation increased (P < 0.001) the CP concentration and reduced (P < 0.001) NDF, hemicellulose, and lignin concentrations of hay. Total DMI was greater (P < 0.05) for steers fed hays treated with Ec or NH(3) than for those fed control hays. All additive treatments increased (P < 0.05) DM digestibility, and NH(3), Ec, and Eb treatments also increased (P < 0.01) NDF digestibility. The initial and final BW, ADG, BCS, G:F, and hip height of the steers were not affected (P > 0.05) by treatment. The wash loss fractions in hays treated with Ec and Eb were lower than that in the control hay, but the potentially degradable fraction, total degradable fraction, and the effective degradability were increased (P < 0.01) by NH(3) treatment. Application at cutting was the most promising method of enzyme treatment, and this treatment was almost as effective as ammonia for enhancing forage quality.

Elimination of linezolid by an in vitro extracorporeal circuit model.

Linezolid is an oxazolidinone antibiotic with activity against important grampositive aerobic bacteria, including nosocomial pathogens. It is not known whether dosage adjustments are necessary in patients treated with continuous renal replacement therapies. This in vitro study was conducted to investigate the elimination of linezolid in an in vitro continuous hemo(dia)filtration model using different filter materials (polysulfone, polyacrylonitrile, polyamide), surface areas, and different modes of renal replacement therapies. Linezolid was measured using HPLC with UV-detection. No adsorption of linezolid to any of the tested membranes was detected. Recovery of linezolid in the ultrafiltrate was 98.2 +/- 10.5% in the filtration mode. During dialysis, recovery was significantly less (87.6 +/- 16.1%; p = 0.02). Linezolid elimination was not altered by filter size, when polysulfone filters with surface areas of 0.7 m2 and 1.3 m2 were tested. In conclusion, the dosage recommendations for linezolid are independent of the filter materials. However, the elimination is significantly higher during hemofiltration compared to dialysis.

[Detection and identification of the pathogenic cause of a brain abscess by molecular genetic methods]. / Erregerdetektion und -identifikation bei einem Hirnabszess durch molekulargenetische Methoden.

Brain abscesses are life-threatening and detection and identification of the causative pathogens are crucial for substantiating the diagnosis and for selecting the optimal antibiotic regimen. In approximately 20% of the patients microbiological cultures of abscess material remain sterile. The polymerase chain reaction (PCR) provides a methodological alternative, but data about the use of broad spectrum PCR assays to detect the causative pathogens in brain abscesses are rare. We report on the case of a 65-years-old patient with a brain abscess caused by Fusobacterium spp., which was only diagnosed by broad spectrum PCR. To our knowledge this is the second report about a brain abscess, where Fusobacterium spp. was identified only by broad spectrum PCR and subsequent DNA sequencing.

Spinal epidural abscess--a rare complication after epidural analgesia for labour and delivery.

We report a case of spinal epidural abscess formation after short-term epidural catheter placement for analgesia during labour and delivery. The patient was previously healthy and did not have any predisposing factors. Increasing back pain was the only complaint. A contrast-enhanced CT study on day 5 was inconclusive. Magnetic resonance imaging was performed and showed a large triangular-shaped abscess with adjacent inflammation of the paravertebral muscles. One day later, the patient developed a sensory deficit in the left lower limb. The neurological deficit completely resolved after surgical decompression and debridement, which was followed by antibiotic treatment.

An alternative to antibiotic-based drugs in feed for enhancing performance of broilers grown on Eimeria spp.-infected litter.

Three trials were conducted to evaluate the effects of lasalocid, an anticoccidial feed additive (90.7 kg/ton); bacitracin, a growth-promoter (50 g/ton); and yeast culture residue (YCR) (1 kg/ton) on the performance of broiler chicks reared to 42 d of age on recycled litter. Recycled litter consisted of pine wood shavings containing droppings from chicks infected with 3 select strains of coccidia (Eimeria tenella, Eimeria maxima, and Eimeria acervulina). Response variables (BW, intestinal tract and litter coliform counts, cecal and liver relative weights, and litter moisture content) were recorded biweekly. Mean BW of chicks fed the diet supplemented with YCR was higher than that of the controls (P < 0.05) and comparable to that of the lasalocid-treated birds in all 3 trials. Mean BW of chicks in all treatment groups decreased uniformly as the litter aged and moisture content increased. The mean intestinal coliform population from YCR-treated chicks was lower (P < 0.05) than those of the control and lasalocid populations. The coliform count was consistently lower than that in chicks on a bacitracin-supplemented diet. Coliform counts from the control and lasalocid-treated birds did not differ. The litter coliform counts increased with increased use of the litter. Cecal and liver relative weights calculated from the chicks in trial 3 showed that only the liver was significantly affected by treatments. YCR appeared to be a viable alternative to bacitracin and lasalocid medication in enhancing growth of broiler chicks reared on recycled litter.

Influence of underlying disease on the outcome of critically ill patients with acute renal failure.

BACKGROUND AND OBJECTIVE: The development of acute renal failure (ARF) in critically ill patients is associated with an increase in hospital mortality. Recently, it was shown that starting renal replacement therapy early and using high-filtrate flow rates can improve the outcome, but this could not be confirmed in later investigations. Studying selected patient subgroups could provide a useful basis for patient selection in future trials evaluating the outcome of renal replacement therapies. We, therefore, investigated the impact of the underlying disease on the outcome of patients with ARF. METHODS: We retrospectively analysed 306 patients with ARF who were treated with renal replacement therapy. Patients were classified according to six initial diagnosis groups: haemorrhagic shock, post-cardiac surgery, post-liver transplantation, trauma, severe sepsis and miscellaneous. Univariate and multivariate multiple logistic regression analysis was used to determine which factors influenced the outcome. RESULTS: Underlying disease proved to be the only independent risk factor for mortality that was present at intensive care unit (ICU) admission (P = 0.047). Patients with severe sepsis had a significantly higher mortality rate (68%) than ARF patients as a whole (51%) (P = 0.02). Length of stay in the ICU, the use of catecholamines, the delay before ARF onset, and the correlation between APACHE II score and ICU length of stay proved to be additional independent predictors of outcome. CONCLUSIONS: Patient selection and subgroup definition according to the underlying disease could augment the usefulness of future trials evaluating the outcome of ARF.

[Calibration of a room air gas monitor with certified reference gases]. / Kalibrierung eines Raumluft-Gasmonitors mit zertifizierten Prüfgasen.

Photo-acoustic infrared spectrometry is considered to be the gold standard for on-line measurement of anesthetic waste gas in room air. For maintenance of the precision of the measurements, the manufacturer recommends calibration of the gas monitor monitor every 3-12 months. We investigated whether the use of reference gases with analysis certificate could serve as a feasible alternative to commercial recalibration. We connected a multi-gas monitor type1302 (Bruel & Kjaer, Naerum, Denmark) to compressed air bottles containing reference gases with analysis certificate. Using a T-piece with a flow-meter, we avoided the entry of room air during the calibration phase. Highly purified nitrogen was used for zero calibration. The reference concentrations for desflurane, enflurane, halothane, isoflurane, and sevoflurane ranged from 41.6-51.1 ml/m(3) (ppm) in synthetic air. Since there is an overlap of the infrared absorption spectra of volatile anesthetics with alcohol used in operating rooms, we performed a cross-compensation with iso-propanol (107.0 ppm). A two-point calibration was performed for N(2)O (96.2 and 979.0 ppm), followed by cross-compensation with CO(2). Nafion tubes were used in order to avoid erroneous measurements due to molecular relaxation phenomena. The deviation of the measurement values ranged initially from 0-2.0% and increased to up to 4.9% after 18 months. For N(2)O, the corresponding values were 4.2% and 2.7%, respectively. Thus, our calibration procedure using certified reference gases yielded precise measurements with low deterioration over 18 months. It seems to be advantageous that the precision can be determined whenever deemed necessary. This allows for an individual decision, when the gas monitor needs to be calibrated again. The costs for reference gases and working time as well as logistic aspects such as storage and expiration dates must be individually balanced against the costs for commercial recalibration.