Impacto de la implantación de un Código Sepsis intrahospitalario en la prescripción de antibióticos y los resultados clínicos en una unidad de cuidados intensivos / Impact of the implementation of a Sepsis Code hospital protocol in antibiotic prescription and clinical outcomes in an intensive care unit

INTRODUCCIÓN: Se analiza el impacto de un Código Sepsis intrahospitalario sobre el uso y consumo de antibióticos, la estancia hospitalaria y la mortalidad. DISEÑO: Estudio retrospectivo cuasiexperimental observacional. Ámbitos: UCI polivalente de 11 camas en un hospital de tercer nivel. PACIENTES: Pacientes ingresados en UCI con diagnóstico de sepsis grave o shock séptico. INTERVENCIONES: Un grupo postintervención (POST-CS) (septiembre 2012-agosto 2013) se comparó con un grupo histórico (PRE-CS) control (enero-diciembre 2010). VARIABLES: Tipo de tratamiento antibiótico, estrategia terapéutica antibiótica y resultados clínicos. El consumo de antibióticos fue expresado en dosis diarias definidas/100 estancias. RESULTADOS: Se incluyeron 42 pacientes con sepsis grave/shock séptico en el grupo POST-CS y 50 en el grupo PRE-CS. El consumo total de antibióticos (dosis diarias definidas) fue similar en ambos grupos. En el grupo POST-CS la tasa de desescalamiento fue significativamente mayor (75 vs. 30,8%, p < 0,005), mientras que la prescripción de antibióticos de uso restringido fue significativamente menor (74 vs. 52%, p = 0,031). Finalmente, el grupo de pacientes POST-CS presentó una mortalidad intrahospitalaria y a 28 días significativamente menor (23 vs. 44% [p = 0,035] y 31 vs. 56% [p = 0,01]), así como una disminución de la estancia en UCI en el límite de la significación estadística (5 vs. 10,5 días, p = 0,05). CONCLUSIÓN: La implantación de un programa de Código Sepsis intrahospitalario se asoció a una mejor utilización del tratamiento antibiótico, incrementándose significativamente el desescalamiento terapéutico y disminuyendo el uso de antibióticos de uso restringido, así como a una significativa disminución de la mortalidad y una tendencia hacia una menor estancia en UCI

INTRODUCTION: A study was performed to analyze the impact of an in-hospital Sepsis Code (SC) program on use of antibiotic and clinical outcomes. DESIGN: Quasi-experimental observational retrospective study. SETTING: Polyvalent 11 beds ICU belonging to a tertiary Universitary hospital. PATIENTS: Patients admitted consecutively to the ICU with diagnosis of severe sepsis or septic shock. INTERVENTIONS: A post intervention group (POST-SC) (September 2012-August 2013) was compared with a historical group (PRE-SC) used as control (January-December 2010). VARIABLES: Antibiotic treatment, therapeutic antibiotic strategy, mortality and length of stay. Antibiotic consumption was expressed as defined daily doses (DDD)/ 100 stays. RESULTS: 42 patients with SS/SS in POST-SC group and 50 patients in PRE-SC group were consecutively recluted and further analyzed. Total antibiotic consumption (DDD) was similar in both groups. Rate of de-escalation therapy was significantly higher in POST-SC group (75% vs 30,8%, p < 0,005) while prescription of restricted antibiotics was significantly lower (74% vs 52%, p = 0,031). Finally POST-SC patients showed a significantly decrease in hospital and 28 days mortality rates [23% vs 44%, (p = 0,035) and 31% vs 56% (p = 0,014) respectively] as well as a reduction in ICU length of stay compared to PRE-SC cohort (5 days vs 10,5 days, p = 0,05). CONCLUSION: The implementation of a Sepsis Code-hospital protocol is associated to an improvement in the management of antibiotic therapy with a significant increase in de-escalation therapy and lesser utilization of restricted use antibiotics, as well as a significant reduction in mortality, and a tendency towards shorter ICU length stay

Impact of the implementation of a Sepsis Code hospital protocol in antibiotic prescription and clinical outcomes in an intensive care unit. / Impacto de la implantación de un Código Sepsis intrahospitalario en la prescripción de antibióticos y los resultados clínicos en una unidad de cuidados intensivos.

INTRODUCTION: A study was performed to analyze the impact of an in-hospital Sepsis Code (SC) program on use of antibiotic and clinical outcomes. DESIGN: Quasi-experimental observational retrospective study. SETTING: Polyvalent 11 beds ICU belonging to a tertiary Universitary hospital. PATIENTS: Patients admitted consecutively to the ICU with diagnosis of severe sepsis or septic shock. INTERVENTIONS: A post intervention group (POST-SC) (September 2012-August 2013) was compared with a historical group (PRE-SC) used as control (January-December 2010). VARIABLES: Antibiotic treatment, therapeutic antibiotic strategy, mortality and length of stay. Antibiotic consumption was expressed as defined daily doses (DDD)/ 100 stays. RESULTS: 42 patients with SS/SS in POST-SC group and 50 patients in PRE-SC group were consecutively recluted and further analyzed. Total antibiotic consumption (DDD) was similar in both groups. Rate of de-escalation therapy was significantly higher in POST-SC group (75% vs 30,8%, p<0,005) while prescription of restricted antibiotics was significantly lower (74% vs 52%, p=0,031). Finally POST-SC patients showed a significantly decrease in hospital and 28 days mortality rates [23% vs 44%, (p=0,035) and 31% vs 56% (p=0,014) respectively] as well as a reduction in ICU length of stay compared to PRE-SC cohort (5 days vs 10,5 days, p=0,05). CONCLUSION: The implementation of a Sepsis Code-hospital protocol is associated to an improvement in the management of antibiotic therapy with a significant increase in de-escalation therapy and lesser utilization of restricted use antibiotics, as well as a significant reduction in mortality, and a tendency towards shorter ICU length stay.

Comparison of drug survival rates for tumor necrosis factor antagonists in rheumatoid arthritis.

BACKGROUND: Persistence of anti-tumor necrosis factor (TNF) therapy in rheumatoid arthritis (RA) is an overall marker of treatment success. OBJECTIVE: To assess the survival of anti-TNF treatment and to define the potential predictors of drug discontinuation in RA, in order to verify the adequacy of current practices. DESIGN: An observational, descriptive, longitudinal, retrospective study. SETTING: The Hospital Clínico Universitario de Valladolid, Valladolid, Spain. PATIENTS: RA patients treated with anti-TNF therapy between January 2011 and January 2012. MEASUREMENTS: Demographic information and therapy assessments were gathered from medical and pharmaceutical records. Data is expressed as means (standard deviations) for quantitative variables and frequency distribution for qualitative variables. Kaplan-Meier survival analysis was used to assess persistence, and Cox multivariate regression models were used to assess potential predictors of treatment discontinuation. RESULTS: In total, 126 treatment series with infliximab (n = 53), etanercept (n = 51) or adalimumab (n = 22) were administered to 91 patients. Infliximab has mostly been used as a first-line treatment, but it was the drug with the shortest time until a change of treatment. Significant predictors of drug survival were: age; the anti-TNF agent; and the previous response to an anti-TNF drug. LIMITATION: The small sample size. CONCLUSION: The overall efficacy of anti-TNF drugs diminishes with time, with infliximab having the shortest time until a change of treatment. The management of biologic therapy in patients with RA should be reconsidered in order to achieve disease control with a reduction in costs.

Utilización y eficacia de la vacunación antigripal en la prevención de ingresos hospitalarios por descompensación cardiorrespiratoria en pacientes de alto riesgo en Cáceres (réplica) / Use and effectivity of influenza vaccination for the prevention of hospital admissions of high risk patients with cardiopulmonary decompensation

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Utilización y eficacia de la vacunación antigripal en la prevención de ingresos hospitalarios por descompensación cardiorrespiratoria en pacientes de alto riesgo en Cáceres / Utilization and effectiveness of the flu vaccination in the prevention of the hospitalization induced by cardiorespiratory decompensation in high-risk patients in Cáceres

Introducción. A pesar de las recomendaciones de vacunar anualmente contra la gripe a todos los ancianos y personas con diversas enfermedades crónicas, éstas no se cumplen. Hemos analizado el grado de utilización de la vacunación antigripal en la temporada 2000/2001 en pacientes mayores de 65 años con patologías crónicas de alto riesgo y su eficacia en cuanto a evitar ingresos hospitalarios por descompensación cardiorrespiratoria, reducir el número de consultas a su médico de Atención Primaria y días e ingreso hospitalario en un estudio casos/control en el servicio de Medicina Interna del Hospital de Cáceres. Pacientes y métodos. Se estudiaron 227 pacientes mayores de 65 años con enfermedad cardiorrespiratoria crónica, diabetes, insuficiencia renal crónica, hepatopatía, neumonía previa u otras causas de inmunosupresión. De ellos, 116 ingresaron por descompensación cardíaca o respiratoria (casos) y 99 pacientes seguidos en consultas externas que no ingresaron este año (controles), con características clínicas similares. A todos se les realizó un cuestionario que incluía características demográficas y de su enfermedad de base, se agruparon según el número de enfermedades subyacentes (una, dos o más), si había recibido la vacunación antigripal correcta, número de consultas a su médico de familia ese año por infecciones respiratorias, ingresos el año anterior y, en caso de ingreso, días que permaneció ingresado. Resultados. La edad media fue de 71 años, el 63 por ciento había ingresado el año anterior. El porcentaje de vacunados fue del 60 por ciento, la vacunación fue más empleada en los mayores de 75 años (p < 0,001), con enfermedad pulmonar obstructiva crónica (EPOC) (p < 0,005) e insuficiencia cardíaca (p < 0,01) y enfermos con dos o más factores de riesgo (p < 0,001). No encontramos diferencias entre casos y controles en cuanto a la edad, número de enfermos con insuficiencia cardíaca congestiva (ICC), diabetes mellitus (DM) ni padecer dos o más factores de riesgo, pero los que ingresaron padecían más de EPOC (OR: 3,6; IC: 2,01-6,45) y tenían más antecedentes de neumonía (OR: 5,24; IC: 2,4-11,14). Los factores que más influyeron en la posibilidad de ingreso fueron: EPOC (OR: 3,67; IC: 1,90-7,13) y antecedente de neumonía previa (OR: 3,88; IC: 1,69-8,95). La estimación de ingresos evitados por la vacunación fue del 59 por ciento (OR: 0,41; IC: 0,22-0,79), aunque no disminuyó el número de consultas a su médico ni los días de ingreso. Conclusiones. La vacunación antigripal parece infrautilizada en pacientes mayores de 65 años con pluripatología en el medio hospitalario. La vacunación parece ser eficaz en cuanto a que disminuye el número de ingresos por descompensación cardiorrespiratoria, incluso en estaciones no epidémicas. Deberíamos insistir en el empleo de la vacunación antigripal en estos pacientes de alto riesgo (AU)

[Utilization and effectiveness of the flu vaccination in the prevention of the hospitalization induced by cardiorespiratory decompensation in high-risk patients in Cáceres]. / Utilización y eficacia de la vacunación antigripal en la prevención de ingresos hospitalarios por descompensación cardiorrespiratoria en pacientes de alto riesgo en Cáceres.

INTRODUCTION: Despite the recommendations to vaccinate annually against the flu to all the elderly and people with various chronic diseases, these recommendations are not comon to fulfill. In this case-control study performed in the service of Internal Medicine of the Hospital of Cáceres we have analyzed the degree of utilization of the flu vaccination in the season 2000/2001 in patients over 65 years of age with high-risk chronic diseases, as well as the effectiveness of this vaccination to avoid the hospitalization induced by cardiorespiratory decompensation, in order to reduce the number of consultations to the primary care physician and in order to reduce the issue of days of hospitalization. PATIENTS OF METHOD: 227 patients over 65 years of age with chronic cardiorespiratory disease, diabetes, chronic renal insufficiency, hepatopathy, previous pneumonia, or other causes of immunosuppression were studied. Of them, 116 were admitted because of cadiac or respiratory decompensation (cases); the control group was made up of 99 patients who went to outpatient consultations, with clinical manifestations similar to the cases and they were not hospitalized during the year of study. All the participants filled a questionnaire that included demographic characteristics and data about the underlying disease; the participants were grouped according to the number of underlying disease (one, two or more), according to if had received correctly the flu vaccination, according to the number of consultations to its Family doctor during the year of the study because of respiratory infections, according to the hospitalizations during the previous year and in the patients that were hospitalized acording to the number of days of the hospitalization. RESULTS: The average age was 71 years and 63% patients had been hospitalized the previous year. The percentage of vaccinated was of 60% and the vaccination was applied most frequently to the patients older than 75 years (p < 0.001), with EPOC (p < 0.005), and with cardiac insufficiency (p < 0.01), as well as to the patients with 2 or more risk factors (p < 0.001). Differences were not observed among the cases and the controls with regard to the age, to the incidence of ICC, to the incidence of DM, nor to the presence of 2 or more risk factors; however, the patients who were hospitalized presented a greater incidence of chronic obstructive pulmonary disease (COPD) (OR: 3.6; IC: 2.01-6.45) and of previous pneumonía (OR: 5.24: CI: 2.4-11-14): The factors most influencing the possibility of hospitalization were: EPOC (OR: 3.67; CI: 1.90-7.13); previous pneumonía (OR: 3.88: CI: 1.69-8.95). The estimate of hospitalizations avoided by the vaccination was of 59 (OR: 0.41; IC: 0.22-0.79). The vaccination did not decrease the number of consultations to the physician nor the days of the hospitalization. CONCLUSIONS: The flu vaccination looks underused in patients over 65 years of age with multiple diseases in the hospital environment. The vaccination seems to be effective in order to diminish the number of hospital admissions because of cardiorespiratory decompensation, even in non-epidemic seasons. We should insist on the use of the flu vaccination in these high-risk patients.