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The current methodology for calculating central-line–associated bloodstream infection (CLABSI) rates, used for pay-for-performance measures, does not account for multiple concurrent central lines.
To compare CLABSI rates using standard National Healthcare Safety Network (NHSN) denominators to rates accounting for multiple concurrent central lines.
Descriptive analysis and retrospective cohort analysis.
We identified all adult patients with central lines at 2 academic medical centers over an 18-month period. CLABSI rates were calculated for intensive care units (ICUs) and non-ICUs using the standard NHSN methodology and denominator (a patient could only have 1 central-line day for a given patient day) and a modified denominator (number of central lines in 1 patient in 1 day count as number of line days). We also compared characteristics of patients with and without multiple concurrent central lines.
Among 18,521 hospital admissions, there were 156,574 central-line days and 239 CLABSIs (ICU, 105; non-ICU, 134). Our modified denominator reduced CLABSI rates by 25% in ICUs (1.95 vs 1.47 per 1,000 line days) and 6% (1.30 vs 1.22 per 1,000 line days) in non-ICUs. Patients with multiple concurrent central lines were more likely to be in an ICU, to have a longer admission, to have a dialysis catheter, and to have a CLABSI.
Using the number of central lines as the denominator decreased CLABSI rates in ICUs by 25%. The presence of multiple concurrent central lines may be a marker of severity of illness. The risk of CLABSI per lumen of a central line is similar in ICUs compared to wards.
The current study advanced research on the link between community violence exposure and aggression by comparing the effects of violence exposure on different functions of aggression and by testing four potential (i.e., callous–unemotional traits, consideration of others, impulse control, and anxiety) mediators of this relationship. Analyses were conducted in an ethnically/racially diverse sample of 1,216 male first-time juvenile offenders (M = 15.30 years, SD = 1.29). Our results indicated that violence exposure had direct effects on both proactive and reactive aggression 18 months later. The predictive link of violence exposure to proactive aggression was no longer significant after controlling for proactive aggression at baseline and the overlap with reactive aggression. In contrast, violence exposure predicted later reactive aggression even after controlling for baseline reactive aggression and the overlap with proactive aggression. Mediation analyses of the association between violence exposure and reactive aggression indicated indirect effects through all potential mediators, but the strongest indirect effect was through impulse control. The findings help to advance knowledge on the consequences of community violence exposure on justice-involved youth.
Chemoprophylaxis is the use of an antimicrobial agent to prevent infection. Chemoprophylaxis is often administered after exposure to a virulent pathogen or before a procedure associated with risk of infection. Chronic chemoprophylaxis is sometimes administered to persons with underlying conditions that predispose to recurrent or severe infection. Antibiotics can also be used as pre-emptive therapy (sometimes referred to as secondary prophylaxis) to prevent clinical disease in persons infected with a microorganism such as Mycobacterium tuberculosis. Immunization, another excellent means of preventing infection, is discussed in Chapter 115. For information on prophylaxis of bacterial endocarditis, see Chapter 37, Endocarditis of natural and prosthetic valves: treatment and prophylaxis; for information on prophylaxis in persons infected with the human immunodeficiency virus (HIV), see Chapter 102, Prophylaxis of opportunistic infections in HIV disease; for malaria prophylaxis, see Chapter 200, Malaria; for prophylaxis related to transplant recipients and neutropenic patients, see Chapter 89, Infections in transplant recipients, and Chapter 85, Infections in the neutropenic patient; and for surgical prophylaxis, see Chapter 114, Surgical prophylaxis.
Several concepts are important in determining whether chemoprophylaxis is appropriate for a particular situation. In general, prophylaxis is recommended when the risk of infection is high or the consequences significant. The nature of the pathogen, type of exposure, and immunocompetence of the host are important determinants of the need for prophylaxis. The antimicrobial agent should eliminate or reduce the probability of infection or, if infection occurs, reduce the associated morbidity. The ideal agent is inexpensive, orally administered in most circumstances, and has few adverse effects. The ability to alter the normal microbiota and select for antimicrobial resistance should be limited. The emerging crisis of antibiotic-resistant bacteria underscores the importance of rational and not indiscriminate use of antimicrobial agents.
In no other society in the world have urbanisation and industrialization been as comprehensively based on migrant labour as in South Africa. Rather than focusing on the well-documented narrative of displacement and oppression, A Long Way Home captures the humanity, agency and creative modes of self-expression of the millions of workers who helped to build and shape modern South Africa. The book spans a three-hundred-year history beginning with the exportation of slave labour from Mozambique in the eighteenth century and ending with the strikes and tensions on the platinum belt in recent years. It shows not only the age-old mobility of African migrants across the continent but also, with the growing demand for labour in the mining industry, the importation of Chinese indentured migrant workers. Contributions include 18 essays and over 90 artworks and photographs that traverse homesteads, chiefdoms and mining hostels, taking readers into the materiality of migrant life and its customs and traditions, including the rituals practiced by migrants in an effort to preserve connections to “home” and create a sense of “belonging”. The essays and visual materials provide multiple perspectives on the lived experience of migrant labourers and celebrate their extraordinary journeys. A Long Way Home was conceived during the planning of an art exhibition entitled ‘Ngezinyawo: Migrant Journeys’ at Wits Art Museum. The interdisciplinary nature of the contributions and the extraordinary collection of images selected to complement and expand on the text make this a unique collection.
To assess the impact of a novel, silver-coated needleless connectors (NCs) on central-line–associated bloodstream infection (CLABSI) rates compared with a mechanically identical NCs without a silver coating.
Prospective longitudinal observation study
Two 500-bed university hospitals
All hospitalized adults from November 2009 to June 2011 with non-hemodialysis central lines
Hospital A started with silver-coated NCs and switched to standard NCs in September 2010; hospital B started with standard NCs and switched to silver-coated NCs. The primary outcome was the difference revealed by Poisson multivariate regression in CLABSI rate using standard Centers for Disease Control and Prevention surveillance definitions. The secondary outcome was a comparison of organism-specific CLABSI rates by NC type.
Among 15,845 hospital admissions, 140,186 central-line days and 221 CLABSIs were recorded during the study period. In a multivariate model, the CLABSI rate per 1,000 central-line days was lower with silver-coated NCs than with standard NCs (1.21 vs 1.79; incidence rate ratio=0.68 [95% CI: 0.52–0.89], P=.005). A lower CLABSI rate per 1,000 central-line days for the silver-coated NCs versus the standard NCs was observed with S. aureus (0.11 vs 0.30, P=.02), enterococci (0.10 vs 0.27, P=.03), and Gram-negative organisms (0.28 vs 0.63, P=.003) but not with coagulase-negative staphylococci (0.31 vs 0.36) or Candida spp. (0.42 vs 0.40).
The use of silver-coated NCs decreased the CLABSI rate by 32%. CLABSI reduction efforts should include efforts to minimize contamination of NCs.
The viability of freshwater turtle populations is largely dependent on the survivorship of reproducing females but females are frequently killed on roads as they move to nesting sites. Installing artificial nesting mounds may increase recruitment and decrease the risk of mortality for gravid females by enticing them to nest closer to aquatic habitats. We evaluated the effectiveness of artificial nesting mounds installed in Algonquin Park, Canada. Artificial mounds were monitored for 2 years to determine if turtles would select them for nest sites. We also simulated turtle paths from wetlands to nests to determine the probability that females would encounter the new habitat. A transplant experiment with clutches of Chrysemys picta and Chelydra serpentina eggs compared nest success and incubation conditions in the absence of predation between artificial mounds and natural sites. More turtles than expected used the artificial mounds, although mounds comprised a small proportion of the available nesting habitat and the simulations predicted that the probability of females encountering mounds was low. Hatching success was higher in nests transplanted to artificial mounds (93%) than in natural nests (56%), despite no differences in heat units. Greater use than expected, high hatching success, and healthy hatchlings emerging from nests in artificial mounds suggest promise for their use as conservation tools.
Measurement of central line-associated bloodstream infection (CLABSI) rates outside of intensive care units is challenged by the difficulty in reliably determining central venous catheter (CVC) use. The National Healthcare Safety Network (NHSN) allows for use of electronic data for determination of CVC-days, but validation of electronic data has not been studied systematically.
To design and validate a process to reliably measure CVC-days outside of the intensive care units that leverages electronic documentation.
Thirty-four inpatient wards at 2 academic hospitals using a common electronic platform for nursing documentation were studied. Electronic queries were created to capture patient and CVC information, and tools and processes for tracking and reporting errors in documentation were developed. Strategies to validate electronic data included comparisons with manual CVC-day determinations and automated data validation using customized tools. Interventions included redesign of documentation interface, real-time audit with feedback of errors, and education. The primary outcome was patient-level total error rate in electronic CVC-day measurement compared with manually counted CVC-days.
At baseline, there were a mean (± standard deviation) of 0.32 ± 0.25 electronic CVC-day errors (omission and commission errors summed and counted equally) per manually counted CVC-day. After several process improvement cycles over 7 months, the error rate decreased to <0.05 errors per CVC-day and remained at or below this level for 2 years.
Baseline electronic CVC-day counts had a high error rate. Stepwise interventions reduced errors to consistently low levels. Validation of electronic calculation of CVC-days is essential to ensure accuracy, particularly if these data will be used for interinstitutional comparison.
Fever is common in the postoperative period, and its causes are diverse (Table 26.1). Fever may result from a benign process such as the release of pyrogens from traumatized tissue and have little bearing on the clinical outcome. Alternatively, fever may be an early sign of a potentially life-threatening infection. The clinician's challenge is to identify those important fevers early, while avoiding the excessive use of diagnostic resources and therapeutic interventions such as unnecessary antibiotics.
Evaluation of a febrile surgical patient begins with a careful history and review of the medical record. The presence of symptoms or signs of infection before the operative procedure or underlying medical problems that increase the likelihood of postoperative complications are valuable clues. The type of surgical procedure performed, operative findings, and the temporal relationship between the operation and the onset of fever are also important. Although prolonged endotracheal intubation, indwelling bladder catheters, and intravascular catheters may be important components of patient care, they violate normal host defenses and increase the likelihood of postoperative infection. When a patient has a significant infection, symptoms and signs in addition to fever usually are present. Thus, a careful physical examination is essential. Laboratory and radiographic studies should be directed by the relevant clinical data and not obtained by an undirected “shotgun” approach.
Many bloodstream infections (BSIs) occurring in patients with febrile neutropenia following cytotoxic chemotherapy are due to translocation of intestinal microbiota. However, these infections meet the National Healthcare Safety Network (NHSN) definition of central line-associated BSIs (CLABSIs). We sought to determine the differences in the microbiology of NHSN-defined CLABSIs in patients with and without neutropenia and, using these data, to propose a modification of the CLABSI definition.
Two large university hospitals over 18 months.
All hospital-acquired BSIs occurring in patients with central venous catheters in place were classified using the NHSN CLABSI definition. Patients with postchemotherapy neutropenia (500 neutrophils/mm3 or lower) at the time of blood culture were considered neutropenic. Pathogens overrepresented in the neutropenic group were identified to inform development of a modified CLABSI definition.
Organisms that were more commonly observed in the neutropenic group compared with the nonneutropenic group included Escherichia coli (22.7% vs 2.5%; P < .001) but not other Enterobacteriaceae, Enterococcus faecium (18.2% vs 6.1%; P = .002), and streptococci (18.2% vs 0%; P < .001). Application of a modified CLABSI definition (removing BSI with enterococci, streptococci, or E. coli) excluded 33 of 66 neutropenic CLABSIs and decreased the CLABSI rate in one study hospital with large transplant and oncology populations from 2.12 to 1.79 cases per 1,000 line-days.
Common gastrointestinal organisms were more common in the neutropenia group, suggesting that many BSIs meeting the NHSN criteria for CLABSI in the setting of neutropenia may represent translocation of gut organisms. These findings support modification of the NHSN CLABSI definition.