Ebbing Lautenbach

Risk factors for early postoperative recurrence of Crohn's disease ☆

BACKGROUND & AIMSnDespite many advances in our understanding of Crohns disease, the course of the disease in any given patient remains unpredictable. There is little agreement as to which factors increase a patients risk of early postoperative recurrence. We have attempted to identify predictors of early recurrence after surgical resection, specifically whether the indication for initial surgery (perforating or nonperforating) or the duration of preoperative disease may be associated with early recurrence.nnnMETHODSnWe studied 88 patients who had undergone at least two resections for Crohns disease. Multivariable survival analysis was performed to elucidate predictors of early postoperative recurrence.nnnRESULTSnA perforating indication for initial surgery (P < 0.001) and a longer preoperative disease duration (P = 0.004) were found to be the only independent predictors of earlier postoperative recurrence after initial surgery. A longer preoperative disease duration also showed a borderline significant association with a shorter interval from second to third surgery (P = 0.075). Finally, the indication for initial surgery was predictive of the indication at a subsequent surgery for recurrence (P = 0.001).nnnCONCLUSIONSnA perforating indication for initial resection and a longer duration of disease before initial surgery predicted an earlier postoperative recurrence. The latter association was borderline. This suggests that prognostic groups based on these factors may help to stratify patients with regard to risk of early recurrence.

Enterococcal bacteremia: risk factors for vancomycin resistance and predictors of mortality.

OBJECTIVEnTo identify risk factors for vancomycin resistance and mortality in enterococcal bacteremia.nnnDESIGNnHistorical cohort study.nnnSETTINGnA large academic medical center with a high prevalence of vancomycin-resistant enterococci (VRE).nnnPATIENTSnTwo hundred sixty patients with enterococcal bacteremia, of whom 72 (28%) had VRE.nnnRESULTSnIndependent risk factors for infection with VRE were the mean number of antibiotic days (P<.001), renal insufficiency (P<.001), mean days of vancomycin use (P = .005), and neutropenia (P = .013). A trend toward a significant association between metronidazole use and VRE also was noted (P = .068). Mortality was attributable to the bacteremia in 96 patients (37%). Severity of illness (P<.001) and age (P = .020) were independent risk factors for mortality. Vancomycin resistance was not, however, an independent predictor of mortality.nnnCONCLUSIONnThese results suggest that restrictions on antibiotic use, particularly in patients with renal insufficiency and neutropenia, may help to combat the rising incidence of VRE. Although patients with VRE bacteremia demonstrated higher mortality rates than patients with infection due to susceptible isolates, vancomycin resistance was not an independent predictor of mortality in these patients and likely serves more as a marker of underlying severity of illness.

The Role of Chloramphenicol in the Treatment of Bloodstream Infection Due to Vancomycin-Resistant Enterococcus

The incidence of bacteremia due to vancomycin-resistant Enterococcus (VRE) has increased markedly in recent years. We investigated the role of chloramphenicol in its treatment. All cases of VRE bacteremia occurring at our facility during a 45-month period were analyzed. The response to chloramphenicol, its effect on mortality, and the incidence of adverse effects were assessed. Fifty-one patients (65.4%) received chloramphenicol. Among patients in whom a response could be assessed, 22 (61.1%) of 36 demonstrated a clinical response, while 34 (79.1%) of 43 showed a microbiological response. Forty-two patients (53.8%) died as a result of the bacteremia. Although the mortality rate was lower for patients treated with chloramphenicol, the difference was not significant (odds ratio = 0.72; 95% confidence interval, 0.28-1.85; P = .49), nor was there an association between earlier initiation of therapy and reduced mortality (P = .45). In cases with central line-related bacteremia, there was no difference in mortality among patients treated with chloramphenicol, line removal, or both (P = .36). Although 16 patients (31.4%) had adverse effects, none could be definitely attributed to chloramphenicol. Although chloramphenicol was well-tolerated, no significant effect of its use on mortality could be demonstrated.

Surveillance Cultures for Detection of Methicillin-Resistant Staphylococcus aureus: Diagnostic Yield of Anatomic Sites and Comparison of Provider- and Patient-Collected Samples

We studied provider- and patient-collected samples from multiple anatomic sites to determine the yield for detection of methicillin-resistant Staphylococcus aureus (MRSA). Sampling of multiple sites was required to achieve a sensitivity of more than 90% for MRSA colonization. Groin and perineum samples yielded positive results significantly more often for community-onset MRSA than for hospital-onset MRSA. Agreement rates between provider- and patient-collected swab specimens were excellent.

Pediatric Crohn's disease: risk factors for postoperative recurrence

OBJECTIVE: n nPostoperative recurrence of Crohn’s disease in adults has been extensively studied; however, the course of Crohn’s disease after surgery in children has not been well defined. The aim of this study was to examine the postoperative course of pediatric Crohn’s disease and the factors that may predict early postoperative recurrence. n nMETHODS: n nWe identified 100 resective surgeries in 79 children with Crohn’s disease seen at the Children’s Hospital of Philadelphia between 1978 and 1996. A retrospective, multivariable analysis of factors potentially influencing postoperative clinical recurrence was performed. Preoperative and postoperative height measurements were compared, and z scores were computed for height-for-age. Two-tailed t test was used for the analysis. n nRESULTS: n nClinical recurrence rates were 17% at 1 yr, 38% at 3 yr, and 60% at 5 yr. Patients with colonic Crohn’s disease had a significantly shorter postoperative recurrence-free interval (median 1.2 yr) than patients with ileocecal (median 4.4 yr) or diffuse disease (median 3.0 yr) (p = 0.01). On multivariable analysis, a high Pediatric Crohn’s Disease Activity Index at the time of surgery (p = 0.01) and preoperative use of 6-mercaptopurine (6-MP) (p < 0.005) were also independently associated with higher postoperative recurrence rates. There was a significant improvement in z scores for height (p = 0.04) after surgery. n nCONCLUSIONS: n nIn children undergoing resective surgery for Crohn’s disease, high rates of postoperative Crohn’s disease recurrence are associated with severe disease at the time of surgery, colonic Crohn’s disease, and the preoperative use of 6-MP. Patients who require preoperative use of 6-MP are likely to suffer from a more aggressive disease and would benefit from postoperative 6-MP prophylaxis. Height growth was improved after intestinal resection for Crohn’s disease.

Risk factors for fluoroquinolone resistance in Gram-negative bacilli causing healthcare-acquired urinary tract infections

The prevalence of urinary tract infections caused by fluoroquinolone-resistant Gram-negative bacilli (FQ-resistant GNB-UTIs) has been increasing. Previous studies that explored risk factors for FQ resistance have focused only on UTIs caused by Escherichia coli and/or failed to distinguish colonisation from infection. We conducted a case-control study at two medical centres within the University of Pennsylvania Health System to identify risk factors for FQ resistance among healthcare-acquired GNB-UTIs. Subjects with positive urine cultures for GNB and who met Centers for Disease Control and Prevention criteria for healthcare-acquired UTI were eligible. Cases were subjects with FQ-resistant GNB-UTI and controls were subjects with FQ-susceptible GNB-UTI matched to cases by month of isolation and species of infecting organism. In total, 251 cases and 263 controls were included from 1 January 2003 to 31 March 2005. Independent risk factors (adjusted odds ratio; 95% confidence interval) for FQ resistance included male sex (2.03; 1.21-3.39; P=0.007), African-American race (1.80; 1.10-2.94; P=0.020), chronic respiratory disease (2.58; 1.18-5.62; P=0.017), residence in a long term care facility (4.41; 1.79-10.88; P=0.001), hospitalisation within the past two weeks (2.19; 1.31-3.64; P=0.003), hospitalisation under a medical service (2.72; 1.63-4.54; P<0.001), recent FQ exposure (15.73; 6.15-40.26; P<0.001), recent cotrimoxazole exposure (2.49; 1.07-5.79; P=0.033), and recent metronidazole exposure (2.89; 1.48-5.65; P=0.002).

Point-of-Prescription Interventions to Improve Antimicrobial Stewardship

Antimicrobial stewardship is pivotal to improving patient outcomes, reducing adverse events, decreasing healthcare costs, and preventing further emergence of antimicrobial resistance. In an era in which antimicrobial resistance is increasing, judicious antimicrobial use is the responsibility of every healthcare provider. Antimicrobial stewardship programs (ASPs) have made headway in improving antimicrobial prescribing using such top-down methods as formulary restriction and prospective audit with feedback; however, engagement of prescribers has not been fully explored. Strategies that include frontline prescribers and other unit-based healthcare providers have the potential to expand stewardship, both to augment existing centralized ASPs and to provide alternative approaches to perform stewardship at healthcare facilities with limited resources. This review discusses interventions focusing on antimicrobial prescribing at the point of prescription as well as a pilot project to engage unit-based healthcare providers in antimicrobial stewardship.

Human immunodeficiency virus infection and Crohn's disease : The role of the CD4 cell in inflammatory bowel disease

Crohns disease is believed to have an immunologic basis. The importance of the CD4 cell in particular has been supported by several reports of patients whose symptoms of Crohns disease resolved after a decline in CD4 count associated with human immunodeficiency virus (HIV) infection. A patient with known Crohns disease, however, who was later infected with HIV, was reported to continue to have symptomatic Crohns disease despite an eventual decrease in CD4 count to 84/mm3. We report the new onset of Crohns disease in an HIV-infected patient with a CD4 count of 100/mm3. This report is the first to document the new onset of Crohns disease in a patient with HIV and a CD4 count in the range commonly associated with various opportunistic infections and neoplasms. In addition, it is the first to confirm the recent finding that Crohns disease may be active despite the profound immune deficiency associated with advanced HIV infection. Thus this report further challenges the significance of the CD4 cell in the pathogenesis of Crohns disease.

Derivation and validation of clinical prediction rules for reduced vancomycin susceptibility in Staphylococcus aureus bacteraemia

Reduced vancomycin susceptibility (RVS) may lead to poor clinical outcomes in Staphylococcus aureus bacteraemia. We conducted a cohort study of 392 patients with S. aureus bacteraemia within a university health system. The association between RVS, as defined by both Etest [vancomycin minimum inhibitory concentration (MIC) >1·0 μg/ml] and broth microdilution (vancomycin MIC ≥1·0 μg/ml), and patient and clinical variables were evaluated to create separate predictive models for RVS. In total, 134 (34·2%) and 73 (18·6%) patients had S. aureus isolates with RVS by Etest and broth microdilution, respectively. The final model for RVS by Etest included methicillin resistance [odds ratio (OR) 1·51, 95% confidence interval (CI) 0·97-2·34], non-white race (OR 0·67, 95% CI 0·42-1·07), healthcare-associated infection (OR 0·56, 95% CI 0·32-0·96), and receipt of any antimicrobial therapy ≤30 days prior to the culture date (OR 3·06, 95% CI 1·72-5·44). The final model for RVS by broth microdilution included methicillin resistance (OR 2·45, 95% CI 1·42-4·24), admission through the emergency department (OR 0·54, 95% CI 0·32-0·92), presence of an intravascular device (OR 2·24, 95% CI 1·30-3·86), and malignancy (OR 0·51, 95% CI 0·26-1·00). The availability of an easy and rapid clinical prediction rule for early identification of RVS can be used to help guide the timely and individualized management of these serious infections.