Carbapenem-resistant Enterobacteriaceae in patients admitted to the Emergency Department

New risk factors and occurrence in patients coming directly from the community | Journal of Hospital Infection

Aim: To investigate the prevalence of patients harboring CRE on hospital admission, risk factors associated and the acquisition rate within the emergency department (ED).

Methods: We conducted a cross-sectional with 676 patients consecutively admitted to the ED study during the months of May to July 2016. A questionnaire was performed and rectal swabs were collected from patients on admission, for culture and for multiplex real-time polymerase chain-reaction (RT-PCR). If the patient was hospitalized for more than one week in the ED, samples were taken again to determine the acquisition rate of CRE.

Findings: Forty-six patients were colonized, all positive RT-PCR were KPC. The acquisition rate was 18%. Patients CRE colonized presented a higher mortality rate. Previous exposure to healthcare in the last year, liver disease and use of antibiotics in the last month were risk factors for colonization. Six patients with no previous exposure to healthcare were CRE-colonized on admission, suggesting transmission of CRE within the community.

Conclusion: Screening of high-risk patients on admission to the ED is a strategy to early identify CRE carriage and may contribute to control CRE dissemination.

Full reference: Salomão, M.C. et al. (2017) Carbapenem-resistant Enterobacteriaceae in patients admitted to the Emergency Department: new risk factors and occurrence in patients coming directly from the community. Journal of Hospital Infection. Published online: 18 August 2017

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Impact of an antimicrobial stewardship program to optimize antimicrobial use for outpatients at emergency department

Antimicrobial stewardship programs (ASPs) have proven to be effective in optimizing antibiotic use for inpatients. However, Emergency Department (ED)’s fast-paced clinical setting can be challenging for a successful ASP | The Journal of Hospital Infection

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Aim: In April 2015, an ASP was implemented in our ED and we aimed to determine its impact on antimicrobial use for outpatients.

Methods: Monocentric study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016).

For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24hours) were evaluated by an infectious disease specialist (IDS) and an ED physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified.

Findings: Before and after ASP, 34,671 and 35,925 consultations were registered at our ED, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (p<0.0001). There were 484 (62.9%) and 271 (46.7%) (p<0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliances included unnecessary antimicrobial prescriptions, 197 (25.6%) vs. 101 (17.4%) (p<0.0005); inappropriate spectrum, 108 (14.0%) vs. 54 (9.3%) (p=0.008); excessive treatment duration, 87 (11.3%) vs. 53 (9.1%) (p>0.05); and inappropriate choices, 11 (1.4%) vs. 15 (2.6%) (p>0.05).

Conclusions: The implementation of an ASP dramatically decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

Full reference: Dinh, A. et al. (2017) Impact of an antimicrobial stewardship program to optimize antimicrobial use for outpatients at emergency department. The Journal of Hospital Infection. Published online: 8th July 2017

Severe community-acquired pneumonia: timely management measures in the first 24 hours

Phua, J. et al. Critical Care. Published online: 28 August 2016

Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.

In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.

These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).

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While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.

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Surface cleaning effectiveness in a walk-in emergency care unit: Influence of a multifaceted intervention

Frota, P.O. et al. American Journal of Infection Control. Published online: 24 August 2016

Highlights

  • The interventions immediately improved the effectiveness of cleaning.
  • These improvements disappeared after four months of interventions.
  • Microfiber cloths did not impact any increase in cleaning effectiveness.
  • Continuous education and feedback on cleaning practices appear to be warranted.
  • This policy should be adapted to the particularities of each health care setting.

Abstract

Background: Cleaning of surfaces is essential in reducing environmental bioburdens and health care-associated infection in emergency units. However, there are few or no studies investigating cleaning surfaces in these scenarios. Our goal was to determine the influence of a multifaceted intervention on the effectiveness of routine cleaning of surfaces in a walk-in emergency care unit.

Methods: This prospective, before-and-after interventional study was conducted in 4 phases: phase I (situational diagnosis), phase II (implementation of interventions—feedback on results, standardization of cleaning procedures, and training of nursing staff), phase III (determination of the immediate influence of interventions), and phase IV (determination of the late influence of interventions). The surfaces were sampled before and after cleaning by visual inspection, adenosine triphosphate bioluminescence assay, and microbiologic culture.

Results: We sampled 240 surfaces from 4 rooms. When evaluated by visual inspection and adenosine triphosphate bioluminescence, there was a progressive reduction of surfaces found to be inadequate in phases I-IV (P < .001), as well as in culture phases I-III. However, phase IV showed higher percentages of failure by culture than phase I (P = .004).

Conclusions: The interventions improved the effectiveness of cleaning. However, this effect was not maintained after 2 months.

Read the abstract here

A Comprehensive Review of Common Respiratory Infections Encountered in Urgent and Primary Care

Beam, C. et al. Journal of Emergency Nursing. Published online: 21 July 2016

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Concern about antibiotic overuse has become heightened as bacterial resistance to antibiotics continues to increase. Patients experiencing respiratory symptoms frequently present to urgent/emergent care settings such as fast-track emergency care departments and primary care retail settings with the expectation that they will be prescribed antibiotics.
The Centers for Disease Control and Prevention (CDC) reports that approximately 2 million people will become ill with bacteria that are resistant to at least one antibiotic, approximately 23,000 people die as a direct result of these infections, and many others die as a result of complications related to antibiotic-resistant infections.
Read the abstract here

A Comprehensive Review of Common Respiratory Infections Encountered in Urgent and Primary Care

Beam, C. et al. Journal of Emergency Nursing. Published online: July 21 2016

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Image shows digitally colorized electron micograph of influenza virions 

Concern about antibiotic overuse has become heightened as bacterial resistance to antibiotics continues to increase. Patients experiencing respiratory symptoms frequently present to urgent/emergent care settings such as fast-track emergency care departments and primary care retail settings with the expectation that they will be prescribed antibiotics.

The Centers for Disease Control and Prevention (CDC) reports that approximately 2 million people will become ill with bacteria that are resistant to at least one antibiotic, approximately 23,000 people die as a direct result of these infections, and many others die as a result of complications related to antibiotic-resistant infections.

Read the abstract here

The influence of contaminated urine cultures in inpatient and emergency department settings

Klausing, B.T. et al. American Journal of Infection Control. Published online: 13 June 2016

Highlights

  • Urine culture contamination results in substantial impact to patients.
  • Morbidity includes unnecessary testing and antibiotic exposure.
  • Reducing urine culture contamination is an important quality intervention.

We retrospectively evaluated 131 patients with contaminated urine cultures during a 12-month period. Sixty-four patients (48.8%) experienced 139 potential complications related to these specimens. The most common complication was inappropriate antibiotic administration (noted in 58 patients [44.3%]). Contaminated urine cultures led to additional diagnostic evaluation and unnecessary antibiotic use.

Read the abstract here