Richard B. Brown

Complications of Viral Influenza

Abstract Viral influenza is a seasonal infection associated with significant morbidity and mortality. In the United States more than 35,000 deaths and 200,000 hospitalizations due to influenza occur annually, and the number is increasing. Children aged less than 1 year and adults aged more than 65 years, pregnant woman, and people of any age with comorbid illnesses are at highest risk. Annual vaccination is the cornerstone of prevention, but some older patients may derive less benefit from immunization than otherwise fit individuals. If started promptly, antiviral medications may reduce complications of acute influenza, but increasing resistance to amantadine and perhaps neuraminidase inhibitors underscores the need for novel prevention and treatment strategies. Pulmonary complications of influenza are most common and include primary influenza and secondary bacterial infection. Either may cause pneumonia, and each has a unique clinical presentation and pathologic basis. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with high mortality. During influenza season, treatment of pneumonia should include empiric coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may manifest in persons of any age.

Surgical wound infections documented after hospital discharge

Shorter lengths of hospitalization may result in more surgical wound infections being documented after hospital discharge. The current investigation analyzed 1644 surgical procedures performed over a 3-month period, and documented surgical wound infections both before and for 1 month after hospital discharge. Physician and patient questionnaires were used. One hundred eight infections were noted, of which 50 (46%) were seen after hospital discharge by either the patient or the surgeon. Rates of infection were 5.2%, 7.5%, and 7.5% for clean, clean-contaminated, and contaminated-dirty categories, respectively. Had postdischarge surveillance not been used, rates would have appeared to be 2.5%, 6.5%, and 6.8% for the same surgical classes. Infections following clean and clean-contaminated procedures were more likely to be noticed after hospital discharge. Excluding those that were patient-documented, wound infection rates would have been 4.2% (clean), 6.3% (clean-contaminated) and 6.8% (contaminated-dirty). Postdischarge surveillance is imperative to meaningfully document true rates of surgical wound infection, inasmuch as increasing numbers are likely to occur only after patients leave the hospital.

A comparison of infections in different ICUs within the same hospital

Infections identified between 1981 and 1983 in a hospitals medical/surgical, pediatric, neonatal, coronary care, and cardiac surgery ICUs were compared. Among 14,360 admissions, 1840 infections occurred in 1360 patients. Total infection rates ranged from 1.0% (cardiac surgery ICU) to 23.5% (medical/surgical ICU). Rates of ICU-acquired infection ranged from 0.8% (cardiac surgery ICU) to 11.2% (medical/surgical ICU), indicating that only about half of infections in the latter unit were acquired from within.Primary bacteremias comprised 14.5% of neonatal ICU infections, a rate 500% higher than in other ICUs. Meningitis and genitourinary infections were more common in pediatric and coronary care ICUs. Candida and Pseudomonas species and Klebsiella-Enterobacter-Ser-ratia were most common in the medical/surgical ICU. Survival rate of infected patients was over 87% in pediatric and neonatal ICUs, compared with only 55.4% in the medical/surgical ICU.These differences in types and rates of infection have an important bearing on infection-control activities in the ICU, and also provide a yardstick against which similar institutions can gauge their ICU infection status.

Antibiotic adverse reactions and drug interactions.

When contemplating antibiotic use, intensivists must consider possible beneficial and harmful drug interactions. After antibiotics are instituted, adverse reactions must be anticipated. Acute illness, comorbidities, and concurrent medications affect the presentation and management of antibiotic-related adverse events. Intensivists should use the fewest possible antibiotics, carefully choosing agents that maximize antimicrobial activity and minimize potential drug interactions and adverse reactions.

Hospital charges and long-term survival of ICU versus non-ICU patients.

Hospital charges and long-term (2 yr) survival were evaluated for 558 ICU and 124 non-ICU patients from a large community hospital. Although the ICU patients represented only 9.5% of total hospital admissions, they incurred nearly 30% of the total hospital charges and had a median hospital charge of greater than four times the non-ICU comparison group. For the ICU patients, the overall in-hospital mortality rate was 17.3% and the overall 2-yr mortality rate was 35.6%, whereas the non-ICU group rates were 3.4 and 14.8%, respectively. Given a patient was discharged alive from the hospital, the proportion surviving an additional 2 yr was strikingly similar for the two groups (83.3% of ICU patients and 89.1% of non-ICU patients). Because the excess mortality for ICU patients discharged from a community hospital was not significantly greater than for non-ICU patients, the long-term outlook for discharged patients after receiving intensive care is not as bleak as is generally assumed.

Prospective study of clinical bleeding in intensive care unit patients

We investigated prospectively clinical bleeding in 1,328 consecutive patients admitted to a medical/surgical ICU over 1 yr. One hundred thirty-eight (10.4%) patients bled after ICU admission, and an additional 388 (29.2%) bled coincident with admission. The upper GI tract was the site of bleeding in 34.8% of patients whose bleeds commenced in the ICU, and accounted for 22% of total sites. Patients with clinical bleeding after ICU admission had a significantly (p less than .001) higher likelihood of death than those who did not bleed, and those with multiple bleeding sites had a higher mortality (54.9%) than those with single sites (31%) (p less than .006). Multiple logistic regression analyses revealed that risk ratios (RR) for bleeding after ICU admission were mechanical ventilation (RR = 1.82), nutritional failure (RR = 3.45), acute renal failure (RR = 3.36), antiulcer medication (RR = 3.36), and anticoagulants (RR = 4.19). No antibiotics could be specifically incriminated. This study defines the scope, characteristics, and importance of bleeding in ICU patients and establishes risk factors.

Two-year outcome of adult intensive care patients.

Five hundred fifty-eight patients admitted to a general/medical surgical intensive care unit were studied 2 years after hospital discharge to determine whether they were still alive, were able to perform daily activities, and had returned to work. The overall 2-year survivorship (hospital and long-term) was 63.5%. Two-year survival was considerably lower for patients with certain condition or treatment characteristics than for others. This ranged from 14% 2-year survival for patients with 48 or more hours of coma to 82.2% for patients with no condition or treatment characteristics recorded. Once a patient was discharged alive, the 2-year cumulative survival of surgical ICU patients (84.6%) was significantly better than that of medical ICU patients (76.5%). Among ICU survivors responding to a follow-up survey, 85% were able to perform daily activities, but only 66% were working. Of the 44 patients experiencing a change in ability to perform daily activities at time of follow-up compared with pre-ICU admission, functional status of 34 (77%) improved, while 10 (23%) got worse. By comparison, of the 45 patients experiencing a change in working status, only 7 patients (16%) who did not work prior to ICU admission had returned to work, whereas the remaining 38 patients (84%) who worked prior to ICU admission were not working at time of follow-up study.

Outbreak of nosocomial Flavobacterium meningosepticum respiratory infections associated with use of aerosolized polymyxin B

Flavobacterium meningosepticum is an uncommon cause of adult nosocomial infection. On a medical/surgical intensive care unit we recently encountered an adult outbreak of respiratory colonization and infection caused by this organism, which was associated with the prophylactic use of aerosolized polymyxin B that had been used in an attempt to abort an outbreak of infection caused by highly resistant strains of Pseudomonas aeruginosa. Twenty isolates (95% from respiratory secretions) of F. meningosepticum from nine persons were identified during a 2 1/2-month period. No environmental source has been identified to date. Pneumonia developed in five patients, and two deaths associated with this organism occurred. All isolates were sensitive to ciprofloxacin; none were sensitive to other antibiotics tested, including third-generation cephalosporins, aminoglycosides, erythromycin, trimethoprim-sulfamethoxazole, antipseudomonal penicillins, aztreonam, and imipenem/cilastatin. Two patients with nosocomial pneumonia were successfully treated with oral ciprofloxacin. F. meningosepticum may emerge as an important pathogen if prophylactic use of polymyxin B becomes more widespread. Ciprofloxacin may become the agent of choice for treatment of this organism.

Impact of Mandatory Inpatient Infectious Disease Consultation on Outpatient Parenteral Antibiotic Therapy

Background:Outpatient parenteral antibiotic therapy (OPAT) has had an important impact on infections historically requiring prolonged intravenous antibiotic treatment. Within the past decade, new antibiotics with oral/intravenous bioequivalence, plus recent data on infection management, have increased the potential role of the Infectious Disease (ID) consultant for OPAT. Methods:We studied the impact of mandatory ID consultation on the use and outcomes of OPAT in patients initially hospitalized. The study was approved by the Institutional Review Board and the Executive Committee of the Medical Staff of Baystate Medical Center. Patients older than 18 years of age being considered for discharge to home on OPAT were identified, primarily through discharge planning. Formal ID consultation was performed to determine both need for OPAT and a variety of issues regarding antibiotic choice. Thirty-day telephone follow-up determined outcomes. Data regarding demographics, outcomes, and costs were analyzed. Results:Forty-four patients received mandatory ID consultation, 39 (88.6%) of whom had some change in antibiotic recommendations. Seventeen (38.6%) were discharged on oral antibiotics, 1 (2.3%) had antibiotics discontinued, 13 (29.6%) had a change in parenteral antibiotic, 5 (11.4%) had a change in antibiotic dose, and 3 (6.8%) had a change in antibiotic duration. Follow-up demonstrated a single rehospitalization for unrelated issues. The total cost savings were

Management of infective endocarditis in outpatients: clinical experience with outpatient parenteral antibiotic therapy.

33,667.00, approximately