Sanjay Saint
University of Michigan
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American Journal of Infection Control | 2002
Naomi P. O'Grady; Mary Alexander; Lillian A. Burns; E. Patchen Dellinger; Jeffery S. Garland; Stephen O. Heard; Pamela A. Lipsett; Henry Masur; Leonard A. Mermel; Michele L. Pearson; Issam Raad; Adrienne G. Randolph; Mark E. Rupp; Sanjay Saint
Naomi P. O’Grady, Mary Alexander, E. Patchen Dellinger, Julie L. Gerberding, Stephen O. Heard, Dennis G. Maki, Henry Masur, Rita D. McCormick, Leonard A. Mermel, Michele L. Pearson, Issam I. Raad, Adrienne Randolph, and Robert A. Weinstein National Institutes of Health, Bethesda, Maryland; Infusion Nurses Society, Cambridge, and University of Massachusetts Medical School, Worcester, and The Children’s Hospital, Boston, Massachusetts; University of Washington, Seattle; Office of the Director, Centers for Disease Control and Prevention (CDC), and Division of Healthcare Quality Promotion, National Center for Infectious Diseases, CDC, Atlanta, Georgia; University of Wisconsin Medical School and Hospital and Clinics, Madison; Rhode Island Hospital and Brown University School of Medicine, Providence, Rhode Island; MD Anderson Cancer Center, Houston, Texas; and Cook County Hospital and Rush Medical College, Chicago, Illinois
Clinical Infectious Diseases | 2010
Thomas M. Hooton; Suzanne F. Bradley; Diana D. Cardenas; Richard Colgan; Suzanne E. Geerlings; James C. Rice; Sanjay Saint; Anthony J. Schaeffer; Paul A. Tambayh; Peter Tenke; Lindsay E. Nicolle
Guidelines for the diagnosis, prevention, and management of persons with catheter-associated urinary tract infection (CA-UTI), both symptomatic and asymptomatic, were prepared by an Expert Panel of the Infectious Diseases Society of America. The evidence-based guidelines encompass diagnostic criteria, strategies to reduce the risk of CA-UTIs, strategies that have not been found to reduce the incidence of urinary infections, and management strategies for patients with catheter-associated asymptomatic bacteriuria or symptomatic urinary tract infection. These guidelines are intended for use by physicians in all medical specialties who perform direct patient care, with an emphasis on the care of patients in hospitals and long-term care facilities.
Critical Care Medicine | 2005
Nasia Safdar; Cameron Dezfulian; Harold R. Collard; Sanjay Saint
Background:Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in critically ill patients. The clinical and economic consequences of VAP are unclear, with a broad range of values reported in the literature Objective:To perform a systematic review to determine the incidence of VAP and its attributable mortality rate, length of stay, and costs. Data Source:Computerized PUBMED and MEDLINE search supplemented by manual searches for relevant articles, limited to articles published after 1990. Study Selection:English-language observational studies and randomized trials that provided data on the incidence of VAP were included. Matched cohort studies were included for calculation of attributable mortality rate and length of stay. Data Extraction:Data were extracted on patient population, diagnostic criteria for VAP, incidence, outcome, type of intensive care unit, and study design. Data Synthesis:The cumulative incidence of VAP was calculated by combining the results of several studies using standard formulas for combining proportions, in which the weighted average and variance are calculated. Results from studies comparing intensive care unit and hospital mortality due to VAP, additional length of stay, and additional days of mechanical ventilation were pooled using a random effects model, with assessment of heterogeneity. Results:Our findings indicate a) between 10% and 20% of patients receiving >48 hrs of mechanical ventilation will develop VAP; b) critically ill patients who develop VAP appear to be twice as likely to die compared with similar patients without VAP (pooled odds ratio, 2.03; 95% confidence interval, 1.16–3.56); c) patients with VAP have significantly longer intensive care unit lengths of stay (mean = 6.10 days; 95% confidence interval, 5.32–6.87 days); and d) patients who develop VAP incur ≥
Annals of Internal Medicine | 2002
Nathorn Chaiyakunapruk; David L. Veenstra; Benjamin A. Lipsky; Sanjay Saint
10,019 in additional hospital costs. Conclusions:Ventilator-associated pneumonia occurs in a considerable proportion of patients undergoing mechanical ventilation and is associated with substantial morbidity, a two-fold mortality rate, and excess cost. Given these findings, strategies that effectively prevent VAP are urgently needed. LEARNING OBJECTIVESOn completion of this article, the reader should be able to: Define the incidence of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Explain the economic consequences of VAP. Use this information in a clinical setting. All authors have disclosed that they have no financial relationships or interests in any commercial companies pertaining to this educational activity. Wolters Kluwer Health has identified and resolved all faculty conflicts of interest regarding this educational activity. Visit the Critical Care Medicine Web site (www.ccmjournal.org) for information on obtaining continuing medical education credit.
The Lancet | 2006
John M. Hollingsworth; Mary A.M. Rogers; Samuel R. Kaufman; Timothy J Bradford; Sanjay Saint; John T. Wei; Brent K. Hollenbeck
Context Intravascular catheterrelated bloodstream infection is an important and potentially avoidable cause of morbidity. Various antiseptic solutions for skin disinfection and catheter-site care may help prevent catheter-related infections. Contribution This article summarizes data from eight randomized trials that compared antiseptic solutions. Approximately 1% of the patients with chlorhexidine gluconate disinfectant developed bloodstream infections from intravascular catheters. In the patients with disinfection by povidone-iodine, the rate was 2% (risk ratio, 0.49 [95% CI, 0.28 to 0.88]). Implications Chlorhexidine gluconate is more effective than povidoneiodine for intravascular catheter-site care. It is also more expensive. The Editors Intravascular catheters are commonly used in caring for hospitalized patients but can lead to serious infectious complications (1). Catheter-related bloodstream infection is associated with increased morbidity, mortality, length of hospitalization, and medical costs (2-6). Use of an antiseptic solution for skin disinfection at the catheter insertion site helps prevent catheter-related infections. Povidone-iodine solution is the most commonly used agent for this purpose (7, 8). Recently, several studies have compared the efficacy of povidone-iodine with that of chlorhexidine gluconate solutions for reducing vascular catheterrelated infections (7, 9-14; Knasinski V, Maki DG. A prospective, randomized, controlled trial of 1% chlorhexidine 75% alcohol vs. 10% povidone iodine for cutaneous disinfection and follow-up site care with central venous and arterial catheters [Presented paper]. San Diego: National Association of Vascular Access Network Conference; 2000). Unfortunately, because few clinical events have been observed in individual studies, it remains unclear which antiseptic solution is best, both statistically and clinically, for reducing the risk for catheter-related bloodstream infection, particularly in patients with central-line catheters. We sought to aid clinical decision making by evaluating the effectiveness of chlorhexidine gluconate versus povidone-iodine as a skin disinfectant for catheter-site care. We performed a meta-analysis of all available published and unpublished studies comparing chlorhexidine gluconate with povidone-iodine solution for vascular catheter-site care. Methods Study Selection We manually searched Index Medicus (1960 to 1965) and electronically searched MEDLINE (1966 to 2001), CINAHL: Nursing and Allied Health (1982 to 2001), Doctoral Dissertation Abstracts (1861 to 2001), International Pharmaceutical Abstracts (1970 to 2001), EMBASE, Lexis-Nexus, Web of Sciences, and Cochrane Library databases for publications in any language. For our search strategy, we used the Medical Subject Headings chlorhexidine and catheterization and the exploded key words chlorhexidine and catheter. We restricted the searches to clinical trials. To ensure that our search would be thorough, we consulted a research librarian at the University of Washington. To identify additional original studies, we reviewed the reference lists of the retrieved articles and any identified review articles. Studies presented at recent scientific meetings in the area of infection control were also identified by reviewing meeting programs and published meeting proceedings and by attending medical meetings on related topics. We contacted the manufacturer of chlorhexidine gluconate solution, the corresponding authors of relevant studies, and experts in the field to inquire about possible additional studies. To be included in the meta-analysis, a study needed 1) to be a randomized trial comparing any type of chlorhexidine gluconate solution with a povidone-iodine solution for vascular catheter-site care and 2) to report the incidence of catheter colonization or catheter-related bloodstream infection with sufficient data to calculate the risk ratio. Outcome Measures The primary outcome was catheter-related bloodstream infection, which we defined as isolation of the same organism (that is, identical species with the same antibiograms) from a peripheral blood culture and a semiquantitative or quantitative culture of a catheter segment. Our secondary outcome, catheter colonization, was defined as significant growth of microorganisms from a catheter segment, according to quantitative (>1000 colony-forming units [CFUs] per mL) or semiquantitative (>15 CFU) culture techniques (15, 16). Data Extraction Using a standardized data form, two investigators independently abstracted data on the size of the study sample, type of patient population, type of vascular catheter used, type of antiseptic used, anatomic site of insertion, use of catheter exchange with guide wire, concurrent use of other interventions, and incidence of catheter colonization and catheter-related bloodstream infection. We also evaluated the following methodologic components of each study: randomization procedure, extent of blinding, and description of eligible participants. The authors of studies that did not contain sufficient data were contacted for additional information. Statistical Analysis We separately analyzed the incidences of catheter colonization and catheter-related bloodstream infection. The summary risk ratios and 95% CIs were calculated by using the DerSimonian and Laird method under a random-effects model (17). A statistical test of heterogeneity was performed by using the Mantel-Haenszel method (18). To explore potential clinical sources of heterogeneity, we conducted sensitivity analyses according to characteristics of the study, the study participants, the types of catheters used, outcome definitions, and concentrations of antiseptics used. We explored publication bias using the funnel-plot method by graphing the effect size of trials on the horizontal axis and the number of participants in each trial on the vertical axis (19); asymmetry in the funnel plot suggested publication bias. Because some studies allowed patients to receive more than one vascular catheter during the study period, the within-patient correlation could underestimate the standard error of the effect measure. To investigate this effect, we inflated the variance of the risk ratio for each study by multiplying it by the average number of catheters per patient (20). To perform all statistical analyses, we used Stata software, version 6.0 (Stata Corp. College Station, Texas), by employing the command METAN. Results Study Selection We located 302 articles from our manual and computerized searches (Figure 1). Reviews of the titles and abstracts from the computerized search, followed by review of the full manuscripts of potentially relevant articles, identified 6 published studies that met our inclusion criteria. Of the 296 remaining studies, 285 were excluded because chlorhexidine gluconate was not used for catheter-site care (n = 268), use of the disinfectants was not determined by random allocation (n = 13), povidone-iodine was not used as a comparator (n = 2), or colonization or catheter-related bloodstream infection was not recorded (n = 2). The other 11 excluded studies were duplicate studies retrieved from different databases. In addition to the 6 studies identified from searches, 1 published abstract (9) and 1 published study (10) were identified from the reference list of a review article (21). Thus, our meta-analysis comprised 8 total studies. Studies were reviewed by two investigators, and there were no discrepancies in the abstracted data. Figure 1. Trial flow depicting the selection process of studies included in the meta-analysis. Study Characteristics Table 1 shows the characteristics of the eight included studies. These trials used 4143 catheters (1493 central venous, 1361 peripheral venous, 704 peripheral arterial, 395 pulmonary arterial, 75 peripherally inserted central venous, 62 introducer sheaths, and 53 hemodialysis). Five studies included only patients from intensive care units (7, 9, 11, 12, 14); three studies included patients from any unit in the hospital (10, 13; Knasinski V, Maki DG [Presented paper]). One study was a multicenter clinical trial (10). Among the included studies that reported patient age, the average age ranged from 50 to 65 years (7, 10-12, 14). The mean duration of catheterization for the chlorhexidine gluconate and povidone-iodine groups was similar in all studies that provided this information, except one in which the chlorhexidine gluconate group was catheterized longer (9.9 vs. 5.9 days) (14). There was no significant difference in the anatomic sites (such as subclavian or femoral) in which catheters were inserted between the chlorhexidine gluconate and povidone-iodine groups. One study allowed catheter exchange via a guide wire (7). Only one study noted adverse effects from the use of either antiseptic solution: Maki and colleagues (7) found erythema at the insertion site in 28.3% of catheters in the povidone-iodine group and in 45.3% of catheters in the chlorhexidine gluconate group (P < 0.001). However, there was no statistically significant difference in erythema among these two groups and patients whose sites were disinfected with alcohol (7). Table 1. Characteristics of Studies Comparing Chlorhexidine Gluconate Solutions with Povidone-Iodine Solutions for Vascular Catheter-Site Care The included studies used several formulations of chlorhexidine gluconate. Five studies (10, 13, 14; Knasinski V, Maki DG [Presented paper]) used an alcoholic solution, and three studies (7, 9, 11) used an aqueous solution. All studies used 10% povidone-iodine solution for the control group. However, only one study specified the sequence of applications of 70% alcohol and 10% povidone-iodine (13). Five studies clearly described their procedures for care of the catheter site (7, 10-12, 14); in these studies, the dressing was changed and the insertion site was typically cleansed every 48 to 72 hours (7). Sterile gau
American Journal of Infection Control | 2000
Sanjay Saint
BACKGROUND Medical therapies to ease urinary-stone passage have been reported, but are not generally used. If effective, such therapies would increase the options for treatment of urinary stones. To assess efficacy, we sought to identify and summarise all randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat urinary stone disease. METHODS We searched MEDLINE, Pre-MEDLINE, CINAHL, and EMBASE, as well as scientific meeting abstracts, up to July, 2005. All randomised controlled trials in which calcium-channel blockers or alpha blockers were used to treat ureteral stones were eligible for inclusion in our analysis. Data from nine trials (number of patients=693) were pooled. The main outcome was the proportion of patients who passed stones. We calculated the summary estimate of effect associated with medical therapy use using random-effects and fixed-effects models. FINDINGS Patients given calcium-channel blockers or alpha blockers had a 65% (absolute risk reduction=0.31 95% CI 0.25-0.38) greater likelihood of stone passage than those not given such treatment (pooled risk ratio 1.65; 95% CI 1.45-1.88). The pooled risk ratio for alpha blockers was 1.54 (1.29-1.85) and for calcium-channel blockers with steroids was 1.90 (1.51-2.40). The proportion of heterogeneity not explained by chance alone was 28%. The number needed to treat was 4. INTERPRETATION Although a high-quality randomised trial is necessary to confirm its efficacy, our findings suggest that medical therapy is an option for facilitation of urinary-stone passage for patients amenable to conservative management, potentially obviating the need for surgery.
JAMA | 2014
Jeffrey M. Rohde; Derek E. Dimcheff; Neil Blumberg; Sanjay Saint; Kenneth M. Langa; Latoya Kuhn; Andrew Hickner; Mary A.M. Rogers
Indwelling catheters are strongly associated with the development of bacteriuria, which can lead to significant morbidity in hospitalized patients. This report, a review of the literature, evaluates the infectious outcomes of patients with indwelling catheters to determine the precise clinical and economic impact of catheter-related infection. Statistical pooling was used to estimate the incidence of bacteriuria in hospitalized patients with indwelling catheters. In addition, the proportion of patients with catheter-related bacteriuria in whom symptomatic urinary tract infection and bacteremia will develop was estimated through quantitative synthesis of previous reports. Costs were estimated by using microcosting techniques. Of patients who have indwelling catheters for 2 to 10 days, bacteriuria is expected to develop in 26% (95% confidence interval [CI], 23% to 29%). Among patients with bacteriuria symptoms of urinary tract infection will develop in 24%, (95% CI, 16% to 32%), and bacteremia from a urinary tract source will develop in 3.6% (95% CI, 3.4% to 3.8%). Each episode of symptomatic urinary tract infection is expected to cost an additional
Annals of Internal Medicine | 2003
Harold R. Collard; Sanjay Saint; Michael A. Matthay
676, and catheter-related bacteremia is likely to cost at least
Infection Control and Hospital Epidemiology | 2008
Susan E. Coffin; Michael Klompas; David C. Classen; Kathleen M. Arias; Kelly Podgorny; Deverick J. Anderson; Helen Burstin; David P. Calfee; Erik R. Dubberke; Victoria Fraser; Dale N. Gerding; Frances A. Griffin; Peter Gross; Keith S. Kaye; Evelyn Lo; Jonas Marschall; Leonard A. Mermel; Lindsay Nicolle; David A. Pegues; Trish M. Perl; Sanjay Saint; Cassandra D. Salgado; Robert A. Weinstein; Robert J. Wise; Deborah S. Yokoe
2836. Given the clinical and economic burden of urinary catheter-related infection, infection control professionals and hospital epidemiologists should use the latest infection control principles and technology to reduce this common complication.
Annals of Internal Medicine | 2010
Allen Kachalia; Samuel R. Kaufman; Richard C. Boothman; Susan Anderson; Kathleen Welch; Sanjay Saint; Mary A.M. Rogers
IMPORTANCE The association between red blood cell (RBC) transfusion strategies and health care-associated infection is not fully understood. OBJECTIVE To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction. DATA SOURCES MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014. STUDY SELECTION Randomized clinical trials with restrictive vs liberal RBC transfusion strategies. DATA EXTRACTION AND SYNTHESIS Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method. MAIN OUTCOMES AND MEASURES Incidence of health care-associated infection such as pneumonia, mediastinitis, wound infection, and sepsis. RESULTS The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight. CONCLUSIONS AND RELEVANCE Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care-associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care-associated infection.