Search

Background: Acinetobacter baumannii is increasingly recognized as being a significant pathogen associated with nosocomial outbreaks in both civilian and military treatment facilities. Current analyses of these outbreaks frequently describe patient-to-patient transmission. To date, occupational transmission of A. baumannii from a patient to a health care worker (HCW) has not been reported. We initiated an investigation of an HCW with a complicated case of A. baumannii pneumonia to determine whether a link existed between her illness and A. baumannii-infected patients in a military treatment facility who had been entrusted to her care., Methods: Pulsed-field gel electrophoresis and polymerase chain reaction/electrospray ionization mass spectrometry, a form of multilocus sequencing typing, were done to determine clonality. To further characterize the isolates, we performed a genetic analysis of resistance determinants., Results and Conclusions: A "look-back" analysis revealed that the multidrug resistant A. baumannii recovered from the HCW and from a patient in her care were indistinguishable by pulsed-field gel electrophoresis. In addition, polymerase chain reaction/electrospray ionization mass spectrometry indicated that the isolates were similar to strains of A. baumannii derived from European clone type II (Walter Reed Army Medical Center strain type 11). The exposure of the HCW to the index patient lasted for only 30 min and involved endotracheal suctioning without use of an HCW mask. An examination of 90 A. baumannii isolates collected during this investigation showed that 2 major and multiple minor clone types were present and that the isolates from the HCW and from the index patient were the most prevalent clone type. Occupational transmission likely occurred in the hospital; HCWs caring for patients infected with A. baumannii should be aware of this potential mode of infection spread.

Purpose: To evaluate the clinical benefit of in-hospital observation after the switch from intravenous (IV) to oral antibiotics in a large Medicare population. Retrospective studies of relatively small size indicate that the practice of in-hospital observation after the switch from IV to oral antibiotics for patients hospitalized with community-acquired pneumonia (CAP) is unnecessary., Methods: We performed a retrospective examination of the US Medicare National Pneumonia Project database. Eligible patients were discharged with an ICD-9-CM diagnosis consistent with community-acquired pneumonia and divided into 2 groups: 1) a "not observed" cohort, in which patients were discharged on the same day as the switch from IV to oral antibiotics and 2) an "observed for 1 day" cohort, in which patients remained hospitalized for 1 day after the switch from IV to oral antibiotics. We compared clinical outcomes between these 2 cohorts., Results: A total of 39,242 cases were sampled, representing 4341 hospitals in all 50 states and the District of Columbia. There were 5248 elderly patients who fulfilled eligibility criteria involving a length of stay of no more than 7 hospital days (2536 "not observed" and 2712 "observed for 1 day" patients). Mean length of stay was 3.8 days for the "not observed" cohort and 4.5 days for the "observed for 1 day" cohort (P <.0001). There was no significant difference in 14-day hospital readmission rate (7.8% in the "not observed" cohort vs 7.2% "observed for 1 day" cohort, odds ratio 0.91; 95% confidence interval [CI] 0.74-1.12; P =.367) and 30-day mortality rate (5.1% "not observed" cohort vs 4.4% in the "observed for 1 day" cohort, odds ratio 0.86; 95% CI, 0.67-1.11; P =.258) between the "not observed" and "observed for 1 day" cohorts., Conclusions: Our analysis of the US Medicare Pneumonia Project database provides further evidence that the routine practice of in-hospital observation after the switch from IV to oral antibiotics for patients with CAP may be avoided in patients who are clinically stable although these findings should be verified in a large randomized controlled trial.

We describe a case of severe necrotizing pneumonia due to community-acquired Pseudomonas aeruginosa. Cultures of fluid obtained from the filter of the patient's hot tub grew the same P. aeruginosa strain as that grown from culture of the patient's sputum. Centers for Disease Control and Prevention guidelines should be strictly followed for hot tub maintenance to prevent P. aeruginosa overgrowth: the range of free chlorine levels in the water should be kept at 1-3 mg/L, and the pH should be kept at 7.2-7.8.

Objectives: To evaluate risk factors for ventilator-associated pneumonia (VAP), as well as its influence on in-hospital mortality, resource utilization, and hospital charges., Design: Retrospective matched cohort study using data from a large US inpatient database., Patients: Patients admitted to an ICU between January 1998 and June 1999 who received mechanical ventilation for > 24 h., Measurements: Risk factors for VAP were examined using crude and adjusted odds ratios (AORs). Cases of VAP were matched on duration of mechanical ventilation, severity of illness on admission (predicted mortality), type of admission (medical, surgical, trauma), and age with up to three control subjects. Mortality, resource utilization, and billed hospital charges were then compared between cases and control subjects., Results: Of the 9,080 patients meeting study entry criteria, VAP developed in 842 patients (9.3%). The mean interval between intubation, admission to the ICU, hospital admission, and the identification of VAP was 3.3 days, 4.5 days, and 5.4 days, respectively. Identified independent risk factors for the development of VAP were male gender, trauma admission, and intermediate deciles of underlying illness severity (on admission) [AOR, 1.58, 1.75, and 1.47 to 1.70, respectively]. Patients with VAP were matched with 2,243 control subjects without VAP. Hospital mortality did not differ significantly between cases and matched control subjects (30.5% vs 30.4%, p = 0.713). Nevertheless, patients with VAP had a significantly longer duration of mechanical ventilation (14.3 +/- 15.5 days vs 4.7 +/- 7.0 days, p < 0.001), ICU stay (11.7 +/- 11.0 days vs 5.6 +/- 6.1 days, p < 0.001), and hospital stay (25.5 +/- 22.8 days vs 14.0 +/- 14.6 days, p < 0.001). Development of VAP was also associated with an increase of > $40,000 USD in mean hospital charges per patient ($104,983 USD +/- $91,080 USD vs $63,689 USD+/- $75,030 USD, p < 0.001)., Conclusions: This retrospective matched cohort study, the largest of its kind, demonstrates that VAP is a common nosocomial infection that is associated with poor clinical and economic outcomes. While strategies to prevent the occurrence of VAP may not reduce mortality, they may yield other important benefits to patients, their families, and hospital systems.

Objectives: To investigate a cluster of seven pneumonia cases among persons exposed to a pet-shop worker hospitalized with psittacosis., Design: Epidemiological study of the outbreak, sero-diagnostic evaluation of exposed persons with pneumonia; and retrospective review of the pneumonia cases., Setting: 450-bed teaching community hospital., Participants: Employees of the nursing unit where the patient with psittacosis was hospitalized., Results: The index case had laboratory and clinical evidence of psittacosis. Four of the seven exposed persons who developed pneumonia had serologic results that met criteria for a diagnosis of psittacosis, and three met criteria for Chlamydia pneumoniae infection, possibly reflecting cross-reactivity between the microimmunofluorescence assays for the two diseases. The epidemiological graph suggested a relationship between the index case and the cluster of pneumonias in exposed individuals., Conclusions: Psittacosis may have been transmitted person to person in a hospital setting.

In Missouri, community-acquired pneumonia is the second leading cause of hospital admission in the Medicare population. Analysis of 1993 discharges revealed that more than 18,000 Medicare patients were admitted to acute care hospitals with a principal diagnosis of pneumonia. Statewide, the case fatality rate for these admissions was 9.6%, with an average length of stay of 8.2 days. Under the auspices of Medicare's Health Care Quality Improvement Program, the Missouri Patient Care Review Foundation (MPCRF) collaborated with five hospitals in the state on a project to enhance the outcomes and quality of care for patients admitted with community-acquired pneumonia. Narrowing the focus to bacterial community-acquired pneumonia, the five hospitals agreed to collect data, for a specified period, on each Medicare patient admitted with this diagnosis. The hospitals were encouraged to implement recommended critical pathways and guidelines for the initial management and treatment of community-acquired pneumonia. MPCRF assumed responsibility for data management activities for the project as well as production of feedback reports that were shared routinely with the hospitals. Although evaluation of the project continues, preliminary analysis of claims data for admissions occurring after process changes were implemented indicates that there has been improvement in the two outcome measures, patient mortality and length of stay. These results suggest that monitoring of key process indicators, coupled with ongoing analysis and feedback, has potential for facilitating positive change in the quality of care for patients with community acquired pneumonia.