Publications by authors named "Jorge P Parada"

42 Publications

Antimicrobial susceptibility of biliary stents do not predict infectious complications after whipple.

Surgery 2020 09 15;168(3):457-461. Epub 2020 Jul 15.

Department of Surgery, Loyola University Medical Center, Maywood, IL.

Background: Postoperative infectious complications after a pancreaticoduodenectomy remain a significant cause of morbidity. Studies have demonstrated that a preoperative biliary stent increases the risk of postoperative infectious complications. Few studies have investigated the specific preoperative biliary stent bacterial sensitivities to preoperative antibiotics and the effect on infectious complications. The goal of this study was to investigate if the presence of a preoperative biliary stent increases the risk of postoperative infectious complications in patients undergoing a pancreaticoduodenectomy. Additionally, we aimed to investigate biliary stent culture sensitivities to preoperative antibiotics and determine if those sensitivities impacted postoperative infectious complications after a pancreaticoduodenectomy.

Methods: A retrospective chart review of patients who had undergone a pancreaticoduodenectomy at a single institution tertiary care center from 2007 to 2018 was performed. Perioperative variables including microbiology cultures from biliary stents were collected and analyzed.

Results: A total of 244 patients underwent a pancreaticoduodenectomy. A preoperative biliary stent was present in 45 (18%) patients. Infectious complications occurred in 25% of those patients with a preoperative biliary stent, and 19% of those without (P = .37). Of those patients with a stent that was cultured intraoperatively, 92% grew bacteria and 61% of those were resistant to the preoperative antibiotics administered. Of the patients with a preoperative biliary stent and bacteria resistant to the preoperative antibiotics, 17% developed a postoperative infectious complication, compared with 20% if the bacteria cultured was susceptible to the preoperative antibiotics (P = .64).

Conclusion: Infectious complications after pancreaticoduodenectomy are a significant cause of morbidity. Stent bacterial sensitivities to preoperative antibiotics did not reduce the postoperative infectious complications in the preoperative biliary stent group suggesting a multifactorial cause of infections.
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http://dx.doi.org/10.1016/j.surg.2020.05.025DOI Listing
September 2020

Variability in catheter-associated asymptomatic bacteriuria rates among individual nurses in intensive care units: An observational cross-sectional study.

PLoS One 2019 10;14(7):e0218755. Epub 2019 Jul 10.

Marquette University College of Nursing, WI, United States of America.

Catheter-associated asymptomatic bacteriuria (CAABU) is frequent in intensive care units (ICUs) and contributes to the routine use of antibiotics and to antibiotic-resistant infections. While nurses are responsible for the implementation of CAABU-prevention guidelines, variability in how individual nurses contribute to CAABU-free rates in ICUs has not been previously explored. This study's objective was to examine the variability in CAABU-free outcomes of individual ICU nurses. This observational cross-sectional study used shift-level nurse-patient data from the electronic health records from two ICUs in a tertiary medical center in the US between July 2015 and June 2016. We included all adult (18+) catheterized patients with no prior CAABU during the hospital encounter and nurses who provided their care. The CAABU-free outcome was defined as a 0/1 indicator identifying shifts where a previously CAABU-free patient remained CAABU-free (absence of a confirmed urine sample) 24-48 hours following end of shift. The analytical approach used Value-Added Modeling and a split-sample design to estimate and validate nurse-level CAABU-free rates while adjusting for patient characteristics, shift, and ICU type. The sample included 94 nurses, 2,150 patients with 256 confirmed CAABU cases, and 21,729 patient shifts. Patients were 55% male, average age was 60 years. CAABU-free rates of individual nurses varied between 94 and 100 per 100 shifts (Wald test: 227.88, P<0.001) and were robust in cross-validation analyses (correlation coefficient: 0.66, P<0.001). Learning and disseminating effective CAABU-avoidance strategies from top-performers throughout the nursing teams could improve quality of care in ICUs.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0218755PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6619985PMC
February 2020

Physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort.

J Intensive Care 2019 21;7:13. Epub 2019 Feb 21.

Immunexpress Inc, 425 Pontius Avenue North, Suite 430, Seattle, WA 98109 USA.

Background: Differentiating sepsis from the systemic inflammatory response syndrome (SIRS) in critical care patients is challenging, especially before serious organ damage is evident, and with variable clinical presentations of patients and variable training and experience of attending physicians. Our objective was to describe and quantify physician agreement in diagnosing SIRS or sepsis in critical care patients as a function of available clinical information, infection site, and hospital setting.

Methods: We conducted a post hoc analysis of previously collected data from a prospective, observational trial ( = 249 subjects) in intensive care units at seven US hospitals, in which physicians at different stages of patient care were asked to make diagnostic calls of either SIRS, sepsis, or indeterminate, based on varying amounts of available clinical information (clinicaltrials.gov identifier: NCT02127502). The overall percent agreement and the free-marginal, inter-observer agreement statistic kappa ( ) were used to quantify agreement between evaluators (attending physicians, site investigators, external expert panelists). Logistic regression and machine learning techniques were used to search for significant variables that could explain heterogeneity within the indeterminate and SIRS patient subgroups.

Results: Free-marginal kappa decreased between the initial impression of the attending physician and (1) the initial impression of the site investigator ( 0.68), (2) the consensus discharge diagnosis of the site investigators ( 0.62), and (3) the consensus diagnosis of the external expert panel ( 0.58). In contrast, agreement was greatest between the consensus discharge impression of site investigators and the consensus diagnosis of the external expert panel ( 0.79). When stratified by infection site, for agreement between initial and later diagnoses had a mean value + 0.24 (range - 0.29 to + 0.39) for respiratory infections, compared to + 0.70 (range + 0.42 to + 0.88) for abdominal + urinary + other infections. Bioinformatics analysis failed to clearly resolve the indeterminate diagnoses and also failed to explain why 60% of SIRS patients were treated with antibiotics.

Conclusions: Considerable uncertainty surrounds the differential clinical diagnosis of sepsis vs. SIRS, especially before organ damage has become highly evident, and for patients presenting with respiratory clinical signs. Our findings underscore the need to provide physicians with accurate, timely diagnostic information in evaluating possible sepsis.
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http://dx.doi.org/10.1186/s40560-019-0368-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383290PMC
February 2019

Use of adenosine triphosphate to audit reprocessing of flexible endoscopes with an elevator mechanism.

Am J Infect Control 2018 11 21;46(11):1272-1277. Epub 2018 May 21.

Department of Gastroenterology, Loyola University Medical Center, Maywood, IL. Electronic address:

Background: There have been reported outbreaks of carbapenem-resistant Enterobacteriaceae infections linked to endoscopes with elevator mechanisms. Adenosine triphosphate (ATP) testing has been used as a marker for bioburden and monitoring manual cleaning for flexible endoscopes with and without an elevator mechanism. The objective of this study was to determine whether routine ATP testing could identify areas of improvement in cleaning of endoscopes with an elevator mechanism.

Methods: ATP testing after manual cleaning of TJF-Q180V duodenoscopes and GF-UCT180 linear echoendoscopes (Olympus America Inc, Center Valley, PA) was implemented. Samples were tested from the distal end, the elevator mechanism, and water flushed through the lumen of the biopsy channel. Data were recorded and compared by time point, test point, and reprocessing technician.

Results: Overall failure rate was 6.99% (295 out of 4,219). The highest percentage of failed ATP tests (17.05%) was reported in the first quarter of routine testing, with an overall decrease in rates over time. The elevator mechanism and working channel lumen had higher failure rates than the distal end. Quality of manual cleaning between reprocessing technicians showed variation.

Conclusion: ATP testing is effective in identifying residual organic material and improving quality of manual cleaning of endoscopes with an elevator mechanism. Cleaning efficacy is influenced by reprocessing technicians and location tested on the endoscope. Close attention to the working channel and elevator mechanism during manual cleaning is warranted.
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http://dx.doi.org/10.1016/j.ajic.2018.04.224DOI Listing
November 2018

Validation of a Host Response Assay, SeptiCyte LAB, for Discriminating Sepsis from Systemic Inflammatory Response Syndrome in the ICU.

Am J Respir Crit Care Med 2018 10;198(7):903-913

11 Immunexpress Inc., Seattle, Washington.

Rationale: A molecular test to distinguish between sepsis and systemic inflammation of noninfectious etiology could potentially have clinical utility.

Objectives: This study evaluated the diagnostic performance of a molecular host response assay (SeptiCyte LAB) designed to distinguish between sepsis and noninfectious systemic inflammation in critically ill adults.

Methods: The study employed a prospective, observational, noninterventional design and recruited a heterogeneous cohort of adult critical care patients from seven sites in the United States (n = 249). An additional group of 198 patients, recruited in the large MARS (Molecular Diagnosis and Risk Stratification of Sepsis) consortium trial in the Netherlands ( www.clinicaltrials.gov identifier NCT01905033), was also tested and analyzed, making a grand total of 447 patients in our study. The performance of SeptiCyte LAB was compared with retrospective physician diagnosis by a panel of three experts.

Measurements And Main Results: In receiver operating characteristic curve analysis, SeptiCyte LAB had an estimated area under the curve of 0.82-0.89 for discriminating sepsis from noninfectious systemic inflammation. The relative likelihood of sepsis versus noninfectious systemic inflammation was found to increase with increasing test score (range, 0-10). In a forward logistic regression analysis, the diagnostic performance of the assay was improved only marginally when used in combination with other clinical and laboratory variables, including procalcitonin. The performance of the assay was not significantly affected by demographic variables, including age, sex, or race/ethnicity.

Conclusions: SeptiCyte LAB appears to be a promising diagnostic tool to complement physician assessment of infection likelihood in critically ill adult patients with systemic inflammation. Clinical trial registered with www.clinicaltrials.gov (NCT01905033 and NCT02127502).
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http://dx.doi.org/10.1164/rccm.201712-2472OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6835074PMC
October 2018

Evaluation of Risk Factors for Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Recipients.

Pharmacotherapy 2017 Apr 30;37(4):420-428. Epub 2017 Mar 30.

Division of Infectious Diseases, Department of Medicine, Loyola University Medical Center, Maywood, Illinois.

Study Objectives: The primary objective was to determine the impact of hematologic malignancies and/or conditioning regimens on the risk of developing Clostridium difficile infection (CDI) in patients undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives were to determine if traditional CDI risk factors applied to patients undergoing HSCT and to determine the presence of CDI markers of severity of illness among this patient population.

Design: Single-center retrospective case-control study.

Setting: Quaternary care academic medical center.

Patients: A total of 105 patients who underwent HSCT between December 2009 and December 2014; of these patients, 35 developed an initial episode of CDI (HSCT/CDI group [cases]), and 70 did not (controls). Controls were matched in a 2:1 ratio to cases based on age (± 10 yrs) and date of HSCT (± 6 mo).

Measurements And Main Results: Baseline characteristics of the two groups were well balanced regarding age, sex, race, ethnicity, and type of HSCT. No significant differences in conditioning regimen, hematologic malignancy, total body irradiation received for HSCT, use of antibiotics within 60 days of HSCT, or use of prophylactic antibiotics after HSCT were noted between the two groups. Patients in the control group were 10.57 (95% confidence interval 1.24-492.75) more likely to have received corticosteroids prior to HSCT than patients in the HSCT/CDI group (p=0.01). Use of proton pump inhibitors at the time of HSCT was greater among the control group than among patients in the HSCT/CDI group (97% vs 86%, p=0.048). No significant difference in mortality was noted between the groups at 3, 6, and 12 months after HSCT. Metronidazole was frequently prescribed for patients in the HSCT/CDI group (34 patients [97%]). Severe CDI was not common among patients within the HSCT/CDI group (13 patients [37%]); vancomycin was infrequently prescribed for these patients ([31%] 4/13 patients).

Conclusion: Hematologic malignancies and a conditioning regimen administered for HSCT were not significant risk factors for the development of CDI after HSCT. Use of corticosteroids prior to HSCT and use of proton pump inhibitors at the time of HSCT were associated with a significantly decreased risk of CDI.
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http://dx.doi.org/10.1002/phar.1914DOI Listing
April 2017

Outbreak of Gastroenteritis in Adults Due to Rotavirus Genotype G12P[8].

Clin Infect Dis 2015 Aug 13;61(4):e20-5. Epub 2015 Apr 13.

Chicago Department of Public Heath, Illinois.

Background: Rotavirus infection in adults is poorly understood and few rotavirus outbreaks among US adults have been reported in the literature. We describe an outbreak due to genotype G12P[8] rotavirus among medical students, faculty, and guests who attended a formal dinner event in April 2013.

Methods: A web-based questionnaire was distributed to event attendees to collect symptom and exposure data. A clinical case was defined as a person who developed diarrhea after attending the formal event. A laboratory-confirmed case was defined as a clinical case who attended the formal event, with rotavirus detected in stool by enzyme immunoassay or reverse transcription-polymerase chain reaction (RT-PCR) assay.

Results: Among 334 dinner attendees, 136 (41%) completed the web-based questionnaire; 58 (43%) respondents reported illness. Symptom onset ranged from 1 to 8 days, with peak onset 3 days after the event. In addition to diarrhea, predominant symptoms included fever (91%), abdominal pain (84%), and vomiting (49%). The median duration of illness was 2.5 days. Thirteen (22%) of 58 cases sought medical attention; none were hospitalized. Analysis of food exposures among questionnaire respondents did not identify significant associations between any specific food or drink item and illness. Stool specimens were negative for bacterial pathogens by culture and negative for norovirus by RT-PCR assay; 4 specimens were positive for rotavirus by enzyme immunoassay or PCR. G12P[8]-R1-C1-M1-A1-N1-T1-E1-H1 was identified as the causative full-genome genotype.

Conclusions: Rotavirus outbreaks can occur among adults, including young adults. Health professionals should consider rotavirus as a cause of acute gastroenteritis in adults.
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http://dx.doi.org/10.1093/cid/civ294DOI Listing
August 2015

Cost-effectiveness comparison of response strategies to a large-scale anthrax attack on the chicago metropolitan area: impact of timing and surge capacity.

Biosecur Bioterror 2012 Sep 30;10(3):264-79. Epub 2012 Jul 30.

Demetrios N. Kyriacou, MD, PhD, is Professor of Emergency Medicine and Preventive Medicine, Department of Emergency Medicine and Department of Preventive Medicine, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA.

Rapid public health response to a large-scale anthrax attack would reduce overall morbidity and mortality. However, there is uncertainty about the optimal cost-effective response strategy based on timing of intervention, public health resources, and critical care facilities. We conducted a decision analytic study to compare response strategies to a theoretical large-scale anthrax attack on the Chicago metropolitan area beginning either Day 2 or Day 5 after the attack. These strategies correspond to the policy options set forth by the Anthrax Modeling Working Group for population-wide responses to a large-scale anthrax attack: (1) postattack antibiotic prophylaxis, (2) postattack antibiotic prophylaxis and vaccination, (3) preattack vaccination with postattack antibiotic prophylaxis, and (4) preattack vaccination with postattack antibiotic prophylaxis and vaccination. Outcomes were measured in costs, lives saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We estimated that postattack antibiotic prophylaxis of all 1,390,000 anthrax-exposed people beginning on Day 2 after attack would result in 205,835 infected victims, 35,049 fulminant victims, and 28,612 deaths. Only 6,437 (18.5%) of the fulminant victims could be saved with the existing critical care facilities in the Chicago metropolitan area. Mortality would increase to 69,136 if the response strategy began on Day 5. Including postattack vaccination with antibiotic prophylaxis of all exposed people reduces mortality and is cost-effective for both Day 2 (ICER=$182/QALY) and Day 5 (ICER=$1,088/QALY) response strategies. Increasing ICU bed availability significantly reduces mortality for all response strategies. We conclude that postattack antibiotic prophylaxis and vaccination of all exposed people is the optimal cost-effective response strategy for a large-scale anthrax attack. Our findings support the US government's plan to provide antibiotic prophylaxis and vaccination for all exposed people within 48 hours of the recognition of a large-scale anthrax attack. Future policies should consider expanding critical care capacity to allow for the rescue of more victims.
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http://dx.doi.org/10.1089/bsp.2011.0105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3440066PMC
September 2012

Granulomatous hepatitis due to Bartonella henselae infection in an immunocompetent patient.

BMC Infect Dis 2012 Jan 23;12:17. Epub 2012 Jan 23.

Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA.

Background: Bartonella henselae (B. henselae) is considered a rare cause of granulomatous hepatitis. Due to the fastidious growth characteristics of the bacteria, the limited sensitivity of histopathological stains, and the non-specific histological findings on liver biopsy, the diagnosis of hepatic bartonellosis can be difficult to establish. Furthermore, the optimal treatment of established hepatic bartonellosis remains controversial.

Case Presentation: We present a case of hepatic bartonellosis in an immunocompetent woman who presented with right upper quadrant pain and a five cm right hepatic lobe mass on CT scan. The patient underwent a right hepatic lobectomy. Surgical pathology revealed florid necrotizing granulomatous hepatitis, favoring an infectious etiology. Despite extensive histological and serological evaluation a definitive diagnosis was not established initially. Thirteen months after initial presentation, hepatic bartonellosis was diagnosed by PCR studies from surgically excised liver tissue. Interestingly, the hepatic granulomas persisted and Bartonella henselae was isolated from the patient's enriched blood culture after several courses of antibiotic therapy.

Conclusion: The diagnosis of hepatic bartonellosis is exceedingly difficult to establish and requires a high degree of clinical suspicion. Recently developed, PCR-based approaches may be required in select patients to make the diagnosis. The optimal antimicrobial therapy for hepatic bartonellosis has not been established, and close follow-up is needed to ensure successful eradication of the infection.
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http://dx.doi.org/10.1186/1471-2334-12-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287964PMC
January 2012

Methicillin-resistant Staphylococcus aureus nasal colonization among women admitted to labor and delivery and their newborn infants.

Infect Control Hosp Epidemiol 2011 Oct 24;32(10):1045-6. Epub 2011 Aug 24.

Department of Pediatrics, Loyola University Medical Center, Maywood, Illinois, USA.

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http://dx.doi.org/10.1086/662018DOI Listing
October 2011

Identification, management, and clinical characteristics of hospitalized patients with influenza-like illness during the 2009 H1N1 influenza pandemic, Cook County, Illinois.

Infect Control Hosp Epidemiol 2011 Oct 30;32(10):998-1002. Epub 2011 Aug 30.

Chicago Department of Public Health, Chicago, Illinois, USA.

Objective: To describe the identification, management, and clinical characteristics of hospitalized patients with influenza-like illness (ILI) during the peak period of activity of the 2009 pandemic strain of influenza A virus subtype H1N1 (2009 H1N1).

Design: Retrospective review of electronic medical records.

Patients And Setting: Hospitalized patients who presented to the emergency department during the period October 18 through November 14, 2009, at 4 hospitals in Cook County, Illinois, with the capacity to perform real-time reverse-transcriptase polymerase chain reaction testing for influenza.

Methods: Vital signs and notes recorded within 1 calendar day after emergency department arrival were reviewed for signs and symptoms consistent with ILI. Cases of ILI were classified as recognized by healthcare providers if an influenza test was performed or if influenza was mentioned as a possible diagnosis in the physician notes. Logistic regression was used to determine the patient attributes and symptoms that were associated with ILI recognition and with influenza infection.

Results: We identified 460 ILI case patients, of whom 412 (90%) had ILI recognized by healthcare providers, 389 (85%) were placed under airborne or droplet isolation precautions, and 243 (53%) were treated with antiviral medication. Of 401 ILI case patients tested for influenza, 91 (23%) had a positive result. Fourteen (3%) ILI case patients and none of the case patients who tested positive for influenza had sore throat in the absence of cough.

Conclusions: Healthcare providers identified a high proportion of hospitalized ILI case patients. Further improvements in disease detection can be made through the use of advanced electronic health records and efficient diagnostic tests. Future studies should evaluate the inclusion of sore throat in the ILI case definition.
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http://dx.doi.org/10.1086/661912DOI Listing
October 2011

Is universal screening of children for nasal methicillin-resistant Staphylococcus aureus colonization necessary on hospital admission?

Infect Control Hosp Epidemiol 2011 Jun;32(6):626-7

Department of Pediatrics, Loyola University Medical Center, Maywood, Illinois 60153, USA.

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http://dx.doi.org/10.1086/660199DOI Listing
June 2011

Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands.

Infect Control Hosp Epidemiol 2010 Jun;31(6):565-70

Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois, USA.

Background: Alcohol-based hand rubs (ABHRs) are an effective means of decreasing the transmission of bacterial pathogens. Alcohol is not effective against Clostridium difficile spores. We examined the retention of C. difficile spores on the hands of volunteers after ABHR use and the subsequent transfer of these spores through physical contact.

Methods: Nontoxigenic C. difficile spores were spread on the bare palms of 10 volunteers. Use of 3 ABHRs and chlorhexidine soap-and-water washing were compared with plain water rubbing alone for removal of C. difficile spores. Palmar cultures were performed before and after hand decontamination by means of a plate stamping method. Transferability of C. difficile after application of ABHR was tested by having each volunteer shake hands with an uninoculated volunteer.

Results: Plain water rubbing reduced palmar culture counts by a mean (+/- standard deviation [SD]) of 1.57 +/- 0.11 log10 colony-forming units (CFU) per cm2, and this value was set as the zero point for the other products. Compared with water washing, chlorhexidine soap washing reduced spore counts by a mean (+/- SD) of 0.89 +/- 0.34 log10 CFU per cm2; among the ABHRs, Isagel accounted for a reduction of 0.11 +/- 0.20 log10 CFU per cm2 (P = .005), Endure for a reduction of 0.37 +/- 0.42 log10 CFU per cm2 (P = .010), and Purell for a reduction of 0.14 +/- 0.33 log10 CFU per cm2 (P = .005). There were no statistically significant differences between the reductions achieved by the ABHRs; only Endure had a reduction statistically different from that for water control rubbing (P = .040). After ABHR use, handshaking transferred a mean of 30% of the residual C. difficile spores to the hands of recipients.

Conclusions: Hand washing with soap and water is significantly more effective at removing C. difficile spores from the hands of volunteers than are ABHRs. Residual spores are readily transferred by a handshake after use of ABHR.
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http://dx.doi.org/10.1086/652772DOI Listing
June 2010

Racial variations in care and outcomes for inpatient HIV-related pneumocystis pneumonia.

J Health Care Poor Underserved 2010 Feb;21(1):318-33

Health Services Research and Policy, Hines VA Hospital in Hines, Illinois, USA.

Racial disparities in HIV-care include the disproportionate impact of HIV/AIDS on African Americans. We conducted a retrospective review of 1,855 cases at 78 hospitals in nine cities to evaluate racial variations in inpatient care for AIDS-related Pneumocystis pneumonia (PCP) shortly after the introduction of highly active anti-retroviral therapies. While inpatient HIV-related PCP mortality was comparable between Whites and Hispanics (p=0.94), African Americans were less likely than Whites to die in-hospital (AOR 0.69, 95% CI 0.48, 0.99) and more likely to receive timely anti-PCP medications (AOR 1.67, 95% CI 1.21, 2.30) and timely corticosteroids (AOR 1.46, 95% CI 1.17, 1.82). Findings were compared with those from our study involving 1,547 patients at 82 hospitals in five cities over the first decade of the AIDS epidemic. In contrast to the first study, in the second decade African Americans were more likely to receive timely and appropriate therapy for HIV-related PCP, and resultantly were more likely to survive the hospitalization.
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http://dx.doi.org/10.1353/hpu.0.0249DOI Listing
February 2010

Spontaneous vertebral osteomyelitis due to Staphylococcus epidermidis.

J Med Microbiol 2010 May 21;59(Pt 5):599-601. Epub 2010 Jan 21.

Hines VA Hospital, Hines, IL, USA.

Few reports in the literature have documented 'spontaneous' vertebral osteomyelitis due to Staphylococcus epidermidis. Herein, we describe a case of S. epidermidis lumbar osteomyelitis presenting as progressive back pain, but without a known port of entry or underlying pre-existing high-risk predisposing conditions. A low threshold for the consideration of infectious osteomyelitis is warranted in persons presenting with new, progressive back pain.
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http://dx.doi.org/10.1099/jmm.0.013730-0DOI Listing
May 2010

Molecular epidemiology of Clostridium difficile over the course of 10 years in a tertiary care hospital.

Clin Infect Dis 2009 Oct;49(8):1141-7

Division of Infectious Diseases, Loyola University Chicago Medical Center, Maywood 60153, USA.

Background: The molecular epidemiology of endemic and outbreak Clostridium difficile strains across time is not well known.

Methods: HindIII restriction endonuclease analysis (REA) typing was performed on available clinical C. difficile isolates from 1982 to 1991.

Results: The annual incidence of C. difficile infection (CDI) ranged from 3.2 to 9.9 cases per 1000 discharges and was significantly higher in 1982, 1983, 1985, and 1991 (high-incidence years) than in other years (mean standard deviation number of cases for the high- vs the low-incidence years, 121.8 +/-20.4 and 70.0 +/-15.0; P =.002). A total of 696 (76.6%) of 908 C. difficile isolates were available for REA typing over the 10-year period. Large clusters (>or=10 CDI cases in consecutive months) were caused by REA types B1 and B2 in 1982 and 1983, F2 and B1 in 1985, and K1 in 1991 (high-incidence years). Small clusters of 4-9 CDI cases in consecutive months were caused by REA types G1 (1984), Y4 and Y6 (1987), Y2 (1988), L1 (1989), Y1 (1990), and K1 (1991). Current epidemic REA group BI (unrelated to type B1) was isolated 6 times, twice in 1984, 1988, and 1990.

Conclusions: Years with a high incidence of CDI were associated with large clusters of specific REA types that changed yearly. The molecular epidemiology of CDI in this hospital was characterized by a wide diversity of C. difficile types and an ever-changing dominance of specific C. difficile types over time. The current epidemic BI group was found sporadically on 6 occasions. A changing CDI molecular epidemiology should be expected in the future.
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http://dx.doi.org/10.1086/605638DOI Listing
October 2009

Mupirocin resistance among methicillin-resistant Staphylococcus aureus-colonized patients at admission to a tertiary care medical center.

J Clin Microbiol 2009 Jul 27;47(7):2279-80. Epub 2009 May 27.

Loyola University Health Systems, Maywood, IL 60153, USA.

All patients admitted to our tertiary care hospital from 1 December 2007 to 10 June 2008 were screened for methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) nasal colonization, and the isolates were tested for mupirocin susceptibility by using Etest. Mupirocin resistance (MR) was noted to occur in 3.4% of MRSA carriers, and high-level MR was noted to occur in 0.62% of carriers.
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http://dx.doi.org/10.1128/JCM.01834-08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2708468PMC
July 2009

Hepatotoxicity associated with long- versus short-course HIV-prophylactic nevirapine use: a systematic review and meta-analysis from the Research on Adverse Drug events And Reports (RADAR) project.

Drug Saf 2009 ;32(2):147-58

Department of Medicine, Northwestern University Feinberg School of Medicine, and Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois 60611, USA.

Background And Objective: The antiretroviral nevirapine can cause severe hepatotoxicity when used 'off-label' for preventing mother-to-child HIV transmission (PMTCT), newborn post-exposure prophylaxis and for pre- and post-exposure prophylaxis among non-HIV-infected individuals. We describe the incidence of hepatotoxicity with short- versus long-course nevirapine-containing regimens in these groups.

Methods: We reviewed hepatotoxicity cases among non-HIV-infected individuals and HIV-infected pregnant women and their offspring receiving short- (or=5 days) nevirapine prophylaxis. Sources included adverse event reports from pharmaceutical manufacturers and the US FDA, reports from peer-reviewed journals/scientific meetings and the Research on Adverse Drug events And Reports (RADAR) project. Hepatotoxicity was scored using the AIDS Clinical Trial Group criteria.

Results: Toxicity data for 8216 patients treated with nevirapine-containing regimens were reviewed. Among 402 non-HIV-infected individuals receiving short- (n=251) or long-course (n=151) nevirapine, rates of grade 1-2 hepatotoxicity were 1.99% versus 5.30%, respectively, and rates of grade 3-4 hepatotoxicity were 0.00% versus 13.25%, respectively (p<0.001 for both comparisons). Among 4740 HIV-infected pregnant women receiving short- (n=3031) versus long-course (n=1709) nevirapine, rates of grade 1-2 hepatotoxicity were 0.62% and 7.04%, respectively, and rates of grade 3-4 hepatotoxicity were 0.23% versus 4.39%, respectively (p<0.001 for both comparisons). The rates of grade 3-4 hepatotoxicity among 3074 neonates of nevirapine-exposed HIV-infected pregnant women were 0.8% for those receiving short-course (n=2801) versus 1.1% for those receiving long-course (n=273) therapy (p<0.72).

Conclusions: Therapy duration appears to significantly predict nevirapine hepatotoxicity. Short-course nevirapine for HIV prophylaxis is associated with fewer hepatotoxic reactions for non-HIV-infected individuals or pregnant HIV-infected women and their offspring, but administration of prophylactic nevirapine for >or=2 weeks appears to be associated with high rates of hepatotoxicity among non-HIV-infected individuals and HIV-infected pregnant mothers. When full highly active antiretroviral therapy (HAART) regimens are not available, single-dose nevirapine plus short-course nucleoside reverse transcriptase inhibitors to decrease the development of HIV viral resistance is an essential therapeutic option for PMTCT and these data support the safety of single-dose nevirapine in this setting.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768573PMC
http://dx.doi.org/10.2165/00002018-200932020-00007DOI Listing
May 2009

Epidemiology of hospital-acquired infections in veterans with spinal cord injury and disorder.

Infect Control Hosp Epidemiol 2008 Mar;29(3):234-42

Department of Veterans Affairs, Center for Management of Complex Chronic Care, and the Infection Control Section, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL 60141, USA.

Objective: To describe the epidemiology of hospital-acquired infections (HAIs) in veterans with spinal cord injury and disorder (SCI&D).

Design: Retrospective medical record review.

Setting: Midwestern Department of Veterans Affairs spinal cord injury center.

Participants: A total of 226 patients with SCI&D hospitalized at least once during a 2-year period (October 1, 2001, through September 30, 2003).

Results: A total of 549 hospitalizations were included in the analysis (mean duration of hospitalization, 33.7 days); an HAI occurred during 182 (33.2%) of these hospitalizations. A total of 657 HAIs occurred during 18,517 patient-days in the hospital (incidence rate, 35.5 HAIs per 1,000 patient-days). Almost half of the 226 patients had at least 1 HAI; the mean number of HAIs among these patients was 6.0 HAIs per patient. The most common HAIs were urinary tract infection (164 [25.0%] of the 657 HAIs; incidence rate, 8.9 cases per 1,000 patient-days), bloodstream infection (111 [16.9%]; incidence rate, 6.0 cases per 1,000 patient-days), and bone and joint infection (103 [15.7%]; incidence rate, 5.6 cases per 1,000 patient-days). The most common culture isolates were gram-positive bacteria (1,082 [45.6%] of 2,307 isolates), including Staphylococcus aureus, and gram-negative bacteria (1,033 [43.6%] of isolates), including Pseudomonas aeruginosa. Multivariable regression demonstrated that predictors of HAI were longer length of hospital stay (P=.002), community-acquired infection (P=.007), and use of a urinary invasive device (P=.01) or respiratory invasive device (P=.04).

Conclusions: The overall incidence of HAIs in persons with SCI&D was higher than that reported for other populations, confirming the increased risk of HAI in persons with spinal cord injury. The increased risk associated with longer length of stay and with community-acquired infection suggests that strategies are needed to reduce the duration of hospitalization and to effectively treat community-acquired infection, to decrease infection rates. There is significant room for improvement in reducing the incidence of HAIs in this population.
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http://dx.doi.org/10.1086/527509DOI Listing
March 2008

Derivation of a triage algorithm for chest radiography of community-acquired pneumonia patients in the emergency department.

Acad Emerg Med 2008 Jan;15(1):40-4

Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: Community-acquired pneumonia (CAP) accounts for 1.5 million emergency department (ED) patient visits in the United States each year.

Objectives: To derive an algorithm for the ED triage setting that facilitates rapid and accurate ordering of chest radiography (CXR) for CAP.

Methods: The authors conducted an ED-based retrospective matched case-control study using 100 radiographic confirmed CAP cases and 100 radiographic confirmed influenzalike illness (ILI) controls. Sensitivities and specificities of characteristics assessed in the triage setting were measured to discriminate CAP from ILI. The authors then used classification tree analysis to derive an algorithm that maximizes sensitivity and specificity for detecting patients with CAP in the ED triage setting.

Results: Temperature greater than 100.4 degrees F (likelihood ratio = 4.39, 95% confidence interval [CI] = 2.04 to 9.45), heart rate greater than 110 beats/minute (likelihood ratio = 3.59, 95% CI = 1.82 to 7.10), and pulse oximetry less than 96% (likelihood ratio = 2.36, 95% CI = 1.32 to 4.20) were the strongest predictors of CAP. However, no single characteristic was adequately sensitive and specific to accurately discriminate CAP from ILI. A three-step algorithm (using optimum cut points for elevated temperature, tachycardia, and hypoxemia on room air pulse oximetry) was derived that is 70.8% sensitive (95% CI = 60.7% to 79.7%) and 79.1% specific (95% CI = 69.3% to 86.9%).

Conclusions: No single characteristic adequately discriminates CAP from ILI, but a derived clinical algorithm may detect most radiographic confirmed CAP patients in the triage setting. Prospective assessment of this algorithm will be needed to determine its effects on the care of ED patients with suspected pneumonia.
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http://dx.doi.org/10.1111/j.1553-2712.2007.00011.xDOI Listing
January 2008

Healthy lifestyles and health-related quality of life among men living with HIV infection.

J Assoc Nurses AIDS Care 2007 Nov-Dec;18(6):54-66

Rehabilitation Outcomes Research Center/Geriatrics Research Education and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA.

Although healthy lifestyles are related to improved quality of life in the general population, little is known about the role of healthy lifestyles during HIV infection. The authors examined the relationships between health-promoting behaviors, risk behaviors, stress, and health-related quality of life (HRQOL) among 226 men with HIV infection who were attending three infectious disease clinics. As hypothesized, health-promoting behaviors were positively related and stress was negatively related with most of the HRQOL dimensions. Contrary to the hypothesis, tobacco use, recreational drug use, and unsafe sexual behaviors were not related to the HRQOL dimensions. Hazardous alcohol use was negatively associated with one HRQOL dimension--social functioning. The association of modifiable factors, such as health-promoting behaviors and stress, with HQROL offers opportunities for improving HIV-related health care. Relatively simple, straightforward changes in lifestyles such as eating well, remaining active, and avoiding stressful life events may result in improvements in HRQOL.
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http://dx.doi.org/10.1016/j.jana.2007.03.010DOI Listing
February 2008

Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system.

J Infect 2007 Dec 5;55(6):495-501. Epub 2007 Nov 5.

Infectious Disease Section, Loyola University Chicago Stritch School of Medicine, Maywood, IL 60153, USA.

Objectives: To determine the response rate of Clostridium difficile disease (CDD) to treatment with metronidazole and assess a scoring system to predict response to treatment with metronidazole when applied at the time of CDD diagnosis.

Methods: Retrospective review of patients with CDD who received primary treatment with metronidazole. We defined success as diarrhea resolution within 6 days of therapy. A CDD score was defined prospectively using variables suggested to correlate with disease severity.

Results: Among 102 evaluable patients, 72 had a successful response (70.6%). Twenty-one of the remaining 30 patients eventually responded to metronidazole, but required longer treatment, leaving 9 'true failures'. The mean CDD score was higher among true failures (2.89+/-1.4) than among all metronidazole responders (0.77+/-1.0) (p<.0001). The score was greater than 2 in 67% of true failures and 2 or less in 94% of metronidazole responders. Leukocytosis and abnormal CT scan findings were individual factors associated with a higher risk of metronidazole failure.

Conclusions: Only 71% of CDD patients responded to metronidazole within 6 days, but the overall response rate was 91%. A CDD score greater than 2 was associated with metronidazole failure in 6 of 9 true failures. The CDD score will require prospective validation.
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http://dx.doi.org/10.1016/j.jinf.2007.09.015DOI Listing
December 2007

Cancer-associated neutropenic fever: clinical outcome and economic costs of emergency department care.

Oncologist 2007 Aug;12(8):1019-26

VA Lakeside Medical Center, Division of General Internal Medicine, Department of Medicine, 400 E. Ontario Street, Suite 205, Chicago, Illinois 60611, USA.

Purpose. Febrile neutropenia (FN) is a common, costly, and potentially fatal complication in oncology. While FN in the inpatient setting has been extensively studied, only one study has evaluated emergency department (ED) care for FN cancer patients. That study found that 96% of patients survived the complication. We evaluated clinical and economic outcomes for cancer patients with chemotherapy-associated FN treated in an ED. Methods. ED records for consecutive oncology patients with FN were reviewed for information on death, intensive care unit (ICU) use, blood cultures, and costs. Results. Forty-eight patients (n = 57 visits) were evaluated. Six patients died from FN (12%) and four received ICU care within 2 weeks and survived (8%). Blood cultures were positive for 37% of the ED visits. The median ED time was 3.3 hours. In 91% of visits, i.v. antibiotics were administered in the ED, ordered at a median of 1.7 hours from triage (interquartile range [IQR], 1.2-2.8 hours). All patients with death or ICU in 2 weeks and all but one patient with positive blood cultures received antibiotics. The median per patient ED costs were $1,455 (IQR, $1,300-$1,579)-42.4% for hospital/nursing, 23.5% for radiology, 20.8% for physician services, 10.9% for diagnostic tests, and 2.4% for antibiotics. Conclusions. Cancer patients with FN in this sample presenting to the ED frequently had no identified source of infection. One third of the patients had positive ED blood cultures and one fifth died or required ICU care within 2 weeks. Costs of ED care were similar to the cost of a single day of inpatient care. Disclosure of potential conflicts of interest is found at the end of this article.
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http://dx.doi.org/10.1634/theoncologist.12-8-1019DOI Listing
August 2007

Long-term outcomes from nosocomial infections in persons with spinal cord injuries and disorders.

Am J Infect Control 2007 Aug;35(6):393-400

Spinal Cord Injury Quality Enhancement Research Initiative, Midwest Center for Health Services and Policy Research, Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, IL 60141, USA.

Background: Nosocomial infection may contribute to poor long-term consequences in persons who have spinal cord injuries and disorders (SCI&D).

Methods: This is a cohort study of individuals who had SCI&D and were hospitalized at least once during 2002. They were followed for 3 years to assess inpatient (IP) admissions, total IP length of stay (LOS), outpatient (OP) visits, and mortality. Count data models and a Cox proportional hazards model were used to assess the relationship between previous infection and subsequent IP and OP use and long-term mortality, respectively.

Results: Of persons who had SCI&D, 59% had at least one nosocomial infection. Multivariable regression indicated that veterans who had SCI&D had more IP admissions (b = 0.405; P < .0001) and longer IP LOS (b = 0.843; P < .0001) if they had a previous infection; however, infection status was not a predictor of future OP visits. Survival time was lower (913.93 versus 1034.75 days, P = .004) in the infection group. Death rate was higher in the nosocomial infection group (30.11% versus 10.77%; P = .004), but the association did not achieve significance in the Cox proportional hazards model (P = .12).

Conclusions: Nosocomial infections have serious subsequent consequences that result in future hospitalization and shorter survival. Efforts to prevent nosocomial infections are needed to reduce long-term adverse effects in persons who have SCI&D.
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http://dx.doi.org/10.1016/j.ajic.2006.08.012DOI Listing
August 2007

Onset of symptoms and time to diagnosis of Clostridium difficile-associated disease following discharge from an acute care hospital.

Infect Control Hosp Epidemiol 2007 Aug 14;28(8):926-31. Epub 2007 Jun 14.

Department of Veterans Affairs, Midwest Center for Health Services and Policy Research and Research Service, Edward Hines Jr. Veterans Affairs Hospital, Hines, IL 60141, USA.

Objective: To identify patients with a diagnosis of Clostridium difficile-associated disease (CDAD) in the ambulatory care setting and determine the relationship of symptom onset and diagnosis to prior hospitalization and exposure to antimicrobials.

Design: Single-center, retrospective study.

Methods: Medical records were reviewed for outpatients and hospitalized patients with a stool assay positive for C. difficile toxin A from January 1998 through March 2005. Patients with recurrent CDAD or residing in an extended-care facility were excluded. CDAD in patients who had been hospitalized in the 100 days prior to diagnosis was considered potentially hospital-associated.

Results: Of the 84 patients who met the inclusion criteria, 75 (89%) received a diagnosis 1-60 days after hospital discharge (median, 12 days), and 71 (85%) received a diagnosis within 30 days after discharge. Of the 69 patients whose records contained information regarding time of symptom onset, 62 (90%) developed diarrhea within 30 days of a previous hospital discharge, including 7 patients with symptom onset prior to discharge and 9 with onset on the day of discharge. The median time from symptom onset to diagnosis was 6 days. Of 84 patients, 77 (92%) had received antimicrobials during a prior hospitalization, but 55 (65%) received antimicrobials both as inpatients and as outpatients.

Conclusion: If all cases of CDAD diagnosed within 100 days of hospital discharge were assumed to be hospital-associated, 71 (85%) of 84 patients with CDAD were identified within 30 days, and 75 (89%) of 84 were identified by day 60. Continued outpatient antimicrobial exposure confounds determination of whether late-onset cases are community- or hospital-associated.
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http://dx.doi.org/10.1086/519178DOI Listing
August 2007

Responding to a small-scale bioterrorist anthrax attack: cost-effectiveness analysis comparing preattack vaccination with postattack antibiotic treatment and vaccination.

Arch Intern Med 2007 Apr;167(7):655-62

Medicine and Neurology Service Line (111), Hines VA Medical Center, Hines, IL 60141, USA.

Background: In 2001, a small-scale bioterrorism-related anthrax attack was perpetrated via the US mail. The optimal future response may require strategies different from those required in a large-scale attack.

Methods: We conducted a cost-effectiveness analysis using Monte Carlo simulation during a 10-year time frame from a societal perspective to determine the optimal response strategy for a small-scale anthrax attack perpetrated against US Postal Service distribution centers in a large metropolitan area. Three strategies were compared: preattack vaccination of all US distribution center postal workers, postattack antibiotic therapy followed by vaccination of exposed personnel, and postattack antibiotic therapy without vaccination of exposed personnel. Outcome measures were costs, quality-adjusted life-years, and incremental cost-effectiveness. The probabilities for anthrax exposure and infection; vaccine and antibiotic benefits, risks, and costs; and associated clinical outcomes were derived from the medical literature and from bioterrorism experts.

Results: Postattack antibiotic therapy and vaccination of exposed postal workers is the most cost-effective response compared with other strategies. The incremental cost-effectiveness is $59 558 per quality-adjusted life-year compared with postattack antibiotic therapy alone. Preattack vaccination of all distribution center workers is less effective and more costly than the other 2 strategies. Assuming complete adherence to preattack vaccination, the incremental cost-effectiveness compared with postattack antibiotic therapy alone is almost $2.6 million per quality-adjusted life-year.

Conclusion: Despite uncertainties about a future anthrax attack and exposure risk, postattack antibiotic therapy and vaccination of exposed personnel seems to be the optimal response to an attack perpetrated through the US Postal Service.
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http://dx.doi.org/10.1001/archinte.167.7.655DOI Listing
April 2007

Systematic review of piperacillin-induced neutropenia.

Drug Saf 2007 ;30(4):295-306

Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Il 60611, USA.

Because penicillin agents are implicated in granulopoiesis inhibition, healthcare professionals frequently consider discontinuation of such therapy in patients with decreasing white blood cell counts. No systematic review to date has described piperacillin and the patient population at risk for this adverse drug reaction (ADR). This review sought to assess the occurrence of piperacillin-induced neutropenia, describe characteristics of affected patients and assess the reporting modalities that most accurately classify this ADR. Case reports, cohort studies and clinical trials identified by comprehensive searches of PubMed and the US FDA Adverse Event Reporting System (AERS) database were reviewed for patient demographics, duration and dose of piperacillin or piperacillin-tazobactam treatment and the occurrence of neutropenia. Causality assessments were performed. Six published case reports, three cohort studies, 178 clinical trials and two compilations of phase I-III trials were reviewed. Review of case reports was notable in that the duration of beta-lactam therapy prior to the noting of leukopenia always exceeded 15 days. No deaths were recorded in this group. Among 13,816 patients enrolled in non-neutropenic fever studies, the occurrence of piperacillin-induced neutropenia was rare: five patients (0.04%) developed neutropenia; none died. The demographics for this group were poorly documented. Through the AERS database, we identified 366 unique cases of piperacillin or piperacillin-tazobactam-induced haematological abnormalities, including neutropenia (n = 183, 50.0%), leukopenia, (n = 99, 27%), agranulocytosis (n = 58, 15.8%) and others. In 62 cases, patients received between 1 and 14 days of therapy (mean 7.7 + 4.1 days). Overall, there were 82 (22.4%) deaths. Reports of haematological ADRs among patients receiving piperacillin or piperacillin-tazobactam are rare. Report of neutropenia associated with piperacillin usage prior to 15 days of therapy is a novel finding that requires further evaluation. Current reporting methods poorly characterise patient groups at risk.
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http://dx.doi.org/10.2165/00002018-200730040-00002DOI Listing
September 2007

Corynebacterium endocarditis species-specific risk factors and outcomes.

BMC Infect Dis 2007 Feb 6;7. Epub 2007 Feb 6.

Section of Infectious Diseases, Louisiana State University Health Sciences Center, 2390 West Congress Street, Lafayette, LA, USA.

Background: Corynebacterium species are recognized as uncommon agents of endocarditis, but little is known regarding species-specific risk factors and outcomes in Corynebacterium endocarditis.

Methods: Case report and Medline search of English language journals for cases of Corynebacterium endocarditis. Inclusion criteria required that cases be identified as endocarditis, having persistent Corynebacterium bacteremia, murmurs described by the authors as identifying the affected valve, or vegetations found by echocardiography or in surgical or autopsy specimens. Cases also required patient-specific information on risk factors and outcomes (age, gender, prior prosthetic valve, other prior nosocomial risk factors (infected valve, involvement of native versus prosthetic valve, need for valve replacement, and death) to be included in the analysis. Publications of Corynebacterium endocarditis which reported aggregate data were excluded. Univariate analysis was conducted with chi-square and t-tests, as appropriate, with p = 0.05 considered significant.

Results: 129 cases of Corynebacterium endocarditis involving nine species met inclusion criteria. Corynebacterium endocarditis typically infects the left heart of adult males and nearly one third of patients have underlying valvular disease. One quarter of patients required valve replacement and one half of patients died. Toxigenic C. diphtheriae is associated with pediatric infections (p < 0.001). Only C. amycolatum has a predilection for women (p = 0.024), while C. pseudodiphtheriticum infections are most frequent in men (p = 0.023). C. striatum, C. jeikeium and C. hemolyticum are associated with nosocomial risk factors (p < 0.001, 0.028, and 0.024, respectively). No species was found to have a predilection for any particular heart valve. C. pseudodiphtheriticum is associated with a previous prosthetic valve replacement (p = 0.004). C. jeikeium infections are more likely to require valve replacement (p = 0.026). Infections involving toxigenic C. diphtheriae and C. pseudodiphtheriticum are associated with decreased survival (p = 0.001 and 0.032, respectively).

Conclusion: We report the first analysis of species-specific risk factors and outcomes in Corynebacterium endocarditis. In addition to species-specific associations with age, gender, prior valvular diseases, and other nosocomial risk factors, we found differences in rates of need for valve replacement and death. This review highlights the seriousness of these infections, as up to 28% of patients required valve replacement and 43.5% died.
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http://dx.doi.org/10.1186/1471-2334-7-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804271PMC
February 2007
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