INFECTION
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Notice to Readers: Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections.
MMWR, February 25, 2000 / 49(07);138.This article reports that every year in the U.S., approximately 2,000,000 patients develop hospital-acquired infections and 88,000 die from them. The cost of hospital-acquired infections has been estimated at $4.6 billion. These estimates are conservative, because they do not take into account nosocomial infections occurring in patients in nursing homes, outpatient clinics, dialysis centers and other health care centers.
Mortality associated with nosocomial infections: analysis of multiple cause-of-death data.
White MC.
J Clin Epidemiol 1993 Jan;46(1):95-100.This article emphasizes that hospital-acquired infections are among the 10 leading cause of death in the U.S.
The nationwide nosocomial infection rate. A new need for vital statistics.
Haley RW, Culver DH, White JW, Morgan WM, Emori TG.
Am J Epidemiol 1985 Feb;121(2):159-67.The results of this study indicate that in 1985, the incidence of hospital-acquired infections in the U.S. was 5.7 per 100 patients. Extrapolation of these data to the 6,449 acute-care hospitals revealed that every year, in the U.S., approximately 2 million infections occur in hospitalized patients. However, after adjustment for accuracy of detection methods, trend toward a nationwide increase in infection rates, and number of infections in nursing home patients, the estimated number of yearly nosocomial infections increased to 4 millions. The authors emphasizes that these data greatly exceed previous evaluations, and call for correct statistics to properly address the problem.
Trends in infectious disease hospitalizations in the United States, 1980-1994.
Simonsen L, Conn LA, Pinner RW, Teutsch S.
Arch Intern Med 1998 Sep 28;158(17):1923-8.The results of this study show that from 1980 to 1994, mortality rates in individuals hospitalized for infectious disease doubled, from 1.9% to 4.0%.
Trends in infectious diseases mortality in the Unites States.
Pinner RW, et al.
JAMA 1996 Jan 17;275(3):189-93.The results of this study show that from 1980 to 1992, death due to infectious diseases in the U.S. increased 58%, from 41 to 65 deaths per 100,000 population. Of note, death due to infectious diseases increased 6.3 times in individuals aged 25- to 44-years-old, from 6 to 38 deaths per 100,000 population. These data indicate that despite previsions of a decline in rates of infectious diseases in the U.S., mortality rates from infectious diseases have actually been progressively increasing in recent years.
Nosocomial bloodstream infections. Secular trends in rates, mortality, and contribution to total hospital deaths.
Pittet D, Wenzel RP.
Arch Intern Med 1995 Jun 12;155(11):1177-84.The results of this study show that the incidence of hospital-acquired bloodstream infections increased threefold in the period from 1980 to 1992, from a rate of 6.7 to 18.4 infections per 1,000 discharges. Population-attributable risk of death from this complication also rose during this period, from 3.55 to 6.22 deaths per 1,000 discharges.
Nosocomial enterococci resistant to vancomycin--United States, 1989-1993.
MMWR Morb Mortal Wkly Rep 1993 Aug 6;42(30):597-9.This article reports that from 1989 to 1993, the rate of enterococci responsible for hospital-acquired infections that acquired resistance to the antibiotic vancomycin increased by more than 20 folds. The majority of these bacteria are resistant to all available antibiotics. In the intensive care units, the percentage of vancomycin-resistant enterococci strains increased from 0.4% in 1989 to 13.6% in 1993.
Emerging and reemerging microbial threats. Nosocomial fungal infections.
Henderson VJ, Hirvela ER.
Arch Surg 1996 Mar;131(3):330-7.This article shows that the rate of fungal hospital-acquired infections increased steadily in the past 25 years, from a rate of 2.0 infections per 1000 discharges to as high as 6.6 infections per 1000 discharges.
Hospital-acquired candidemia. The attributable mortality and excess length of stay.
Wey SB, Mori M, Pfaller MA, Woolson RF, Wenzel RP.
Arch Intern Med 1988 Dec;148(12):2642-5.The results of this study show that from 1977 to 1984, the incidence of hospital-acquired bloodstream infections caused by Candida species in the U.S. tripled. Patients with fungemia have a 3-fold increased risk of dying, compared to uninfected, closely matched patients. Hospital length of stay in patients who survived the bloodstream infection was 70 days, as compared to 40 days in matched controls. Candida infections were responsible for 10% of all bloodstream infections.
Secular trends in the epidemiology of nosocomial fungal infections in the United States, 1980-1990.
National Nosocomial Infections Surveillance System.
Beck-Sague C, Jarvis WR.
J Infect Dis 1993 May;167(5):1247-51.This article reports on the increase in the incidence of hospital-acquired fungal infections in U.S. hospitals, as determined by evaluation of data submitted to the National Nosocomial Infections Surveillance System. The rate of this complication increased from 2.0 per 1000 discharges in 1980 to 3.8 per 1000 discharges in 1990, an almost two-fold increase. Candida species accounted for three-quarters of infections. Patients with a central intravascular catheter had a 3-fold increased risk of developing a fungal bloodstream infection, compared to those without it. Thirty percent of patients with hospital-acquired fungemia died, compared to 17% of those with bloodstream infections due to other microorganisms.
Accuracy of reporting nosocomial infections in intensive-care-unit patients to the National Nosocomial Infections Surveillance System: a pilot study.
Emori TG, et al.
Infect Control Hosp Epidemiol 1998 May;19(5):308-16.The results of this study indicate that the National Nosocomial Infections Surveillance (NNIS) System is not a reliable indicator of the true incidence of nosocomial infections in hospital settings. This system was instituted under the sponsorship of the Centers for Disease Control (CDC) to monitor rates of hospital-acquired infections through voluntarily reporting of this complication by participating hospitals. The accuracy of the system in reflecting the rate of nosocomial infections was evaluated by reviewing the charts of 1,136 patients admitted to the intensive care units of 9 hospitals. There were 611 reports of hospital-acquired infections submitted to the NNIS system for this cohort. However, when some trained epidemiologists evaluated retrospectively the charts of the patients, they identified 340 extra infections that had not been previously reported. These data indicate that the voluntary system of reporting of hospital-acquired infections is significantly underestimating the true incidence of nosocomial infections in U.S. hospitals, and, as a consequence, all studies that utilize data from the NNIS system are misrepresenting the real magnitude of the problem.
Influence of nosocomial infection on mortality rate in an intensive care unit.
Bueno-Cavanillas A, et al.
Crit Care Med 1994 Jan;22(1):55-60.The results of this study show that patients who develop hospital-acquired infections have a twofold increased risk of death, compared to uninfected patients. The increased risk of death persists even after adjustment for several confounding factors, and is particularly high in younger patients with less severe disease.
A survey of nosocomial infections and their influence on hospital mortality rates.
Dinkel RH, Lebok U.
J Hosp Infect 1994 Dec;28(4):297-304.The results of this study show that even after controlling for possible confounders, patients who develop a hospital-acquired infection have a two-fold increased risk of death, compared to patients without this complication. The risk of death increases by three-folds in patients hospitalized for trauma who develop a hospital-acquired infection.
Nosocomial infections in elderly patients in the United States, 1986-1990.
National Nosocomial Infections Surveillance System.
Emori TG, et al.
Am J Med 1991 Sep 16;91(3B):289S-293S.This study reports that from 1986 to 1990, 89 hospitals submitted to the National Nosocomial Infections Surveillance (NNIS) system a total of 101,479 reports of hospital-acquired infections occurring in 75,398 adult patients. In 12% of the infections the patients died. In 54% of elderly patients that died an in 59% of younger patients that died the infection was judged to be related to their death. Bloodstream infections and pneumonias were associated with the highest mortality rates.
The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.
Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ.
Infect Control Hosp Epidemiol 1999 Nov;20(11):725-30.The results of this study, conducted on 255 pairs of matched surgical patients with and without surgical site infection, indicate that infected patients have a 2.2-fold increased risk of dying, a 60% increased risk of being admitted to an intensive care unit, and a twofold increased hospital length of stay, compared to uninfected patients. In addition, patients who survive a surgical site infection are approximately 6 times more likely to be readmitted to the hospital in the 30-days following discharge, compared to uninfected patients. The study estimated that, after the inclusion of the second hospital admission, each surgical site infection was associated with an excess hospital stay of 12 days and with an excess cost of $5,038 per patient. The authors highlight that the implementation of measures designed to reduce the rates of surgical site infections will likely result in a significant reduction of infection-related morbidity, mortality and health care costs.
Nosocomial infections in surgical patients in the United States, January 1986-June 1992.
National Nosocomial Infections Surveillance (NNIS) System.
Horan TC, Culver DH, Gaynes RP, Jarvis WR, Edwards JR, Reid CR.
Infect Control Hosp Epidemiol 1993 Feb;14(2):73-80.This study reports that from 1986 to 1992, 106 hospitals reported to the National Nosocomial Infections Surveillance System a total of 59,351 hospital-acquired infections occurring in 48,168 surgical patients. The probability that these infections were related to the death of the patients ranged from 22% for urinary tract infections, to 90% for organ/space surgical site infections.
Infection in surgical patients: effects on mortality, hospitalization, and postdischarge care.
DiPiro JT, Martindale RG, Bakst A, Vacani PF, Watson P, Miller MT.
Am J Health Syst Pharm 1998 Apr 15;55(8):777-81.The results of this study show that 12% of patients who undergo moderate to high-risk surgical procedures develop hospital-acquired infections. Mortality rates in infected patients are 14.5%, as compared to 1.8% in uninfected patients. In addition, hospital length of stay more than triples in infected versus uninfected patients (14 days vs. 4 days), and so does the number of patients who require health care assistance after hospital discharge (24% of infected patients versus 7% of uninfected ones).
Nosocomial infection, indices of intrinsic infection risk, and in-hospital mortality in general surgery.
Delgado-Rodriguez M, et al.
J Hosp Infect 1999 Mar;41(3):203-11.The results of this study show that patients who develop a surgical site infection or a bloodstream infection have a 4.5-fold and 17.3-fold increased risk of dying, respectively, compared to uninfected patients.
Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization.
Vegas AA, Jodra VM, Garcia ML.
Eur J Epidemiol 1993 Sep;9(5):504-10.The results of this study show that hospital-length of stay increases by an average of 14 days in patients who develop hospital-acquired wound infections. The study was conducted on a sample of patients from a general and digestive surgical ward, to assess the effect that hospital-acquired infections had on the length of their hospital stay. Infected and uninfected patients were matched for age, diagnosis, surgical procedure, and, when possible, underlying conditions, elective or emergency surgery, and invasive devises. Length of hospital stay increased by l2.6 days in patients who developed superficial wound infection, compared to those without infection. Wound infections, either superficial or deep, and other infections were associated with an extra 14.3 and 7.3 days of hospital stay, respectively.
Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention.
Jarvis WR.
Infect Control Hosp Epidemiol 1996 Aug;17(8):552-7.This study shows that in the U.S., every year, approximately 2 million infections occur in hospital patients, leading to substantial increase in morbidity, mortality, and health care costs. Hospital length of stay increases by 1 to 4 days in patients who contract urinary tract infections, by 7-8 days in those with surgical site infections, by 7 to 21 days in those with bloodstream infections, and by 7 to 30 days in those with pneumonia. Costs associated with these infections have been estimated at $550-$600 for each urinary tract infection, $2,700 for each surgical site infection, $3,000 to $40,000 for each bloodstream infection, and $5,000 for each pneumonia.
Nosocomial pneumonia and mortality among patients in intensive care units.
Fagon JY, Chastre J, Vuagnat A, Trouillet JL, Novara A, Gibert C.
JAMA 1996 Mar 20;275(11):866-9.The results of this study show that 16.6% of patients admitted to an intensive care unit in France develop hospital-acquired pneumonia. The study, conducted on 1978 consecutive patients, also showed that patients who developed pneumonia while in the hospital had a twofold increased rate of death, compared to those without pneumonia, and this increase was unrelated to the severity of underlying diseases.
Hospital-acquired pneumonia. Attributable mortality and morbidity.
Leu HS, Kaiser DL, Mori M, Woolson RF, Wenzel RP.
Am J Epidemiol 1989 Jun;129(6):1258-67.The results of this study show that 30% of patients who develop hospital-acquired pneumonia die. In one third of patients the infection is judged to be directly responsible for the death of the patient.
Nosocomial pneumonia in ventilated patients: a cohort study evaluating attributable mortality and hospital stay.
Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C.
Am J Med 1993 Mar;94(3):281-8.
The results of this study show that the development of hospital-acquired pneumonia is associated with a two-fold increased risk of death in mechanically ventilated patients, and with a significant prolongation of hospital length of stay, from a median of 21 days to a median of 34 days. The increase in death rates is independent from underlying diseases.
Guidelines for Prevention of Nosocomial Pneumonia.
MMWR January 03, 1997 / 46(RR-1);1-79.This article reports that pneumonia accounts for 15% of all hospital-acquired infections (HAIs), and is the second most frequent HAI after urinary tract infections. The incidence of nosocomial pneumonia has been estimated at approximately 6 per 1000 hospitalized patients, and is significantly higher in university hospitals, compared to non-teaching hospitals. Reported mortality rates range from 20% to 50%, and in 30% to 33% of cases the death is directly attributed to the infection contracted in the hospital. Conservative estimates place the total costs of this complication at $1.2 billion per year. Bacteria responsible for the infections are found everywhere in the hospital and are frequently spread from patient to patient through contaminated hands of health care workers. The risk of spreading the infection could be considerably reduced by adhesion to simple hand-washing practices. However, doctors rarely comply with this practice, and as a consequence the use of gloves has been promoted in order to reduce cross-contamination. Unfortunately, transmission of infection has been reported even with use of gloves, and is attributable to either breaks in the glove, or to the omission by health care workers to change their gloves between contacts with different patients.
Hand washing. A modest measure with big effects.
Handwashing Liaison Group.
BMJ 1999;318:686-686 ( 13 March ).This article highlights that hand washing, a simple preventive measure effective in reducing the spread of in-hospital infections, is frequently disregarded as such by health care workers, who often fail to perform it. The incidence of in-hospital infections is significantly high, with an estimated 9% of patients acquiring an infection while being in the hospital. Hands are an important vehicle of transfer of pathogenic bacteria from one patient to the other. The majority of physicians, however, fail to decontaminate their hands after contact with patients. One study documented hand washing in only 9% of physicians, and another documented senior physicians washing their hands only twice during a 21-hour ward shift. Failure of physicians to recognize the risks associated with non-compliance reflects a system of belief that is deeply ingrained and of difficult solution. The authors emphasize how physicians need to recognize that hand contamination is an important mean of transfer of pathogenic bacteria before hand washing practices can be integrated as part of normal duty care.
Current guidelines for the treatment and prevention of nosocomial infections.
Bergogne-Berezin E.
Drugs 1999 Jul;58(1):51-67.This article highlights that in the U.S., 5% to 10% of patients admitted to the hospital develop a hospital-acquired infection. The incidence of this complication is particularly high in the intensive care units, where it occurs in as many as 28% of patients. There are preventive measures that could reduce the incidence of hospital-acquired infections, and they include improvement in nursing practices, decreased rates of antibiotic prescribing, and shortened hospital stay. These measures could significantly lower health care costs and infection-related morbidity and mortality.
Nosocomial Hepatitis B Virus Infection Associated with Reusable Fingerstick Blood Sampling Devices -- Ohio and New York City, 1996.
MMWR. March 14, 1997 / 46(10);217-221.
This article reports on two outbreaks of hepatitis B virus infection that occurred in diabetic patients from an Ohio nursing home and a New York City hospital. In both instances, an epidemiologic investigation revealed that patients became infected because the health-care personnel did not change fingerstick devices for blood-glucose monitoring between patients.
Nosocomial transmission of hepatitis B virus associated with the use of a spring-loaded finger-stick device.
Polish LB, et al.
N Engl J Med 1992 Mar 12;326(11):721-5.This article reports on the case of 26 diabetic patients who developed hepatitis B virus infection in a California hospital. Epidemiologic investigation revealed that the virus was spread from one infected patient to the others due to nursing practices of utilizing the same blood glucose monitoring fingerstick device for several patients.
Hospital infection rates in England out of control. News.
Kmietowicz, Z.
BMJ 2000;320:534 ( 26 February ).This letter explains that in England, every year, at least 100,000 patients develop hospital-acquired infections and 5,000 of them die from the complication. Hospital-acquired infections affect approximately 1 every 10 hospitalized patients, for an annual cost of £1bn ($1.6 billion). Very little effort is put in the prevention of infections, as shown by the scant participation of clinicians and hospital chief executives to the problem. In some areas, for example, 1 infection control nurse is in charge of 1,000 beds, and only 1 of 5 hospitals surveyed has the minimum number of infection control doctors recommended by the Royal College of Pathologists -1 physician per 1,000 beds. These resources are obviously insufficient to guarantee an effective control of the spread of pathogens among hospitalized patients, a negligence that results not only in excess length of hospital stay and health care costs, but also in significant morbidity and mortality.
Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality.
Pittet D, Tarara D, Wenzel RP.
JAMA 1994 May 25;271(20):1598-601.The results of this study show that patients who develop hospital-acquired bloodstream infections have an over three-fold increased risk of dying and an almost two-fold increase in hospital length of stay, compared to uninfected ones. The study was conducted on 86 pairs of patients from a surgical intensive care unit (SICU), with and without bloodstream infection, who were matched for age, sex, length of hospital stay and number of discharge diagnoses. Fifty percent of patients with bloodstream infection died, compared to 15% of those without this complication. In addition, patients who survived the infection spent an additional 24 days in the hospital and an additional 8 days in the SICU, compared to controls (54 vs. 30 days and 15 vs. 7 days, respectively). Health care costs attributable to the bloodstream infection were estimated at $40,000 per patient.
Microbiological factors influencing the outcome of nosocomial bloodstream infections: a 6-year validated, population-based model.
Pittet D, Li N, Woolson RF, Wenzel RP.
Clin Infect Dis 1997 Jun;24(6):1068-78.This study reports that, between 1986 and 1991, a total of 1745 patients developed hospital-acquired bloodstream infections in a 900-bed tertiary care hospital, and 35% of them died from this complication.
Incidence, risk factors, and outcome of severe sepsis and septic shock in adults.
A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis.
Brun-Buisson C, et al.
JAMA 1995 Sep 27;274(12):968-74.The results of this study, conducted on 11,828 consecutive patients admitted during a two-month period to 170 intensive care units in France, show that overall, 9.0% of patients developed signs of severe bloodstream infection and 56% of them died in the 4 weeks following the infection.
The Second National Prevalence Survey of infection in hospitals--overview of the results.
Emmerson AM, Enstone JE, Griffin M, Kelsey MC, Smyth ET.
J Hosp Infect 1996 Mar;32(3):175-90.The results of this study, conducted on over 37,000 patients from 157 hospitals in the UK and Ireland, show that nosocomial infections (infections acquired in the hospital) occur in 9% of patients, and are more frequent in teaching hospital, compared to non-teaching ones.
Epidemiology of infection in ICUs.
Spencer RC.
Intensive Care Med 1994 Nov;20 Suppl 4:S2-6.This study reports the results of the European Prevalence of Infection in Intensive Care Study (EPIC), the largest study on Intensive Care Unit (ICU)-related infections in Western Europe, that was conducted on a cohort of 10,038 patients admitted to 1417 adult ICUs from 17 countries. Overall, 21% of ICU patients developed a minimum of one hospital-acquired infection. Pneumonia was the most frequent infection (47% of cases), followed by other lower respiratory tract infections (18%), urinary tract infections (18%), and bloodstream infections (12%).
The impact of nosocomial infections on patient outcomes following cardiac surgery.
Kollef MH, Sharpless L, Vlasnik J, Pasque C, Murphy D, Fraser VJ.
Chest 1997 Sep;112(3):666-75.This study evaluated the frequency of hospital-acquired infections in a cohort of 605 consecutive patients admitted for cardiac surgery. After the surgery, 22% of patients developed at least one hospital-acquired infection. The risk of this complication was associated with the duration of mechanical ventilation and urinary tract catheterization, and with the initiation of empiric antibiotic therapy after surgery. Infected patients had a two-fold increased risk of dying, compared to uninfected ones.
The impact of nosocomial infections on patient outcomes following cardiac surgery.
Kollef MH, Sharpless L, Vlasnik J, Pasque C, Murphy D, Fraser VJ.
Chest 1997 Sep;112(3):666-75.The results of this study, conducted on a sample population of 605 patients who underwent cardiac surgery in an U.S. hospital, show that approximately 22% of patients developed at least one hospital-acquired infection. Infected patients had a 4-fold increased risk of dying, compared to uninfected ones. In addition, hospital length of stay in patients who survived was two times greater in infected versus uninfected patients (20 days versus 9.7 days). These data indicate that hospital-acquired infections are associated with significant mortality, increased length of stay, and health care costs.
Epidemiology of Nosocomial Infection and Resistant Organisms in Patients Admitted for the First Time to an Acute Rehabilitation Unit.
Mylotte JM, Graham R, Kahler L, Young L, Goodnough S.
Clin Infect Dis 2000 Mar;30(3):425-432.The results of this study indicate that 16.5% of patients admitted to an acute rehabilitation center develop at least one hospital-acquired infection. Urinary tract infections, surgical site infections, Clostridrium difficile diarrhea and bloodstream infections accounted for 30%, 17%, 15% and 13% of the infections, respectively.
Incidence of hospital-acquired infections associated with caesarean section.
Henderson E, Love EJ.
J Hosp Infect 1995 Apr;29(4):245-55.This study, conducted on a cohort of 1335 women who underwent caesarean section in a Canadian teaching hospital, shows that the rate of hospital-acquired infections in women delivered by primary and secondary caesarean section, was 42.1% and 46.1%, respectively. Women delivered by primary section had significantly higher incidence of deep wound infections, endometritis and bacteraemia, compared to those delivered by secondary section. Hospital-acquired infections resulted in increased length of hospital stay.
Post-discharge surveillance and infection rates in obstetric patients.
Couto RC, Pedrosa TM, Nogueira JM, Gomes DL, Neto MF, Rezende NA.
Int J Gynaecol Obstet 1998 Jun;61(3):227-31.The results of this study show that women who deliver by Cesarean section have an almost 50-fold increased risk of developing hospital-acquired surgical site infections, compared to women who deliver by the vaginal route. The study evaluated the incidence of this complication in 2431 women who delivered vaginally and 2032 women who delivered by Cesarean section, by monitoring patients during their hospital stay and up to 30 days after hospital discharge. While the incidence of hospital-acquired surgical site infections detected during hospital stay was 1.6% in women who underwent Cesarean section, this rate increased to 9.6% when cases detected by post-discharge surveillance were included. By comparison, rates of infections in women who delivered by the vaginal route were significantly lower, occurring in only 0.2% of cases. These findings indicate that unless data collected after hospital discharge are included in the estimates of the incidence of surgical site infections after Cesarean delivery, the true prevalence of this complication can be substantially underestimated.
Occurrence of nosocomial bloodstream infections in six neonatal intensive care units.
Brodie SB, et al.
Pediatr Infect Dis J 2000 Jan;19(1):56-65.This study evaluated prospectively the incidence of hospital-acquired bloodstream infections in neonates weighing less than 1,500 g admitted to six neonatal intensive care units (NICUs). Almost 20% of neonates developed a hospital-acquired bloodstream infection, and the risk of this complication was significantly associated with use of Broviac catheters and intravenous nutrition supplements. Since these infections are associated with substantial morbidity and mortality, preventive measures are urgently needed.
Nosocomial infections in pediatric intensive care units in the United States.
National Nosocomial Infections Surveillance System.
Richards MJ, Edwards JR, Culver DH, Gaynes RP.
Pediatrics 1999 Apr;103(4):e39.The results of this study show that approximately 6% of children admitted to a pediatric intensive care unit (ICU) develop hospital-acquired infections. In the study, 6290 infections occurred in a cohort of 110,709 patients admitted to 61 pediatric ICUs, according to data collected through the National Nosocomial Infections Surveillance System -a voluntary system of reporting of hospital-acquired infections. The most common type of infection was bloodstream infection (28%), followed by pneumonia (21%), and urinary tract infection (15%). These complications were almost always associated with use of invasive devices.
Nosocomial infections among neonates in high-risk nurseries in the United States. National Nosocomial Infections Surveillance System.
Gaynes RP, Edwards JR, Jarvis WR, Culver DH, Tolson JS, Martone WJ.
Pediatrics 1996 Sep;98(3 Pt 1):357-61.This study reports data submitted by 99 hospitals participating in the National Nosocomial Infections Surveillance system, a voluntary, hospital-based, reporting system established to monitor rates of hospital-acquired infections, indicating that from 1986 to 1994, a minimum of 13,179 neonates in high-risk nurseries developed this complication. The most common hospital-acquired infections were bloodstream infections, followed by pneumonias and gastrointestinal infections.
Hospital-acquired morbidity on a neurology service.
Shafer SQ, Brust JC, Healton EB, Mayo JB.
J Natl Med Assoc 1993 Jan;85(1):31-5.This study evaluated prospectively the charts of 1317 consecutive patients admitted over a 3-year period to the neurology department of a city hospital, to determine the incidence of hospital-acquired infections in this sample population. Overall, 6.8% of patients developed at least one hospital-acquired infection, which consisted of a bloodstream infection in almost half of the cases. The authors emphasize that these data greatly exceed previously reported estimates.
Surveillance of nosocomial infections in geriatric patients.
Beaujean DJ, et al.
J Hosp Infect 1997 Aug;36(4):275-84.The results of this study, conducted on 300 geriatric patients admitted to a medical ward of a hospital in the Netherlands, show that one third of patients developed at least one hospital-acquired infection (126 infections in 100 patients). Fifty-nine percent of the infections were urinary tract infections, and 20% were infections of the gastrointestinal tract. Seventy percent of patients with asymptomatic urinary tract infection received antibiotics. Age, dehydration, and the presence of a urinary catheter were all significant risk factors for the development of hospital-acquired infections. Hospital length of stays increased by twofold in infected versus uninfected patients.
Hospital-acquired pressure ulcers: risk factors and use of preventive devices.
Perneger TV, Heliot C, Rae AC, Borst F, Gaspoz JM.
Arch Intern Med 1998 Sep 28;158(17):1940-5.
The results of this study, conducted on 2373 patients who did not have pressure ulcers upon admission to a university hospital, show that 10% of them developed this complication during their hospital stay. The study detected suboptimal use of special devices (such as mattresses, cushions, and beds) for the prevention of this complication.
Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay.
Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR.
Adv Wound Care 1999 Jan-Feb;12(1):22-30.The results of this study, conducted on a sample population of 286 patients aged 55 and older, show that those who developed pressure ulcers had, after controlling for several confounders, increased length of hospital stay (21 vs. 13 days) and increased incidence of hospital-acquired infections (46% vs. 20%) and other complications (86% vs. 43%), compared to those who did not. Hospital costs for patients with incident pressure ulcers were estimated at $29,048 compared to 13,819 in those without this ailment.
Epidemiology of infectious and iatrogenic nosocomial diarrhea in a cohort of general medicine patients.
McFarland LV.
Am J Infect Control 1995 Oct;23(5):295-305.The results of this study, conducted on 382 patients admitted over an 11-month period to the general medicine ward of a county hospital, show that the incidence of hospital-acquired diarrhea in this cohort was 33%. The risk of developing this complication increased with increasing patient age, length of stay, number of antibiotics and nasogastric tube feeding. Patients with hospital-acquired diarrhea had an increased risk of developing a second infection, of having a prolonged hospital length of stay, and of dying, than patients without this condition.
Risk factors for Clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients.
McFarland LV, Surawicz CM, Stamm WE.
J Infect Dis 1990 Sep;162(3):678-84.The results of this study show that the incidence of hospital-acquired diarrhea caused by Clostidrium difficile, as evaluated in a cohort of 399 patients, was 7.8 per 100 patients.
C. difficile accounted for one fifth of all hospital-acquired diarrhea, and the risk of developing C. difficile-associated diarrhea increased by 2-3 folds in individuals using cephalosporin, penicillin, enemas, gastrointestinal stimulants, or stool softeners.
Nosocomial infections in the ICU: the growing importance of antibiotic-resistant pathogens.
Weber DJ, Raasch R, Rutala WA.
Chest 1999 Mar;115(3 Suppl):34S-41S.This study indicates that patients in intensive care units have a 5-10 fold increased risk of developing a hospital-acquired infection, compared to those admitted to other hospital units. A major contributor to the morbidity and mortality associated with this complication is the antibiotic-resistance of the pathogens involved in the infection. Measures of prevention include proper handwashing, patient isolation, proper disinfection and sterilization techniques, and judicious use of antibiotics, as demonstrated by the fact that hospitals with the highest rates of hospital-acquired infections also have the highest rates of antibiotic use.
Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.
Kollef MH, Sherman G, Ward S, Fraser VJ.
Chest 1999 Feb;115(2):462-74.The results of this study, conducted on 2000 patients admitted to a medical or surgical intensive care unit, show that 25% of hospitalized patients with community- or hospital-acquired infections receive inappropriate antibiotic treatment. Mortality rates in patients receiving inadequate antibiotic treatment are 42%, compared to 17.7% in patients appropriately treated. After logistic regression analyses it was shown that inappropriate antibiotic treatment was the strongest determinant of hospital mortality for the entire (infected and uninfected) patient cohort, and resulted in a 4.3-fold increased risk of death.
Appropriateness of antibiotic therapy in long-term care facilities.
Jones SR, Parker DF, Liebow ES, Kimbrough RC 3d, Frear RS.
Am J Med 1987 Sep;83(3):499-502.This study evaluated the appropriateness of antibiotic therapy in patients of two nursing homes in Portland, Oregon, over a 3-month period. One hundred twenty infections occurred during the study period. Antibiotic treatment was judged appropriate only in 49% of cases, and inappropriate and unjustified in 42% and 9% of cases, respectively.
Method of physician remuneration and rates of antibiotic prescription.
Hutchinson JM, Foley RN.
CMAJ 1999 Apr 6;160(7):1013-7.The results of this study, conducted on 476 Canadian doctors, show that physicians who are paid for fee-for-service and those with greater volume of patients are much more likely to prescribe antibiotics, compared to doctors paid by salary and with smaller patient volume. These findings indicate that factors unrelated to medical conditions play an important role in physicians' attitude toward antibiotic prescribing.
Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice, and parent beliefs.
Watson RL, Dowell SF, Jayaraman M, Keyserling H, Kolczak M, Schwartz B.
Pediatrics 1999 Dec;104(6):1251-7.This study was conducted on a sample of 366 pediatricians and family physicians from Georgia to determine their antibiotic prescribing practices in pediatric patients with upper respiratory tract infections (URTIs). While 97% of them reported that widespread use of antibiotics was a major contributor to the development of antibiotic resistant bacterial strains, they nevertheless prescribed antibiotics in 72% of visits for URTIs. In addition, contrary to published guidelines for the management of pediatric patients with these conditions, 86% of physicians prescribed antibiotics in patients with bronchitis regardless of the duration of cough, and 42% prescribed antibiotics for the common cold. Interestingly, physicians who prescribed the most antibiotics also had the highest rates of return office visits (up to 30% more). The authors conclude that antibiotic prescribing practices in pediatric patients with URIs often are in disagreement with published guidelines, in spite of physicians' knowledge of the role of injudicious use of antibiotics in the development of antibiotic resistance.
Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis.
Nyquist AC, Gonzales R, Steiner JF, Sande M.
JAMA. 1998 Mar 18;279(11):875-7.This study evaluated the rates of antibiotic prescribing in 531 children younger than 18 years diagnosed with common cold, upper respiratory tract infections (URTIs) or bronchitis. Forty-four percent of children with common cold, 46% of those with URTIs, and 75% of those with brochitis received an antibiotic prescription. Extrapolation of these data to the entire U.S. population revealed that in 1992, physicians wrote 6.5 million prescriptions for children with URTIs or common cold and 4.7 million prescriptions for children with bronchitis, despite the fact that, as emphasized in the article, antibiotic treatment is typically ineffective in these conditions. These data indicate that 21% of all antibiotic prescriptions written for children younger than 18 in 1992 (over 11 million prescriptions) are unnecessary.
Systematic review of the treatment of upper respiratory tract infection.
Fahey T, Stocks N, and Thomas T.
Arch Dis Child 1998;79:225-230 ( September ).The results of this meta-analysis, conducted on 6 randomized, placebo-controlled studies involving 1,699 children, show that antibiotic treatment does not improve clinical outcome or reduce rates of complications in children with upper respiratory tract infections. The authors conclude that there is no evidence from randomized trials supporting the use of antibiotics in the management of children with upper respiratory tract infections.
Outcomes After Judicious Antibiotic Use for Respiratory Tract Infections Seen in a Private Pediatric Practice.
Pichichero, ME. et al.
Pediatrics 2000 Apr;105(4):753-759.The results of this study show that antibiotic treatment is not routinely recommended in the management of children with respiratory tract infections without a concomitant bacterial infection. The study was conducted on a sample of 383 infants and children younger than 12 with respiratory tract infections, to evaluate the effects of a reduction of antibiotic prescribing rates on the incidence of return office visits or subsequent bacterial infections. In the study, physicians prescribed antibiotics only when a bacterial infection was confirmed or presumed, resulting in only 23% of children receiving a prescription. Of note, more than half of the antibiotic prescriptions were written for children who were diagnosed with middle ear infections, even though current evidence (presented later in this text) indicates that antibiotics are no better than placebo in the management of this condition. Evaluation of the frequency of subsequent unscheduled return visits revealed that only 29% of children who did not receive antibiotics returned for an additional visit, compared to 44% of those treated with antibiotics. These data further support judicious use of antibiotics in children and infants with respiratory tract infections, i.e. avoidance of antibiotic treatment when there are no signs of bacterial infection. Less than 1 every 5 infants or children who present with respiratory tract infections require antibiotic treatment. Untreated children had lower rates of subsequent return office visits or bacterial infections, compared to treated children. Physicians should comply with current evidence demonstrating the safety and effectiveness of judicious antibiotic use, especially in consideration of the worldwide increase in antibiotic resistant bacteria, leading to a staggering increase in morbidity, mortality and health care costs due to untreatable infections.
Decreasing Antibiotic Use in Ambulatory Practice. Impact of a Multidimensional Intervention on the Treatment of Uncomplicated Acute Bronchitis in Adults.
Gonzales, R. et al.
JAMA 1999;281:1512-1519.The results of this study show that an intervention program consisting of office-based patient educational materials and clinician educational meetings resulted in a decline in antibiotic prescribing rates from 74% to 48% in patients with uncomplicated bronchitis. No differences in office return visits were observed in the month following the first visit, between the institutions with reduced antibiotic prescribing and those with rates of antibiotic prescribing of 80%, indicating that use of these drugs is unnecessary in the routine management of patients with uncomplicated bronchitis.
Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians.
Gonzales R, Steiner JF, Sande MA.
JAMA 1997 Sep 17;278(11):901-4.The results of this study show that although antibiotics have been shown to be largely ineffective in treating colds, upper respiratory tract infections and bronchitis, they are nevertheless prescribed to 51%-66% of patients diagnosed with these conditions. This study demonstrates that in 1992, an estimated 12 million antibiotic prescriptions, or one fifth of all antibiotics prescriptions filled during that year, were written for patients with colds, upper respiratory tract infections or bronchitis, despite lack of evidence of their effectiveness in the management of these ailments (more than 90% of upper respiratory infections -including bronchitis and colds- note the authors, are caused by a virus and are therefore impervious to antibiotics.) This practice has contributed to the spread of antibiotic-resistant bacteria and consequent infections in community settings.
Antibiotics and upper respiratory infection: do some folks think there is a cure for the common cold.
Mainous AG 3d, Hueston WJ, Clark JR.
J Fam Pract 1996 Apr;42(4):357-61.The results of this study show that 60% of patients who present with a complaint of common cold receive an antibiotic prescription. This practice leads to an estimated annual cost of $37.5 millions for unnecessary treatment of a condition that is not improved by antibiotic treatment.
Trends in antimicrobial drug prescribing among office-based physicians in the United States.
McCaig LF, Hughes JM.
JAMA 1995 Jan 18;273(3):214-9.The results of this study indicate that from 1980 to 1992, rates of prescribing of more expensive antibiotics with a broader antibacterial spectrum have been increasing, while prescribing of cheaper antibiotics with a narrower spectrum have been decreasing. The authors emphasize that this trend leads to an increase use of health care resources and has a potential deleterious effect on the insurgence of antibiotic resistance.
Factors associated with antibiotic use for acute bronchitis.
Gonzales R, Barrett PH Jr, Crane LA, Steiner JF.
J Gen Intern Med 1998 Aug;13(8):541-8.The results of this study show that physicians in primary care office practices prescribe antibiotics to 85% of patients with acute bronchitis. The authors could not identify clinical factors that explained the high rates of antibiotic prescribing and conclude that it seems feasible that a diagnosis of acute bronchitis is interpreted by physicians as an indication for antibiotic treatment, despite available evidence indicating the contrary.
Treatment of acute bronchitis in adults. A national survey of family physicians.
Oeffinger KC, Snell LM, Foster BM, Panico KG, Archer RK.
J Fam Pract 1998 Jun;46(6):469-75.The results of this study show that family physicians prescribe antibiotics to 75% of nonsmoking and otherwise healthy adult patients with acute bronchitis and to 90% of smoking and otherwise healthy adult patients with acute bronchitis, despite evidence from clinical trials indicating that antibiotics are largely ineffective in the management of this condition. The authors emphasize how the increasing prevalence of antibiotic resistance calls for a change in the management of patients with acute bronchitis.
Antimicrobials for acute otitis media? A review from the international primary care network.
Froom, J. et al.
BMJ 1997;315:98-102 (12 July).This article highlights that even though there is no scientific evidence demonstrating that antibiotics are effective in the treatment of middle ear infections, this condition represent the most frequent reason for prescribing antibiotics in outpatient settings in the U.S. The seven randomized studies that evaluated the effectiveness of antibiotics in children with middle ear infection showed little or no benefits compared to placebo. The authors conclude that there is no convincing evidence in support of the use of these drugs in children with middle ear infections, and the management of this condition should therefore be reevaluated. Changing treatment practices is especially important since injudicious use of antibiotics is a major factor implicated in the development of antibiotic resistance and the consequent increase in morbidity, mortality, and health care costs associated with untreatable infections.
Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years.
Damoiseaux, Roger A M J et al.
BMJ 2000;320:350-354 ( 5 February ).The results of this randomized study indicate that use of antibiotics is inappropriate not only in older children with middle ear infections but also in those aged 6 months to 2 years. In the study, 240 children under 2 years diagnosed with middle ear infection were randomly assigned to receive antibiotics or placebo. Signs of inflammation, pain and crying were no different in the group receiving antibiotics, compared to that receiving placebo. One every 7 or 8 treated children showed symptomatic improvement at day 4 of infection, but there were no improvements at day 11 or 42. The small benefits observed in a 13% of children do not justify routine antibiotic use in children of this age group with middle ear infection.
Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults.
Fahey T, Stocks N, Thomas T.
BMJ 1998 Mar 21;316(7135):906-10.This study is a meta-analysis of 9 randomized, placebo-controlled trials evaluating the efficacy of antibiotics in the treatment of individuals with acute cough. The results of the analysis revealed that antibiotics neither improve symptoms nor speed up recovery time in individuals with acute cough, while causing significantly more side effects compared to placebo. These data indicate that antibiotic treatment is inappropriate in individuals with acute cough.
National trends in the use of antibiotics by primary care physicians for adult patients with cough.
Metlay JP, Stafford RS, Singer DE.
Arch Intern Med 1998 Sep 14;158(16):1813-8.The results of this study show that primary care physicians' rates of antibiotic prescribing for adult patients presenting with cough increased significantly from 1980 to 1994. In particular, in 1980 an estimated 59% of patients who went to their doctor with a complaint of cough received an antibiotic prescription, as compared to 70% of patients who presented with cough in 1994. These data indicate an increasing trend of antibiotic prescribing for patients with cough, despite increasing evidence of the lack of efficacy of antibiotic treatment in this condition.
Outpatient visits for infectious diseases in the United States, 1980 through 1996.
Armstrong GL, Pinner RW.
Arch Intern Med 1999 Nov 22;159(21):2531-6.The results of this study show that every year 129 million outpatient visits, or approximately 20% of all outpatient visits to physicians are for infectious diseases. Of these, the majority (38%), are for upper respiratory tract infections, followed by middle ear infections (15.1%) and lower respiratory tract infections. These data indicate that over half of all visits for infectious diseases (approximately 68.5 million annual visits) are for upper respiratory tract infections or otitis, conditions that are typically not improved by antibiotics and for which antibiotics are first choice treatment.
