Andrew Labelle

Treatment-related risk factors for hospital mortality in Candida bloodstream infections

Objective:To examine the relationship between treatment-related variables for Candida bloodstream infection and hospital mortality. Design:Retrospective cohort analysis. Setting:Thousand two hundred-bed academic medical center. Patients:A total of 245 consecutive patients with Candida bloodstream infections who received antifungal therapy. Interventions:Identification of treatment-related risk factors: central vein catheter retention, inadequate initial fluconazole dosing, and delayed administration of antifungal therapy. Measurements and Main Results:A total of 245 patients with Candida bloodstream infections who received antifungal therapy were identified. One hundred eleven (45.3%) patients were managed in an intensive care unit and analyzed as a separate subgroup. In the hospital cohort, 72 (29.4%) patients died during hospitalization and 40 (36.0%) patients died in the intensive care unit cohort. In the hospital cohort, logistic regression analysis identified Acute Physiology and Chronic Health Evaluation II scores (1-point increments) (adjusted odds ratio [AOR], 1.18; 95% confidence interval [CI], 1.11–1.25; p = 0.003), corticosteroid use at the time a positive blood culture was drawn (AOR, 3.41; 95% CI, 1.96–5.93; p = 0.027), inadequate initial fluconazole dosing (AOR, 3.31; 95% CI, 1.83–6.00; p = 0.044), and retention of a central vein catheter (AOR, 4.85; 95% CI, 2.54–9.29; p = 0.015) as independent determinants of hospital mortality. In the intensive care unit cohort, logistic regression analysis identified Acute Physiology and Chronic Health Evaluation II scores (1-point increments) (AOR, 1.21; 95% CI, 1.14–1.29; p = 0.001), inadequate initial fluconazole dosing (AOR, 9.22; 95% CI, 2.15–19.79; p = 0.004), and retention of a central vein catheter (AOR, 6.21; 95% CI, 3.02–12.77; p = 0.011), as independent determinants of hospital mortality. For both cohorts the incremental presence of treatment-related risk factors was statistically associated with greater hospital mortality. Conclusions:Treatment-related factors, including retention of central vein catheters and inadequate initial fluconazole dosing, were associated with increased hospital mortality in patients with Candida bloodstream infections. These data suggest that optimization of initial antifungal therapy and removal of central vein catheters may improve the outcomes of patients with Candida bloodstream infections.

Inappropriate empiric antifungal therapy for candidemia in the ICU and hospital resource utilization: a retrospective cohort study

BackgroundCandida represents the most common cause of invasive fungal disease, and candidal blood stream infections (CBSI) are prevalent in the ICU. Inappropriate antifungal therapy (IAT) is known to increase a patients risk for death. We hypothesized that in an ICU cohort it would also adversely affect resource utilization.MethodsWe retrospectively identified all patients with candidemia on or before hospital day 14 and requiring an ICU stay at Barnes-Jewish Hospital between 2004 and 2007. Hospital length of stay following culture-proven onset of CBSI (post-CBSI HLOS) was primary and hospital costs secondary endpoints. IAT was defined as treatment delay of ≥24 hours from candidemia onset or inadequate dose of antifungal agent active against the pathogen. We developed generalized linear models (GLM) to assess independent impact of inappropriate therapy on LOS and costs.ResultsNinety patients met inclusion criteria. IAT was frequent (88.9%). In the IAT group antifungal delay ≥24 hours occurred in 95.0% and inappropriate dosage in 26.3%. Unadjusted hospital mortality was greater among IAT (28.8%) than non-IAT (0%) patients, p = 0.059. Both crude post-CBSI HLOS (18.4 ± 17.0 vs. 10.7 ± 9.4, p = 0.062) and total costs (

Implementation of a real-time computerized sepsis alert in nonintensive care unit patients*

66,584 ±

Hospital resource utilization and costs of inappropriate treatment of candidemia.

49,120 vs.

A Comparison of Culture-Positive and Culture-Negative Health-Care-Associated Pneumonia

33,526 ±

The determinants of hospital mortality among patients with septic shock receiving appropriate initial antibiotic treatment

27,244, p = 0.006) were higher in IAT than in non-IAT. In GLMs adjusting for confounders IAT-attributable excess post-CBSI HLOS was 7.7 days (95% CI 0.6-13.5) and attributable total costs were

Healthcare-Associated Pneumonia: Approach to Management

13,398 (95% CI

Five Versus Seven Day Antibiotic Course For The Treatment Of Pneumonia In The Intensive Care Unit

1,060-

title

26,736).ConclusionsIAT of CBSI, such as delays and incorrect dosing, occurs commonly. In addition to its adverse impact on clinical outcomes, IAT results in substantial prolongation of hospital LOS and increase in hospital costs. Efforts to enhance rates of appropriate therapy for candidemia may improve resource use.

The Impact of Antibiotic Resistance in Patients With Septic Shock Treated With Appropriate Antimicrobial Therapy

Objective:Early therapy of sepsis involving fluid resuscitation and antibiotic administration has been shown to improve patient outcomes. A proactive tool to identify patients at risk for developing sepsis may decrease time to interventions and improve patient outcomes. The objective of this study was to evaluate whether the implementation of an automated sepsis screening and alert system facilitated early appropriate interventions. Design:Prospective, observational, pilot study. Setting:Six medicine wards in Barnes-Jewish Hospital, a 1250-bed academic medical center. Patients:Patients identified by the sepsis screen while admitted to a medicine ward were included in the study. A total of 300 consecutive patients were identified comprising the nonintervention group (n = 200) and the intervention group (n = 100). Interventions:A real-time sepsis alert was implemented for the intervention group, which notified the charge nurse on the patients hospital ward by text page. Measurements and Main Results:Within 12 hrs of the sepsis alert, interventions by the treating physicians were assessed, including new or escalated antibiotics, intravenous fluid administration, oxygen therapy, vasopressors, and diagnostic tests. After exclusion of patients without commitment to aggressive management, 181 patients in the nonintervention group and 89 patients in the intervention group were analyzed. Within 12 hrs of the sepsis alert, 70.8% of patients in the intervention group had received ≥1 intervention vs. 55.8% in the nonintervention group (p = .018). Antibiotic escalation, intravenous fluid administration, oxygen therapy, and diagnostic tests were all increased in the intervention group. This was a single-center, institution- and patient-specific algorithm. Conclusions:The sepsis alert developed at Barnes-Jewish Hospital was shown to increase early therapeutic and diagnostic interventions among nonintensive care unit patients at risk for sepsis.