[Variability of management for patients hospitalized with 2009 A/H1N1 influenza in three Israeli hospitals].

OBJECTIVES: To assess uniformity of criteria for hospitalization and management of inpatients with documented 2009 A/H1N1 influenza, at a time when national guidelines for management were issued by the public health authorities. METHODS: This was a prospective observational cohort study. We included all adults with laboratory-confirmed pandemic 2009 A/H1N1 influenza in three hospitals in central Israel admitted between 22/7/2009 and 15/2/2010. We compared baseline data, results and treatment management between the three hospitals. Chi-square, ANOVA and Kruskal-WalLis tests were performed. RESULTS: Overall, 496 patients with documented 2009 A/H1N1 influenza were included; the mean age was 44 years (range 19-93). Of all the patients sampled, PCR for influenza was positive in 21.2% [178/840], 27.4% [124/453] and 18.6% [194/1043] in the three hospitals. Differences between hospitals in baseline patient characteristics were few. Significant differences were observed with regard to disease characteristics at admission, including temperature, respiratory symptoms, hypoxia, pulmonary infiltrates (33.7% [60/178], 19.4% [24/124] and 38.7% [75/194]), all influenza complications and severity of illness score (p < 0.05 for all). Differences were observed with regard to oseltamivir treatment, ranging from 79.5% to 98.9% of inpatients. Antibiotic treatment was common (overall 71%) but differences between hospitals were observed with regard to the antibiotic regimens used. The ratio of infectious disease physicians to hospital-bed ratio was low and variable (0.35, and 0.35 per 100 beds). CONCLUSIONS: There was significant variability between hospitals in the hospitalization and management of patients hospitalized with 2009 A/H1N1 influenza.

Duration of antibiotic prophylaxis for cardiac surgery: prospective observational study.

OBJECTIVES: To assess the effect of prolonging antibiotic prophylaxis in cardiac surgery. METHODS: Prospective before-after cohort study. In 2004, cefazolin was given pre- and intraoperatively at 1g doses while in 2007 it was continued after surgery for 24h. All consecutive adult patients undergoing coronary artery bypass graft, valve, and/or aortic operations during the study periods were included. The primary outcomes were deep sternal wound infection (DSWI) and mortality. Univariate and multivariate analyses were conducted to assess risk factors for DSWI. RESULTS: 954 patients between 1/2004 and 12/2004 were compared to 424 patients between 1/2007 and 6/2007. In 2007, there were significantly more patients >60yrs., emergency and combined operations and the mean logistic EuroSCORE was higher compared to 2004 (8.53% vs. 6.92%, p=0.006). The rate of DSWI decreased non-significantly from 3.8% (36/954) in 2004 to 2.6% (11/424) in 2007, p=0.27. The adjusted odds ratio of the study period for DSWI was 0.89 (95% confidence interval 0.70-1.13). There was no difference in 30-day (5.2% vs. 5.4%) or 6-month mortality (9.2% in both periods), despite increasing patients' risk. CONCLUSIONS: Increasing the duration of antibiotic prophylaxis did not result in a significant decrease in DSWI. The value of prolonging antibiotic prophylaxis after cardiac operations should be further evaluated.

Sternal wound infection after coronary artery bypass graft surgery: validation of existing risk scores.

OBJECTIVE: Prediction of surgical site infection and mortality after cardiac surgery might allow for interventions to reduce adverse outcomes. We sought to evaluate existing risk scores. METHODS: We included 809 consecutive patients undergoing coronary artery bypass surgery. Data were collected prospectively. Infections were defined as deep sternal wound infection or mediastinitis by using established criteria and evaluated 60 days after surgical intervention. All-cause mortality was assessed at 30 days and 6 months. We assessed the ability of the National Nosocomial Infections Surveillance risk index, the EuroSCORE, and the Society of Thoracic Surgeons risk score to predict infection and mortality. Discrimination was assessed using the area under the receiver operating curve. RESULTS: The rate of surgical site infection was 3.6% (29/809 patients). The National Nosocomial Infections Surveillance risk index showed moderate discrimination for infection (area under the receiver operating curve of 0.64) and poor ability to stratify patients into infection risk groups. The EuroSCORE predicted infection and 30-day and 6-month mortality with good discrimination (area under the receiver operating curve of 0.72, 0.78, and 0.77, respectively). Ranking patients by the EuroSCORE and dividing the cohort into 3 roughly equal risk groups yielded an ascending risk for infection of 0.7%, 3.0%, and 7.2%. The preoperative and intraoperative Society of Thoracic Surgeons risk scores showed good discrimination for surgical site infection (area under the receiver operating curve of 0.72 and 0.76, respectively) and excellent discrimination for early and late mortality (area under the receiver operating curve of >0.80). Risk grouping based on the Society of Thoracic Surgeons score yielded an ascending risk for infection of 0.7%, 3.6%, and 6.4%. CONCLUSIONS: The EuroSCORE and the Society of Thoracic Surgeons risk score can be used for joint risk stratification for surgical site infection and mortality. Both scores performed better than the National Nosocomial Infections Surveillance risk index.