Xavier Corbella

Reduced burden of bacterial airway colonization with a novel silver-coated endotracheal tube in a randomized multiple-center feasibility study.

Objective:To assess the feasibility and safety of the respiratory infection control (RIC) device, a silver-coated endotracheal tube, and its effect on bacterial burden in the airways. Design:Prospective, randomized, single-blind, multiple-center study. Setting:Three hospitals in Spain and one in the United States. Patients:Patients were eligible adults who required mechanical ventilation for ≥24 hrs and did not have respiratory infections. One hundred forty-nine patients were intubated and analyzed for safety; 121 were intubated ≥24 hrs and analyzed for tube colonization; 67 had negative baseline quantitative endotracheal aspirates and were analyzed for quantitative endotracheal aspirates colonization. Interventions:Intubation with the RIC device or a control endotracheal tube. Measurements and Main Results:The RIC device was associated with delayed colonization on the tube compared with the control device at the threshold of ++, +++, or ≥104 colony-forming units/mL (p = .02, log-rank test; p = .10, Wilcoxons test) and in quantitative endotracheal aspirates at ≥106 colony-forming units/mL (p = .08, log-rank test; p = .05, Wilcoxons test). The RIC device was associated with reduced colonization rate by days on the tube (p = .04, Wilcoxons test) and in quantitative endotracheal aspirates (p = .05, Wilcoxons test) at the same thresholds. The RIC device was associated with lower maximal bacterial burden in tracheal aspirates for 7 days (mean log-transformed burden, 4.2 ± 2.3 vs. 5.5 ± 1.7 log colony-forming units/mL; p = .02, Wilcoxons test). Other between-group differences favored the RIC device but were not significant. Five adverse events were considered device related, including three events in the RIC group and two events in the control group. Conclusions:In this prospectively planned, preliminary analysis, the RIC device was feasible and well tolerated. Larger studies are needed to determine whether delayed colonization, reduced colonization rate, and decreased bacterial burden will decrease the incidence of ventilator-associated pneumonia.

Staphylococcus aureus nasal carriage as a marker for subsequent staphylococcal infections in intensive care unit patients

From January to December 1994, 752 consecutive patients admitted to intensive care units (ICU) for more than two days were studied prospectively forStaphylococcus aureus colonization and infection. Nasal swabs were obtained at admission and weekly during the ICU stay. At ICU admission 166 patients (22.1%) wereStaphylococcus aureus nasal carriers, while 586 were free of nasal colonization. Of the 166 nasal carriers, 163 harbored methicillin-sensitiveStaphylococcus aureus (MSSA) and three methicillinresistantStaphylococcus aureus (MRSA). During the ICU stay 24 of the 586 noncolonized patients became nasal carriers (11 MSSA and 13 MRSA), and one nasal carrier initially colonized by MSSA was recolonized by MRSA. Staphylococcal infections were documented in 51 (6.8%) of the total 752 patients. After 14 days of ICU stay, the probability of developing staphylococcal infections was significantly higher for those patients who were nasal carriers at ICU admission than for those found to be initially negative (relative risk 59.6, 95% Cl 20.37–184.32; p<0.0001). In patients with ICU-acquired nasal colonization, most infections were documented prior to or at the time of the detection of the nasal colonization; thus, in this group of patients nasal carriage showed a lower predictive value for subsequentStaphylococcus aureus infections than that described classically. Paired isolates of nasal colonizing and clinical strains were studied by pulsed-field gel electrophoresis (PFGE) andmecA polymorphism analysis in 30 patients; identity was demonstrated in all but two patients. The results suggest that, outside the setting of an outbreak of MRSA, the detection ofStaphylococcus aureus nasal carriers on admission may be particularly useful in identifying those patients who are at high risk for developing staphylococcal infections during their ICU stay.

Epidemiological significance of cutaneous, pharyngeal, and digestive tract colonization by multiresistant Acinetobacter baumannii in ICU patients

The aim of this prospective study was to assess the relative epidemiological role of digestive tract colonization by Acinetobacter baumannii, in comparison with other body site colonizations, in patients admitted to intensive care units (ICUs). From January to May 1995, axillary, pharyngeal and rectal swabs were taken together within the first 48 h of admission, and then weekly during ICU stay. Seventy-three patients were included, 48 of them (66%) had axillary, pharyngeal, or rectal colonization with A. baumannii, nine (19%) of these 48 during the first 48 h and the remaining 28 (77%) during the first week. Twenty-one (29%) had clinical samples positive for A. baumannii and axillary, pharyngeal, or rectal colonization. In 15 of these 21 (71%), colonization on body sites occurred prior to isolation from clinical samples (mean seven days, range 1-20). Throughout admission, rates of detection of A. baumannii were 75% (36/48) for axillary or pharyngeal swabs and 77% (37/48) for rectal swabs. Combination of two body site swabs yielded culture positive rates of 90% (43/48) for axillary-pharyngeal or axillary-rectal sites, and 96% (46/48) for pharyngeal-rectal. Two epidemic clones were defined by antibiotype and pulsed-field gel electrophoresis (PFGE) of SmaI DNA digests in 48 isolates from 11 patients. We conclude that body sites of patients were a major reservoir for A. baumannii infections in the outbreak. This finding cases doubt on the value of selective decontamination of the digestive tract as an additional infection control measure in this kind of outbreak. The weekly performance of pharyngeal and rectal swabs appears to detect A. baumannii colonization early among ICU patients and enables barrier methods to be applied rapidly.

Mortality and survival in systemic sclerosis: Systematic review and meta-analysis

OBJECTIVE To determine the mortality, survival, and causes of death in patients with systemic sclerosis (SSc) through a meta-analysis of the observational studies published up to 2013. METHODS We performed a systematic review and meta-analysis of the observational studies in patients with SSc and mortality data from entire cohorts published in MEDLINE and SCOPUS up to July 2013. RESULTS A total of 17 studies were included in the mortality meta-analysis from 1964 to 2005 (mid-cohort years), with data from 9239 patients. The overall SMR was 2.72 (95% CI: 1.93-3.83). A total of 43 studies have been included in the survival meta-analysis, reporting data from 13,529 patients. Cumulative survival from onset (first Raynauds symptom) has been estimated at 87.6% at 5 years and 74.2% at 10 years, from onset (non-Raynauds first symptom) 84.1% at 5 years and 75.5% at 10 years, and from diagnosis 74.9% at 5 years and 62.5% at 10 years. Pulmonary involvement represented the main cause of death. CONCLUSIONS SSc presents a larger mortality than general population (SMR = 2.72). Cumulative survival from diagnosis has been estimated at 74.9% at 5 years and 62.5% at 10 years. Pulmonary involvement represented the main cause of death.

Group B streptococcus (Streptococcus agalactiae) pyogenic arthritis in nonpregnant adults.

We analyzed the cases of pyogenic arthritis from group B streptococcus (GBS), or Streptococcus agalactiae, in nonpregnant adults diagnosed in the Hospital Universitari de Bellvitge, a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, during a 10-year period, and we reviewed the available literature to summarize the experience with this infectious entity. From the database of our institution, which does not attend pediatric, obstetric, or burn patients, we collected all microbiologically proven cases of infectious arthritis seen from January 1992 to December 2001. We excluded patients with infection limited to spine; patients with prosthetic joint infection; patients undergoing articular surgery during the year before diagnosis; and those with tuberculous, brucellar, or fungal arthritis. Of a total of 112 patients identified, GBS was the causative organism in 11 (10%) cases. We reviewed the literature using a MEDLINE search (1972–2001), and found 64 additional cases.Of the 75 patients, 34 (45%) were men and 41 (55%) women, with ages ranging from 20 to 87 years (mean age, 57.9 ± 14.9 yr); 37 patients (49%) were over 60 years. Sixty-eight percent (51/75) of the patients presented with monoarthritis, while in 32% (24/75) more than 1 joint was involved. The most common location was the knee (36%), followed by the shoulder (25%). In 66% (43/65) of cases, bacteremia was documented. In 64% (47/74) of patients, a systemic predisposing factor for infection was noted; the most common conditions were diabetes mellitus, malignancies, and chronic liver diseases. In 31% (23/75) of patients, a concomitant infectious process due to the same microorganism was found, mainly vertebral osteomyelitis and urinary tract infection. Penicillin was the main antibiotic used after bacterial identification; surgical drainage was performed in 36% (27/75) of cases. The overall mortality rate was 9% (7/75).GBS is now a significant causative agent of pyogenic arthritis in nonpregnant adults. In this population, joint infection by GBS is a disease that mainly affects aged patients with underlying medical illnesses; polyarticular involvement, bacteremia, and the presence of a concomitant infectious process are frequent conditions. The case-fatality rate is substantial.

Effectiveness and safety of an emergency department short-stay unit as an alternative to standard inpatient hospitalisation

Background: Emergency department short-stay units (EDSSUs) are currently emerging worldwide as an alternative to standard inpatient hospitalisation. In our hospital, a 960-bed teaching tertiary institution in Barcelona, Spain, an EDSSU has been in operation during winter periods (November–March) since 1997. Aim: To determine the efficacy and safety of our EDSSU. Methods: Retrospective analysis of activity and quality outcomes, assessment of patient satisfaction levels and determination of the diagnostic-related groups that were mainly responsible for admissions to the EDSSU, comparing the clinical characteristics of those patients with the characteristics of patients with similar clinical diagnoses admitted to standard hospitalisation units. Results: 5666 patients were treated in the EDSSU, with a progressive increase in the number of patients admitted per period, ranging from 707 in 1997–8 to 1227 in 2003–4 (73.5% increase). The mean length of stay ranged from 3.1 to 2.8 days, mortality from 2.5% to 5.1%, home discharge rate from 84% to 90%, and hospital readmission rate within the first week after discharge from 3.9% to 6.2%. In all, 98% of patients were satisfied with their stay at the EDSSU. The main diagnostic-related groups were chronic obstructive pulmonary disease (COPD = 50%) and acute heart failure (28%). Patients with COPD admitted at the EDSSU (n = 545) showed significantly (p = 0.05) lower mean length of stay (3.4 v 12 days) and mortality (1.7% v 8.1%), but a higher hospital readmission rate (9.9% v 7%) than those admitted to standard inpatient units (n = 1961). Conclusions: In our experience, the EDSSU proved to be an effective and safe alternative to standard inpatient hospitalisation.

Clinical and epidemiological findings in mechanically-ventilated patients with methicillin-resistant Staphylococcus aureus pneumonia

Over the 5-year period from 1990 to 1994, a prospective cohort study was conducted to define the clinical and epidemiological characteristics of ventilator-associated methicillin-resistantStaphylococcus aureus (MRSA) pneumonia acquired during a large-scale outbreak of MRSA infection. Of 2411 mechanically ventilated patients, 347 (14.4%) acquired MRSA, 220 (63.4%) had MRSA positive respiratory tract samples and 41 (18.6%) developed ventilator-associated MRSA pneumonia. The overall attack rate for ventilator-associated MRSA pneumonia was 1.56 episodes/1000 ventilator days, but annual attack rates varied according to the trend of the outbreak (range 4.9–0.2). In comparison with methicillin-sensitiveStaphylococcus aureus (MSSA), which was implicated in 98 episodes of ventilator-associated pneumonia, MRSA caused exclusively late-onset ventilator-associated pneumonia, while MSSA caused both early-onset [55 of 98 (56.1%) episodes] and late-onset [43 of 98 (43.8%) episodes] ventilator-associated pneumonia. Logistic regression analysis of all patients withStaphylococcus aureus pneumonia revealed intubation for more than 3 days (odds ratio (OR),1.11; confidence interval (CI):1.03–1.18) and prior bronchoscopy (OR,5.8; CI,1.85–18.19) to be independent variables associated with MRSA pneumonia. The results indicate that MRSA ventilator-associated pneumonia is a frequent complication in intensive care patients, manifesting itself as late-onset pneumonia in patients who have been intubated for prolonged periods and/or have often undergoing previous bronchoscopy.

High mortality rates from medical problems of frequent emergency department users at a university hospital tertiary care centre.

Background: Frequent emergency department (ED) users are a nebulous group of patients. A high degree of psychiatric problems and higher than expected mortality from medical illness have been reported in this population. Study objectives: We sought to examine the pattern of ED use by adult patients identified as being heavy users of the ED, to examine their demographic characteristics and describe their clinical profile during a one-year period at one institution. Methods: This was a descriptive, retrospective study that took place in the ED of a 1000-bed teaching hospital in Barcelona, Spain, with a population in the metropolitan area of 1.5 million, which attends approximately 110 000 emergency visits per year, excluding paediatrics and obstetrics. The ED computer registration database was used to identify all patients presenting to the hospital ED more than 10 times in a one-year period from 1 January to 31 December 2000. A cohort composed of 86 patients fitting these inclusion criteria was identified as making 1263 (1.1%) of the total 109 857 ED visits. All medical records for each patient were reviewed to determine the primary reason for repeated ED visits. Results: Of the 86 patients enrolled, 58 were men (67.4%). The mean age was 55 years (range 18–91), but only six patients (6.9%) were older than 80 years. The median number of ED visits per patient was 14 throughout the year. Forty-five of the patients (52.3%) were classified as having primarily medical reasons for presenting to the ED, with diagnoses such as shortness of breath and chest pain being the chief symptoms. Seventeen patients (19.7%) had a surgical problem as the cause of their ED visits, and eight (9.3%) had psychiatric problems contributing to the ED visits. Other major reasons for presentation to the ED were as follows: ophthalmic, eight patients (9.3%); otolaryngological, four patients (4.6%); and trauma, four patients (4.6%). A total of 982 (77.8%) of the total ED visits resulted in home discharge. Hospital emergency admissions and outpatient clinics diversions occurred in 106 (8.3%) and 71 (5.6%) ED visits, respectively. The mortality rate was as high as 18.6% (16 frequent ED users died). Conclusion: These data show that there is a high incidence of medical problems in frequent ED users and a high incidence of mortality in patients with heavy ED use.

How to manage the ED crisis when hospital and/or ED capacity is reaching its limits. Report about the implementation of particular interventions during the Christmas crisis.

Emergency admissions are continuing to rise. The massive use of the urban ED during winter is annually accentuated in the Christmas period, which includes the last week of the year and the first week of the new year. The causes of Christmas crisis are complex, but respiratory infections are definitely a major factor. Provision of acceptable patient care under such circumstances requires a fundamental reordering of ED priorities and procedures. Although acute responses have been described that include redesignating wards, redeploying staff, and boarding patients elsewhere in the hospital, few have been evaluated.

Diabetes Mellitus as a Risk Factor for Functional and Cognitive Decline in Very Old People: The Octabaix Study

OBJECTIVES To examine the incidence of functional or cognitive impairment and its associated factors in a sample of individuals aged 85 years or older with and without diabetes mellitus, who were free of significant impairment at baseline. DESIGN Longitudinal study. SETTING Community-based survey study of 7 primary health care centers. PARTICIPANTS A total of 167 individuals born in 1924 who completed 2 years of follow-up. MEASUREMENTS Sociodemographic variables, the Barthel Index (BI), the Spanish version of Mini-Mental State Examination (MEC), the Mini Nutritional Assessment (MNA), the Charlson Comorbidity Index, and a list of chronic drug prescriptions. A comparative analysis was performed between diabetic and nondiabetic patients regarding the rate of functional and cognitive impairment. In addition, in older people with diabetes experiencing incident disability, an analysis of the potential factors involved was carried out. RESULTS The prevalence of diabetes (DM) at baseline in this population was 25.1%. After 2 years of follow-up, 66.8% of patients with DM had developed a new impairment measured as 38.1% for the defined target of loss of BI of 10 or more and 33.3% for the cognitive target (MEC scores lower than 24 or loss >4 points in MEC). In a multivariate analysis, diabetic patients had an increased risk of any new disability (OR 2.05, 95% CI 1.01-4.36; P = .04). Logistic regression showed an association between any new disability and baseline scores of MNA (OR 1.35, 95% CI 1.01-1.82; P = .04) and MEC (OR 1.38, 95% CI 1.02-1.85; P = .003). CONCLUSION This study has identified that in the oldest old, community-dwelling individuals without evidence of severe functional impairment at baseline, diabetes increases the risk of incident disability in only 2 years.