Daniel J. Sexton

Adverse Clinical and Economic Outcomes Attributable to Methicillin Resistance among Patients with Staphylococcus aureus Surgical Site Infection

Data for 479 patients were analyzed to assess the impact of methicillin resistance on the outcomes of patients with Staphylococcus aureus surgical site infections (SSIs). Patients infected with methicillin-resistant S. aureus (MRSA) had a greater 90-day mortality rate than did patients infected with methicillin-susceptible S. aureus (MSSA; adjusted odds ratio, 3.4; 95% confidence interval, 1.5-7.2). Patients infected with MRSA had a greater duration of hospitalization after infection (median additional days, 5; P<.001), although this was not significant on multivariate analysis (P=.11). Median hospital charges were 29,455 dollars for control subjects, 52,791 dollars for patients with MSSA SSI, and 92,363 dollars for patients with MRSA SSI (P<.001 for all group comparisons). Patients with MRSA SSI had a 1.19-fold increase in hospital charges (P=.03) and had mean attributable excess charges of 13,901 dollars per SSI compared with patients who had MSSA SSIs. Methicillin resistance is independently associated with increased mortality and hospital charges among patients with S. aureus SSI.

The Impact of Surgical-Site Infections Following Orthopedic Surgery at a Community Hospital and a University Hospital Adverse Quality of Life, Excess Length of Stay, and Extra Cost

OBJECTIVE To measure the impact of orthopedic surgical-site infections (SSIs) on quality of life, length of hospitalization, and cost. DESIGN A pairwise-matched (1:1) case-control study within a cohort. SETTING A tertiary-care university medical center and a community hospital. PATIENTS Cases of orthopedic SSIs were prospectively identified by infection control professionals. Matched controls were selected from the entire cohort of patients undergoing orthopedic surgery who did not have an SSI. Matching variables included type of surgical procedure, National Nosocomial Infections Surveillance risk index, age, date of surgery, and surgeon. MAIN OUTCOME MEASURES Quality of life, duration of postoperative hospital stay, frequency of hospital readmission, overall direct medical costs, and mortality rate. RESULTS Fifty-nine SSIs were identified. Each orthopedic SSI accounted for a median of 1 extra day of stay during the initial hospitalization (P = .001) and a median of 14 extra days of hospitalization during the follow-up period (P = .0001). Patients with SSI required more rehospitalizations (median, 2 vs 1; P = .0001) and more total surgical procedures (median, 2 vs 1; P = .0001). The median total direct cost of hospitalizations per infected patient was

Outcome of Staphylococcus aureus Bacteremia According to Compliance with Recommendations of Infectious Diseases Specialists: Experience with 244 Patients

24,344, compared with

Role of echocardiography in evaluation of patients with Staphylococcus aureus bacteremia: experience in 103 patients.

6,636 per uninfected patient (P = .0001). Mortality rates were similar for cases and controls. Quality of life was adversely affected for patients with SSI. The largest decrements in scores on the Medical Outcome Study Short Form 36 questionnaire were seen in the physical functioning and role-physical domains. CONCLUSIONS Orthopedic SSIs prolong total hospital stays by a median of 2 weeks per patient, approximately double rehospitalization rates, and increase healthcare costs by more than 300%. Moreover, patients with orthopedic SSIs have substantially greater physical limitations and significant reductions in their health-related quality of life.

Nosocomial methicillin-resistant and methicillin-susceptible Staphylococcus aureus primary bacteremia: at what costs?

To determine whether recommendations of infectious diseases specialists affect outcome for patients, we evaluated 244 hospitalized patients with Staphylococcus aureus bacteremia. We offered our management recommendations to each patients physicians and then assessed the clinical outcome for both patients for whom our consultative advice was followed and those for whom our advice was not heeded. All patients were followed up for 12 weeks after their first positive blood culture. Our management advice was followed for 112 patients (45.9%) and partially or completely ignored for 132 patients (54.1%). Patients for whom our recommendations were followed were more likely to be cured of their S. aureus infection and less likely to relapse (P < .01), despite having significantly more metastatic infections (P < .01) at the outset of therapy, than were those for whom our recommendations were not followed. Failure to follow recommendations to remove an infected intravascular device was the most important risk for treatment failure. After controlling for other factors, logistic regression analysis revealed that patients whose intravascular device was not removed were 6.5 times more likely to relapse or die of their infection than were those whose device was removed. Our findings suggest that patient-specific management advice by infectious diseases consultants can improve the clinical outcome for patients with S. aureus bacteremia.

Mediastinitis After Coronary Artery Bypass Graft Surgery Risk Factors and Long-term Survival

OBJECTIVES The purpose of this prospective study was to examine the role of echocardiography in patients with Staphylococcus aureus bacteremia (SAB). BACKGROUND The reported incidence of infective endocarditis (IE) among patients with SAB varies widely. Distinguishing patients with uncomplicated bacteremia from those with IE is therapeutically and prognostically important, but often difficult. METHODS One hundred-three consecutive patients undergoing both transthoracic (TTE) echocardiography and transesophageal (TEE) echocardiography were prospectively evaluated. All patients presented with fever and > or = 1 positive blood culture and were followed up for 12 weeks. RESULTS Although predisposing heart disease was present in 42 patients (41%), clinical evidence of infective endocarditis (IE) was rare (7%). TTE revealed anatomic abnormalities in 33 patients, but vegetations in only 7 (7%), and was considered indeterminate in 19 (18%). TEE identified vegetations in 22 patients (aortic valve in 5, mitral valve in 9, tricuspid valve in 4, catheter in 2 and pacemaker in 2, abscesses in 2, valve perforation in 1 and new severe regurgitation in 1; 26 total [25%]). Using Duke criteria for the diagnosis of IE, definite IE was present in 26 patients (25%). Clinical findings and predisposing heart disease did not distinguish between patients with and without IE. The sensitivity of TTE for detecting IE was 32%, and the specificity was 100%. The addition of TEE increased the sensitivity to 100%, but resulted in one false positive result (specificity 99%). TEE detected evidence of IE in 19% of patients with a negative TTE and 21% of patients with an indeterminate TTE. At follow-up, cure of staphylococcal infection occurred in a similar percentage of patients with and without IE (77% and 75%, respectively). However, death due to sepsis was significantly more likely among patients with IE (4 of 26 [15%]) than among those without IE (2 of 77 [3%]) (p = 0.03). CONCLUSIONS Our results suggest that IE is common among patients admitted to the hospital with SAB and is associated with an increased risk of death due to sepsis. TEE is essential to establish the diagnosis and to detect associated complications. Therefore, the test should be considered part of the early evaluation of patients with SAB.

Generation of high-affinity human antibodies by combining donor-derived and synthetic complementarity-determining-region diversity.

OBJECTIVE To determine the attributable hospital stay and costs for nosocomial methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant S. aureus (MRSA) primary bloodstream infections (BSIs). DESIGN Pairwise-matched (1:1) nested case-control study. SETTING University-based tertiary-care medical center. PATIENTS Patients admitted between December 1993 and March 1995 were eligible. Cases were defined as patients with a primary nosocomial S. aureus BSI; controls were selected according to a priori matching criteria. MEASUREMENTS Length of hospital stay and total and variable direct costs of hospitalization. RESULTS The median hospital stay attributable to primary nosocomial MSSA BSI was 4 days, compared with 12 days for MRSA (P=.023). Attributable median total cost for MSSA primary nosocomial BSIs was

Early Predictors of In-Hospital Death in Infective Endocarditis

9,661 versus

Comparison of the Burdens of Hospital-Onset, Healthcare Facility-Associated Clostridium difficile Infection and of Healthcare-Associated Infection due to Methicillin-Resistant Staphylococcus aureus in Community Hospitals

27,083 for MRSA nosocomial infections (P=.043). CONCLUSION Nosocomial primary BSI due to S. aureus significantly prolongs the hospital stay. Primary nosocomial BSIs due to MRSA result in an approximate threefold increase in direct cost, compared with those due to MSSA.

Selective Inhibition of Matrix Metalloproteinase-14 Blocks Tumor Growth, Invasion, and Angiogenesis

This study from Duke University Medical Center addresses both the risk factors for the development of mediastinitis, as well as the long-term impact of mediastinal infection on survival in 6459 consecutive patients undergoing coronary artery bypass graft (CABG) surgery at that institution from 1987 to 1994. Data on 20 preoperative and intraoperative variables were collected prospectively and analyzed using univariate and multivariate analyses, with evaluation of long-term survival in the infected and uninfected groups. Eight-three patients (1.3%) developed mediastinitis, defined as deep sternal wound infection requiring extensive debridement and drainage. The mean postoperative hospital stay was prolonged in the mediastinitis group (25 versus 10 days, no statistical analysis provided). Variables associated with an increased incidence of mediastinitis by univariate analysis included obesity (P =.009), New York Heart Association congestive heart failure (NYHA CHF) class (P =.002), diabetes mellitus (P =.009), priorsternotomy (P =.009), duration of cardiopulmonary bypass (P =.02), presence of comorbid conditions (P =.03) and poor hemostasis at sternotomy closure (P =.09). Multivariate logistic regression analysis revealed four independent predictors of mediastinitis development: NYHA CHF class (P =.002), obesity (P =.0002), prior sternotomy (P =.008), and duration of cardiopulmonary bypass (P =.05). Variables without significant influence included age, number of internal mammary artery grafts utilized, duration of preoperative stay, and chronic obstructive pulmonary disease. The median duration of follow-up in the mediastinitis group was 1.5 years, with a follow-up of 3.4 years in the patients without mediastinitis. Interval and cumulative mortality rates were higher in the mediastinitis group up to 2 years following CABG surgery, a difference which persisted when controlled for variables associated with late postoperative mortality, including age, ejection fraction, cere-brovascular disease, and mitral insufficiency. Patients developing mediastinitis suffered a nearly fourfold increase in mortality in the 1–2 postoperative years (8.1% versus 2.3%). The authors provide a review of the literature addressing risk factors for mediastinitis development. In addition, they propose a model of preoperative risk assessment in individual patients, using NYHA CHF class III or IV, obesity, and prior heart surgery as variables. According to their data, patients possessing one factor have a threefold increased incidence of postoperative mediastinitis, and those possessing all three have a nearly 20-fold increased risk of this postoperative complication.