Search

Background Poor outcomes occur when patients with serious infections receive antibiotics to which the organisms are resistant. Methods Decision trees simulated in-hospital mortality, costs, incremental cost-effectiveness ratio per life year saved, and carbapenem resistance according to 3 empirical antibiotic strategies among adults hospitalized for community-acquired (CA) upper urinary tract infections (UTIs): ceftriaxone (CRO) plus gentamicin (GM) in the intensive care unit (ICU), imipenem (IMP), and individualized choice (IMP or CRO) based on clinical risk factors for CA- extended-spectrum β -lactamase (ESBL). Results The estimated prevalence of CA-ESBL on admission was 5% (range, 1.3%-17.6%); 3% and 97% were admitted to the ICU and medical ward (MW), respectively. In the ICU, CRO plus GM was dominated; IMP was cost-effective (incremental cost-effectiveness ratio: €4,400 per life year saved compared with individualized choice). In the MW, IMP had no impact on mortality and was less costly (−€142 per patient vs CRO, −€38 vs individualized choice). The dominance of IMP was consistent in sensitivity analyses. Compared with CRO, colonization by carbapenem-resistant pathogens increased by an odds ratio of 4.5 in the IMP strategy. Conclusion Among the ICU patients, empirical IMP therapy reduces mortality at an acceptable cost. Among MW patients, individualized choice or CRO is preferred to limit carbapenem resistance at a reasonable cost.

Background The duration of gastrointestinal colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) may play a major role in the spread of these organisms. We evaluated the time to, and factors associated with, ESBL-E clearance after hospital discharge. Methods We retrospectively reviewed prospective surveillance results obtained over 14 years in a 1,000-bed hospital. The surveillance collected demographic, hospital stay, microbiologic, and outcome data. An automatic alert system identified readmitted patients with prior ESBL-E carriage. ESBL-E clearance was defined as a negative rectal screening sample at readmission with no new positive clinical sample during the stay. Variables associated with ESBL-E clearance were identified using a Cox model. Results We included 1,884 patients with 2,734 admissions. Four hundred forty-eight patients with readmission screening formed the basis for the study. Of 448 patients with 1 to 16 readmissions, 180 (40%) were persistent carriers. The median time to ESBL-E clearance was 6.6 months. Variables independently associated with clearance was having the first positive culture in a screening sample only (adjusted hazard ratio, 1.31; 95% confidence interval, 1.02-1.69; P = .04) and period 2005-2010 (hazard ratio, 1.88; 95% confidence interval, 1.33-2.67; P Conclusion We found a long duration of ESBL-E carriage after hospital discharge. An automatic alert system was useful for identifying, screening, and isolating previous ESBL-E carriers.

are not usually considered clinically significant unless 2 or more cultures are positive, whereas presence of Staphylococcus aureus in only 1 blood culture bottle is usually sufficient to diagnose a true bacteremia. Initiation of antibiotic treatment on the sole presence of gram-positive cocci on smear examination is not recommended because it is costly and increases unnecessarily antibiotic use and selective pressure. By contrast, delay in treating S aureus bacteremia may be deleterious for the patient. Therefore, rapid differentiation between S aureus and CNS in blood cultures can help to make the correct medical decision. Because traditional isolation and identification of staphylococci require 18 to 24 hours, several rapid methods have been assessed to speed up the differentiation between S aureus and CNS in blood cultures bottles with clustered gram-positive cocci on direct smear examination. These methods include API RAPIDEC staph