Heather L. Evans

Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection

BACKGROUND The successful treatment of intraabdominal infection requires a combination of anatomical source control and antibiotics. The appropriate duration of antimicrobial therapy remains unclear. METHODS We randomly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy (control group), or to receive a fixed course of antibiotics (experimental group) for 4±1 calendar days. The primary outcome was a composite of surgical-site infection, recurrent intraabdominal infection, or death within 30 days after the index source-control procedure, according to treatment group. Secondary outcomes included the duration of therapy and rates of subsequent infections. RESULTS Surgical-site infection, recurrent intraabdominal infection, or death occurred in 56 of 257 patients in the experimental group (21.8%), as compared with 58 of 260 patients in the control group (22.3%) (absolute difference, -0.5 percentage point; 95% confidence interval [CI], -7.0 to 8.0; P=0.92). The median duration of antibiotic therapy was 4.0 days (interquartile range, 4.0 to 5.0) in the experimental group, as compared with 8.0 days (interquartile range, 5.0 to 10.0) in the control group (absolute difference, -4.0 days; 95% CI, -4.7 to -3.3; P<0.001). No significant between-group differences were found in the individual rates of the components of the primary outcome or in other secondary outcomes. CONCLUSIONS In patients with intraabdominal infections who had undergone an adequate source-control procedure, the outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics (approximately 8 days) that extended until after the resolution of physiological abnormalities. (Funded by the National Institutes of Health; STOP-IT ClinicalTrials.gov number, NCT00657566.).

Drawing Blood from Stones: Legal Debt and Social Inequality in the Contemporary United States

The expansion of the U.S. penal system has important consequences for poverty and inequality, yet little is known about the imposition of monetary sanctions. This study analyzes national and state‐level court data to assess their imposition and interview data to identify their social and legal consequences. Findings indicate that monetary sanctions are imposed on a substantial majority of the millions of people convicted of crimes in the United States annually and that legal debt is substantial relative to expected earnings. This indebtedness reproduces disadvantage by reducing family income, by limiting access to opportunities and resources, and by increasing the likelihood of ongoing criminal justice involvement.

Effect of chlorhexidine whole-body bathing on hospital-acquired infections among trauma patients.

OBJECTIVE To demonstrate whether daily bathing with cloths impregnated with 2% chlorhexidine gluconate will decrease colonization of resistant bacteria and reduce the rates of health care-associated infections in critically injured patients. DESIGN Retrospective analysis of data collected 6 months before and after institution of a chlorhexidine bathing protocol. SETTING A 12-bed intensive care unit in a level I trauma center. PATIENTS Two hundred eighty-six severely injured patients underwent daily chlorhexidine bathing during the 6-month intervention; 253 patients were bathed without chlorhexidine prior to the intervention. INTERVENTIONS Daily chlorhexidine bathing. MAIN OUTCOMES MEASURES Rates of ventilator-associated pneumonia (VAP), bloodstream infection, and colonization with resistant organisms (methicillin-resistant Staphylococcus aureus [MRSA] or Acinetobacter species). RESULTS Baseline patient and injury characteristics were similar between cohorts. Patients receiving chlorhexidine baths were significantly less likely to acquire a catheter-related bloodstream infection than comparators (2.1 vs 8.4 infections per 1000 catheter-days, P = .01). The incidence of VAP was not affected by chlorhexidine baths (16.9 vs 21.6 infections per 1000 ventilator-days in those with vs those without chlorhexidine baths, respectively, P = .30). However, patients who received chlorhexidine baths were less likely to develop MRSA VAP (1.6 vs 5.7 infections per 1000 ventilator-days, P = .03). The rate of colonization with MRSA (23.3 vs 69.3 per 1000 patient-days, P < .001) and Acinetobacter (1.0 vs 4.6 per 1000 patient-days, P = .36) was significantly lower in the chlorhexidine group than in the comparison group. CONCLUSIONS Daily bathing of trauma patients with cloths impregnated with 2% chlorhexidine gluconate is associated with a decreased rate of colonization by MRSA and Acinetobacter and lower rates of catheter-related bloodstream infection and MRSA VAP.

Cost of Gram-negative resistance*

Objective: It is unclear that infections with Gram‐negative rods resistant to at least one major class of antibiotics (rGNR) have a greater effect on patient morbidity than infections caused by sensitive strains (sGNR). We wished to test the hypothesis that rGNR infections are associated with higher resource utilization. Design: Retrospective observational cohort study of prospectively collected data. Setting: University hospital surgical intensive care unit and ward. Patients: Surgical patients with at least one GNR infection. Measurements: We compared admissions treated for rGNR infection with those with sGNR infections. Primary outcomes were total hospital costs and hospital length of stay. Other outcomes included antibiotic treatment cost, in‐hospital death, and intensive care unit length of stay. After univariate analysis comparing outcomes after rGNR infection with those after sGNR infection, multivariate linear regression models for hospital cost and length of stay were created to account for potential confounders. Main Results: Cost data were available for 604 surgical admissions treated for at least one GNR infection (Centers for Disease Control and Prevention criteria), 137 (23%) of which were rGNR infections. Admissions with rGNR infections were associated with a higher severity of illness at the time of infection (Acute Physiology and Chronic Health Evaluation II score, 17.6 ± 0.6 vs. 13.9 ± 0.3), had higher median hospital costs (

Impact of antibiotic-resistant Gram-negative bacilli infections on outcome in hospitalized patients.

80,500 vs.

Does the addition of glutamine to enteral feeds affect patient mortality

29,604, p < .0001) and median antibiotic costs (

Effect of an intensive care unit rotating empiric antibiotic schedule on the development of hospital-acquired infections on the non-intensive care unit ward.

2,607 vs.

An evaluation of multidetector computed tomography in detecting pancreatic injury: results of a multicenter AAST study.

758, p < .0001), and had longer median hospital length of stay (29 vs. 13 days, p < .0001) and median intensive care unit length of stay (13 days vs. 1 day, p < .0001). Infection with rGNR within the first 7 days of admission was independently predictive of increased hospital cost (incremental increase in median hospital cost estimated at

Differences in Early-and Late-Onset Ventilator-Associated Pneumonia Between Surgical and Trauma Patients in a Combined Surgical or Trauma Intensive Care Unit

11,075; 95% confidence interval,

Diagnosis of intra-abdominal infection in the critically ill patient.

3,282–