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Objective.Bacteremia is relatively common in patients with skin and skin-structure infection (SSSI) severe enough to require hospitalization. We used selected demographic and clinical characteristics easily assessable at initial evaluation to develop a model for the early identification of patients with SSSI who are at higher risk for bacteremia.Participants.A large database of adults hospitalized with SSSI at 97 hospitals in the United States during the period from 2003 through 2007 and from whom blood samples were obtained for culture at admission.Methods.We compared selected candidate predictor variables for patients shown to have bacteremia and patients with no demonstrated bacteremia. Using stepwise logistic regression to identify independent risk factors for bacteremia, we derived a model by using 75% of a randomly split cohort, converted the model coefficients into a risk score system, and then we validated it by using the remaining 25% of the cohort.Results.Bacteremia was documented in 1,021 (11.7%) of the 8,747 eligible patients. Independent predictors of bacteremia (PP< .001). The model C statistic was 0.71; the Hosmer-Lemeshow testPvalue was .36, indicating excellent model calibration.Conclusions.Using data available at hospital admission, we developed a risk score that differentiated SSSI patients at low risk for bacteremia from patients at high risk. This score may help clinicians identify patients who require more intensive monitoring or antimicrobial regimens appropriate for treating bacteremia.

Background A silver-coated endotracheal tube (ETT) reduced the incidence of ventilator-associated pneumonia (VAP) compared with an uncoated ETT in the North American Silver-Coated Endotracheal Tube (NASCENT) study. Methods To evaluate the effect of an ETT and risk factors on mortality, we performed a retrospective cohort analysis in patients who developed VAP in the NASCENT study. We determined causes of death and VAP due to potentially multidrug-resistant bacteria (eg, Pseudomonas, Acinetobacter) and performed stepwise multivariate logistic regression with the following predefined variables: treatment group, Acute Physiology and Chronic Health Evaluation (APACHE) II score, continuous sedation, coma, COPD, emergency surgery/trauma, immunodeficiency, potentially multidrug-resistant bacteria, and inappropriate initial antibiotics. Results The silver-coated ETT was associated with reduced mortality in patients with VAP (silver vs control, 5/37 [14%] vs 20/56 [36%], P = .03), but not in those without VAP (228/729 [31%] vs 178/687 [26%], P = .03). The only between-group difference in leading causes of death was respiratory failure (silver vs control, 45/233 [19%] vs 22/198 [11%], P = .02). Of the VAP-related deaths, one in the silver group was caused by Acinetobacter sepsis. In the control group, six deaths were caused by sepsis and three by pneumonia; six of nine pathogens were potentially multidrug resistant. In multivariate analysis, the treatment group was a predictor of mortality (odds ratio, silver vs control, 0.28; 95% CI, 0.09–0.89; P = .03). APACHE II ≥ 20 and inappropriate antibiotics also remained in the model (P Conclusions These findings suggest that a silver-coated ETT was associated with reduced mortality in patients who developed VAP in the NASCENT study. Studies are needed to confirm these exploratory findings.

The aim of this study is to describe the initial antibiotic treatment regimens, severity of illness, and in-hospital mortality among culture-negative (CN) and culture-positive (CP) patients with health-care-associated pneumonia (HCAP).We used a retrospective cohort study, examining adult patients with HCAP from Barnes-Jewish Hospital, a 1,200-bed urban teaching hospital.Eight hundred seventy patients with HCAP were identified over a 3-year period (January 2003 through December 2005) of whom 431 (49.5%) were CP. Among the non-CP patients, 290 (66.1%) had no respiratory cultures obtained, and 149 (33.9%) had no growth or nonpathogenic oral flora identified and were classified as CN. CN patients were more likely to have received an initial antibiotic regimen (ceftriaxone +/- azithromycin or moxifloxacin) targeting community-acquired pneumonia pathogens compared with CP patients (71.8% vs 25.5%, P.001). Severity of illness as assessed by ICU admission and mechanical ventilation (MV) was statistically lower in CN compared with CP patients (ICU admittance 12.1% vs 48.7%, P.001; MV: 6.7% vs 44.5%, P.001). In-hospital mortality and hospital length of stay were also statistically lower for CN patients (mortality: 7.4% vs 24.6%, P.001; hospital length of stay: 6.7 +/- 7.4 days vs 12.1 +/- 11.7 days, P.001).In this analysis, patients with CN HCAP had lower severity of illness, hospital mortality, and hospital length of stay compared with CP patients. These data suggest that patients with CN HCAP differ substantially from patients with HCAP with positive microbiologic cultures.

Objectives: The safest site for central venous cannulation (CVC) remains debated. Many emergency physicians (EPs) advocate the ultrasound-guided internal jugular (USIJ) approach because of data supporting its efficiency. However, a number of physicians prefer, and are most comfortable with, the subclavian (SC) vein approach. The purpose of this study was to describe adverse event rates among operators using the USIJ approach, and the landmark SC vein approach without US. Methods: This was a prospective observational trial of patients undergoing CVC of the SC or internal jugular veins in the emergency department (ED). Physicians performing the procedures did not undergo standardized training in either technique. The primary outcome was a composite of adverse events defined as hematoma, arterial cannulation, pneumothorax, and failure to cannulate. Physicians recorded the anatomical site of cannulation, US assistance, indications, and acute complications. Variables of interest were collected from the pharmacy and ED record. Physician experience was based on a self-reported survey. The authors followed outcomes of central line insertion until device removal or patient discharge. Results: Physicians attempted 236 USIJ and 132 SC cannulations on 333 patients. The overall adverse event rate was 22% with failure to cannulate being the most common. Adverse events occurred in 19% of USIJ attempts, compared to 29% of non–US-guided SC attempts. Among highly experienced operators, CVCs placed at the SC site resulted in more adverse events than those performed using USIJ (relative risk [RR] = 1.89, 95% confidence interval [CI] = 1.05 to 3.39). Conclusions: While limited by observational design, our results suggest that the USIJ technique may result in fewer adverse events compared to the landmark SC approach. ACADEMIC EMERGENCY MEDICINE 2010; 17:416–422 © 2010 by the Society for Academic Emergency Medicine

To elucidate the mechanism of action of the silver-coated endotracheal tube in models of the early pathogenesis of ventilator-associated pneumonia.Open-labeled, prospective, controlled, sequentially conducted, preclinical studies, and in vitro assessment of tubes from patients.Microbiology laboratory of a device manufacturer, animal research facility of a university, and a tertiary medical center.Endotracheal tubes were similar except for the silver coating. In the 21-day in vitro elution model, tube samples were incubated in saline solution at 37.8 degrees C. In the in vitro adherence model, coated and uncoated tubes were exposed to 21 respiratory isolates of radiolabeled microorganisms for 2-4 hrs. In the animal model, 12 healthy white rabbits were intubated for 16 hrs with noncuffed silver-coated or uncoated tubes and challenged with buccal administration of Pseudomonas aeruginosa. In the in vitro assessment, tubes from 16 patients underwent quantitative culture assessment and qualitative confocal laser scanning microscopy.After in vitro incubation, the mean residual silver concentration was 2.6 microg/cm, confirming that the coating was not entirely depleted. In vitro adherence to the silver-coated endotracheal tube was less than that of the uncoated tube for 12 of 21 isolates and equivalent for seven. For example, adherence to the silver-coated endotracheal tube was reduced90% for all five isolates of P. aeruginosa (p.05). In rabbits, P. aeruginosa colonization on the silver-coated endotracheal tube was reduced 99.9% compared with that on the uncoated tube (p.0001); colonization in the tracheal and lung tissue was reducedor =99% (p.05). In the in vitro assessment, pathogens were detected on none of nine silver-coated tubes from patients and three of seven control tubes (p.05).: The collective findings of this series of studies demonstrated that the silver-coated endotracheal tube was active in models designed to mimic the early pathogenesis of ventilator-associated pneumonia.

BACKGROUND: Hospitalized patients who develop severe sepsis have significant morbidity and mortality. Early goal-directed therapy has been shown to decrease mortality in severe sepsis and septic shock, though a delay in recognizing impending sepsis often precludes this intervention. OBJECTIVE: To identify early predictors of septic shock among hospitalized non-intensive care unit (ICU) medical patients. DESIGN: Retrospective cohort analysis. SETTING: A 1200-bed academic medical center. PATIENTS: Derivation cohort consisted of 13,785 patients hospitalized during 2005. The validation cohorts consisted of 13,737 patients during 2006 and 13,937 patients from 2007. INTERVENTION: Development and prospective validation of a prediction model using Recursive Partitioning And Regression Tree (RPART) analysis. METHODS: RPART analysis of routine laboratory and hemodynamic variables from the derivation cohort to identify predictors prior to the occurrence of shock. Two models were generated, 1 including arterial blood gas (ABG) data and 1 without. RESULTS: When applied to the 2006 cohort, 347 (54.7%) and 121 (19.1%) of the 635 patients developing septic shock were correctly identified by the 2 models, respectively. For the 2007 patients, the 2 models correctly identified 367 (55.0%) and 102 (15.3%) of the 667 patients developing septic shock, respectively. CONCLUSIONS: Readily available data can be employed to predict non-ICU patients who develop septic shock several hours prior to ICU admission. Journal of Hospital Medicine 2010;5:19–25. © 2010 Society of Hospital Medicine.

Objective.Healthcare-associated infections are likely to be caused by drug-resistant and possibly mixed organisms and to be treated with inappropriate antibiotics. Because prompt appropriate treatment is associated with better outcomes, we studied the epidemiology of healthcare-associated complicated skin and skin-structure infections (cSSSIs).Patients.Persons hospitalized with cSSSI and a positive culture result.Methods.We conducted a single-center retrospective cohort study from April 2006 through December 2007. We differentiated healthcare-associated from community-acquired cSSSIs by at least 1 of the following risk factors: (1) recent hospitalization, (2) recent antibiotics, (3) hemodialysis, and (4) transfer from a nursing home. Inappropriate treatment was defined as no antimicrobial therapy with activity against the offending pathogen(s) within 24 hours after collection of a culture specimen. Mixed infections were those caused by both a gram-positive and a gram-negative organism.Results.Among 717 hospitalized patients with cSSSI, 527 (73.5%) had healthcare-associated cSSSI. Gram-negative organisms were more common (relative risk, 1.24 [95% confidence interval, 1.14–1.35) and inappropriate treatment trended toward being more common (odds ratio, 1.29 [95% confidence interval, 0.85–1.95]) in healthcare-associated cSSSI than in community-acquired cSSSI. Mixed cSSSIs occurred in 10.6% of patients with healthcare-associated cSSSI and 6.3% of those with community-acquired cSSSI (P = .082) and were more likely to be treated inappropriately than to be nonmixed infections (odds ratio, 2.42 [95% confidence interval, 1.43–4.10]). Both median length of hospital stay (6.2 vs 2.9 days; P < .001) and mortality rate (6.6% vs 1.1%; P = .003) were significantly higher for healthcare-associated cSSSI than community-acquired cSSSI.Conclusions.Healthcare-associated cSSSIs are common and are likely to be caused by gram-negative organisms. Mixed infections carry a

Patients receiving prolonged acute mechanical ventilation (PAMV), although comprising a third of all mechanical ventilation (MV) patients, consume two-thirds of all the resources allocated to MV, and their numbers are projected to double by 2020. By virtue of their prolonged hospital length of stay (median LOS, 17 days), they are subject to such nosocomial infections as Clostridium difficile-associated disease (CDAD), the incidence and age-adjusted case fatality rate of which doubled between 2000 and 2005. We examined the rates and outcomes of CDAD among adult PAMV patients.We analyzed 2005 data from the Health Care Utilization Project/Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. PAMV and CDAD were identified using the International Classification of Diseases, ninth revision, clinical modification codes 96.72 and 008.45, respectively.Among 64,910 adult PAMV patients who were discharged in 2005, 3,468 patients (5.34%) had a concurrent diagnosis of CDAD (PAMV patients who were discharged with concomitant diagnosis of CDAD [CDAD+]). CDAD+ patients who were discharged were older (mean [+/- SD] age, 66.7 +/- 15.9 vs 63.7 +/- 16.9 years, respectively; p0.001) and were more likely to have been admitted to the hospital from a long-term care facility (5.7% vs 2.9%, respectively; p0.001) than PAMV patients who were discharged without CDAD (CDAD-). Although crude hospital mortality rates did not differ among PAMV patients who were discharged from the hospital by CDAD status (CDAD+, 32.6%; CDAD-, 33.0%; p = 0.598), both unadjusted calculations and propensity-score adjustment showed a substantial increase in LOS (6.1 days; 95% confidence interval [CI], 4.9 to 7.4) and total costs ($10,355; 95% CI, $7,540 to $13,170) among CDAD+ patients.PAMV patients have an order of magnitude higher risk of having CDAD than other hospitalized patients. Concurrent CDAD infection is associated with increased hospital LOS and costs. The PAMV population is an attractive target for aggressive measures aimed at CDAD prevention.

Objective Prospective single-center study to determine whether the presence of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) has diagnostic utility in patients with pulmonary infiltrates receiving mechanical ventilation and undergoing BAL. Design Prospective cohort study. Setting Barnes-Jewish Hospital, a 1,200-bed urban teaching hospital. Patients Adult patients with acute respiratory failure undergoing BAL for pulmonary infiltrates. Interventions BAL fluid measurement of sTREM-1 concentration using a Quantikine Human TREM-1 Immunoassay (RD Minneapolis, MN). Measurements and main results A total of 105 consecutive patients receiving mechanical ventilation and undergoing BAL were enrolled. Of those, 19 patients (18.1%) met definite microbiologic criteria for bacterial or fungal ventilator-associated pneumonia (VAP). Though the mean sTREM-1 concentration was greater in patients with definite VAP (n = 19; 171.9 ± 158.7 pg/mL) than in patients with definite absence of VAP (n = 21; 96.7 ± 76.2 pg/mL), this difference was not statistically significant (p = 0.06). A cutoff value for sTREM-1 > 200 pg/mL yielded a diagnostic sensitivity of 42.1% and a specificity of 75.6% for definite VAP. Patients with alveolar hemorrhage had the greatest values for sTREM-1 concentration (n = 9; 555 ± 440 pg/mL). Receiver operating curve analysis and multivariate logistic regression analysis demonstrated that measurement of sTREM-1 was inferior to clinical parameters for the diagnosis of VAP. Conclusions Measurement of sTREM-1 in BAL fluid appears to have minimal diagnostic value for VAP.

To evaluate the hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis on processes of medical care and patient outcomes.Retrospective, before and after study design.Barnes-Jewish Hospital, a 1200-bed academic medical center.Bacteremic patients with severe sepsis (200 from the 18-month before period and 200 from the 18-month after period).Hospital-wide implementation of a standardized order set for the management of bacteremic severe sepsis.A total of 400 patients with bacteremia and severe sepsis were selected at random within the specified time periods. Patients in the after group received more intravenous fluids in the first 12 hours after onset of hypotension (1627 +/- 1862 mL vs. 2054 +/- 2237 mL; p = 0.04) and were more likely to receive appropriate initial antibiotic therapy (53.0% vs. 65.5%, p = 0.01). In-hospital mortality was statistically decreased in the after group (55.0% vs. 39.5%, p0.01), as was the hospital length of stay (28.7 +/- 30.1 days vs. 22.4 +/- 20.9 days; p = 0.02). Compared with the before group, the after group had reduced occurrence of renal failure (49.0% vs. 36.0%, p0.01), cardiovascular failure (70.5% vs. 57.0%, p0.01), and were less likely to require vasopressors after initial fluid resuscitation (68.5% vs. 52.5%, p0.01).The implementation of a hospital-wide standardized order set for the management of bacteremic severe sepsis was associated with greater fluid administration, improved antibiotic therapy, decreased incidence of organ failure, and improved survival.

Ventilator-associated pneumonia (VAP) is a target for health care quality improvement. The Institute for Healthcare Improvement has led the charge with its ventilator bundle aimed at VAP prevention. We set out to review the literature on the effectiveness of the bundle to prevent VAP.Systematic literature review.Intensive care unit.We identified four studies that met the inclusion criteria. The review revealed major methodologic flaws in design, reporting and results of the studies, including bias, confounding, and lack of generalizability.Lack of methodologic rigor of the reported studies precludes any conclusive statements about the bundle's effectiveness or cost-effectiveness. To assure efficient allocation of the limited healthcare resources, rigorous evaluation of optimal strategies for VAP prevention is needed to 1) establish best practices and 2) create a benchmark against which new technologies' value can be assessed. The vent bundle is not a viable quality measure in the intensive care unit at this time.

OBJECTIVE: To examine the relationship between treatment-related variables for Candida bloodstream infection and hospital mortality. DESIGN: Retrospective cohort analysis. SETTING: Thousand two hundred-bed academic medical center. PATIENTS: A total of 245 consecutive patients with Candida bloodstream infections who received antifungal therapy. INTERVENTIONS: Identification of treatment-related risk factors: central vein catheter retention, inadequate initial fluconazole dosing, and delayed administration of antifungal therapy. MEASUREMENTS AND MAIN RESULTS: A total of 245 patients with Candida bloodstream infections who received antifungal therapy were identified. One hundred eleven (45.3%) patients were managed in an intensive care unit and analyzed as a separate subgroup. In the hospital cohort, 72 (29.4%) patients died during hospitalization and 40 (36.0%) patients died in the intensive care unit cohort. In the hospital cohort, logistic regression analysis identified Acute Physiology and Chronic Health Evaluation II scores (1-point increments) (adjusted odds ratio [AOR], 1.18; 95% confidence interval [CI], 1.11-1.25; p = 0.003), corticosteroid use at the time a positive blood culture was drawn (AOR, 3.41; 95% CI, 1.96-5.93; p = 0.027), inadequate initial fluconazole dosing (AOR, 3.31; 95% CI, 1.83-6.00; p = 0.044), and retention of a central vein catheter (AOR, 4.85; 95% CI, 2.54-9.29; p = 0.015) as independent determinants of hospital mortality. In the intensive care unit cohort, logistic regression analysis identified Acute Physiology and Chronic Health Evaluation II scores (1-point increments) (AOR, 1.21; 95% CI, 1.14-1.29; p = 0.001), inadequate initial fluconazole dosing (AOR, 9.22; 95% CI, 2.15-19.79; p = 0.004), and retention of a central vein catheter (AOR, 6.21; 95% CI, 3.02-12.77; p = 0.011), as independent determinants of hospital mortality. For both cohorts the incremental presence of treatment-related risk factors was statistically associated with greater hospital mortality. CONCLUSIONS: Treatment-related factors, including retention of central vein catheters and inadequate initial fluconazole dosing, were associated with increased hospital mortality in patients with Candida bloodstream infections. These data suggest that optimization of initial antifungal therapy and removal of central vein catheters may improve the outcomes of patients with Candida bloodstream infections.

Background: Patients with health-care–associated pneumonia (HCAP) are frequently infected with a resistant pathogen and receive inappropriate empiric antibiotics (ie, pathogens resistant to administered treatment). Initial inappropriate treatment has been shown to increase hospital mortality. It is not known whether escalation in response to culture results mitigates this risk. Methods: We identified patients admitted with a culture-positive pneumonia between January 2003 and December 2005. HCAP patients met one or more of the following criteria indicating ongoing contact with the health-care system: recent hospitalization (< 12 months), admission from a nursing home, immunosuppression, or long-term dialysis. We compared survivors to nonsurvivors among those patients with HCAP still hospitalized beyond 48 h. Results: Of 431 HCAP patients, 396 patients (92%) were alive and still hospitalized beyond 48 h. The crude mortality rate was 21.5%. Compared to survivors, nonsurvivors were significantly more likely to be treated with inappropriate empiric antibiotics (37.6% vs 24.1%, p 0.013). Although mortality was higher among patients receiving inappropriate than appropriate therapy (30.0% vs 18.3%, p 0.013), this difference was more pronounced among nonbacteremic patients (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.26 to 4.75) than bacteremic patients (OR, 1.25; 95% CI, 0.41 to 3.57). In a logistic regression, inappropriate empiric antibiotic treatment among nonbacteremic patients was independently associated with mortality (OR, 2.88; 95% CI, 1.46 to 5.67); treatment escalation did not attenuate the risk of death. Conclusion: Among HCAP patients alive and hospitalized beyond 48 h, hospital mortality was high and, in the absence of bacteremia, greater with initial inappropriate antibiotic treatment. Despite subsequent escalation, initial inappropriate antibiotic choice nearly tripled the risk of hospital death. (CHEST 2008; 134:963–968)

During the Health Care-Associated Pneumonia Summit conducted in June 2007, it was found that there is a need for educational efforts in several areas of health care-associated infections (HAI) that extend beyond pneumonia. This supplement to Clinical Infectious Diseases represents the proceedings of the HAI Summit, a diverse panel of clinical investigators whose goal was to assess the quality of evidence regarding issues surrounding HAI and to discuss potential implications for its diagnosis and treatment in the future.

Background: Methicillin-resistant Staphylococcus aureus causes significant morbidity and mortality. Initially inappropriate antibiotic therapy for methicillin-resistant S. aureus increases the risk for mortality. The impact of initially inappropriate antibiotic therapy on hospital length of stay and costs remains unknown. Methods: We identified patients admitted with nonnosocomial methicillin-resistant S. aureus sterile-site infections during a 3 yr period and compared those given appropriate antibiotic therapy with those given initially inappropriate antibiotic therapy. Appropriate therapy was defined based on timely administration of an anti-infective to which the pathogen was in vitro susceptible. Hospital length of stay served as the primary end point whereas total hospital costs represented a secondary end point. We attempted to adjust for multiple potential confounders including demographics, comorbid illnesses, infection characteristics, and severity of illness. We conducted subgroup analyses in patients who survived their hospital stay and in those requiring admission to the intensive care unit. Results: The cohort included 291 patients and 77% received initially inappropriate antibiotic therapy. Approximately one in five patients died during their hospitalization. The median length of stay among the appropriately treated population was 2 days shorter than those given initially inappropriate antibiotic therapy (7.1 vs. 9.3 days, p = .050). After adjusting for covariates in a Cox proportional hazards model, initially appropriate therapy remained associated with a reduced length of stay (hazard ratio: 0.69, 95% confidence interval: 0.51-0.92, p = .013). Median crude costs in those treated appropriately were $13,688 compared with $19,427 (p = .019). Restricting the analysis to either hospital survivors or to those needing intensive care did not alter our observations. Conclusion: Initially inappropriate antibiotic therapy for methicillin-resistant S. aureus prolongs length of stay and increases hospital costs. Efforts to lower rates of initially inappropriate antibiotic therapy for methicillin-resistant S. aureus sterile-site infections will likely improve outcomes for both patients and for healthcare institutions.

Traditionally, pneumonia is categorized by epidemiologic factors into community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). Microbiologic studies have shown that the organisms which cause infections in HAP and VAP differ from CAP in epidemiology and resistance patterns. Patients with HAP or VAP are at higher risk for harboring resistant organisms. Other historical features that potentially place patients at a higher risk for being infected with resistant pathogens and organisms not commonly associated with CAP include history of recent admission to a health care facility, residence in a long-term care or nursing home facility, attendance at a dialysis clinic, history of recent intravenous antibiotic therapy, chemotherapy, and wound care. Because these "risk factors" have health care exposure as a common feature, patients presenting with pneumonia having these historical features have been more recently categorized as having health care-associated pneumonia (HCAP). This publication was prepared by the HCAP Working Group, which is comprised of nationally recognized experts in emergency medicine, infectious diseases, and pulmonary and critical care medicine. The aim of this article is to create awareness of the entity known as HCAP and to provide knowledge of its identification and initial management in the emergency department.

Human ehrlichiosis is a serious disease that can be fatal if not treated appropriately. We examined patients with a clinical presentation consistent with the syndrome of ehrlichiosis and a positive blood polymerase chain reaction (PCR) test for all known Ehrlichia species or Anaplasma phagocytophilum admitted to Barnes-Jewish Hospital in St. Louis, MO, from 1996 to 2006. Patients who had doxycycline initiated within the first 24 hours of admission to the hospital were compared with patients who did not have empiric doxycycline therapy. A total of 46 patients had a positive blood PCR test for Ehrlichia or Anaplasma phagocytophilum, and 28 (60.9%) had a delay in doxycycline therapy. At presentation, patients with a delay in therapy were more likely to present with an abnormal lung exam and altered mental status. None of the patients experiencing a delay in doxycycline treatment had the diagnosis of ehrlichiosis documented at the time of hospital admission, compared with 13 (72.2%) of the patients who were treated empirically (p0.001). Patients not started on doxycycline at hospital admission had a significantly increased rate of transfer to the intensive care unit (39.3% vs. 0%; p0.001) and requirement for mechanical ventilation (28.6% vs. 0%; p0.001). Patients with a treatment delay also had a longer hospital stay (12.3 +/- 11 d vs. 3.9 +/- 1.9 d, respectively; p0.001) and a longer length of illness (20.9 +/- 14.2 d vs. 8.9 +/- 2.7 d, respectively; p = 0.001). These data suggest that clinicians living in an area where Ehrlichia is endemic should have a high suspicion for ehrlichiosis, and a low threshold for instituting empiric antibiotic therapy with doxycycline.

To compare the predictive accuracy for 30-day mortality of the CURB65 score adopted by the British Thoracic Society and the simpler CRB65 score to APACHE (acute physiology and chronic health evaluation) II in patients with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia.A retrospective, single-center, observational cohort study.Barnes-Jewish Hospital, a 1,200-bed urban teaching hospital.Adult patients requiring hospitalization identified to have MRSA pneumonia.Retrospective data collection from automated hospital, microbiology, and pharmacy databases.Two hundred eighteen patients with MRSA pneumonia were identified over a 3-year period. Forty-four patients (20.2%) died during hospitalization. All three prediction rules had high negative predictive values but relatively low positive predictive values at most cut-off points examined. APACHE II had the greatest area under the receiver operating characteristic curve (0.805; 95% confidence interval [CI], 0.743 to 0.866) compared to CURB65 (0.634; 95% CI, 0.541 to 0.727) and CRB65 (0.643; 95% CI, 0.546 to 0.739) [p0.05 for both comparisons]. Similar results were obtained when the subgroups of community-acquired MRSA pneumonia and health-care-associated MRSA pneumonia were examined separately.APACHE II outperformed CURB65 and CRB65 for initial prognostic assessment in MRSA pneumonia.

Pneumonia occurring outside of the hospital setting has traditionally been categorized as community-acquired pneumonia (CAP). However, when pneumonia is associated with health care risk factors (prior hospitalization, dialysis, residing in a nursing home, immunocompromised state), it is now more appropriately classified as a health care-associated pneumonia (HCAP). The relative incidences of CAP and HCAP among patients requiring hospital admission is not well described. The objective of this retrospective cohort study, involving 639 patients with culture-positive CAP and HCAP admitted between 1 January 2003 and 31 December 2005, was to characterize the incidences, microbiology, and treatment patterns for CAP and HCAP among patients requiring hospital admission. HCAP was more common than CAP (67.4% versus 32.6%). The most common pathogens identified overall included methicillin-resistant Staphylococcus aureus (24.6%), Streptococcus pneumoniae (20.3%), Pseudomonas aeruginosa (18.8%), methicillin-sensitive Staphylococcus aureus (13.8%), and Haemophilus influenzae (8.5%). The hospital mortality rate was statistically greater among patients with HCAP than among those with CAP (24.6% versus 9.1%; P < 0.001). Administration of inappropriate initial antimicrobial treatment was statistically more common among HCAP patients (28.3% versus 13.0%; P < 0.001) and was identified as an independent risk factor for hospital mortality. Our study found that the incidence of HCAP was greater than that of CAP among patients with culture-positive pneumonia requiring hospitalization at Barnes-Jewish Hospital. Patients with HCAP were more likely to initially receive inappropriate antimicrobial treatment and had a greater risk of hospital mortality. Health care providers should differentiate patients with HCAP from those with CAP in order to provide more appropriate initial antimicrobial therapy.

Vancomycin is effective against methicillin-resistant Staphylococcus aureus and has been widely used in the past few years. However, several recent reports have highlighted the limitations of vancomycin, and its role in the management of serious infections is now being reconsidered. Vancomycin treatment failure rates are associated with an increase in the minimum inhibitory concentration as well as a decrease in the rate of bacterial killing. The intrinsic limitations of vancomycin also include poor tissue penetration, particularly in the lung; relatively slow bacterial killing; and the potential for toxicity. In addition, intermediate-level vancomycin resistance has emerged among staphylococci, as have rare cases of fully resistant strains. Because of these problems, when using vancomycin, it is probably prudent to carefully establish the diagnosis, test for antimicrobial susceptibility, and monitor serum trough concentrations to ensure adequate dosing.

Objective: The goal of this investigation was to determine whether more aggressive vancomycin dosing is associated with greater risk for renal toxicity in patients with health care‐associated pneumonia (HCAP) attributed to methicilllin-resistant Staphylococcus aureus (MRSA). Methods: This was a retrospective, single-center, observational cohort study. The following information was obtained for all study patients from automated hospital, microbiology, and pharmacy databases: age, sex, weight, serial serum creatinine (SCr), ageand sex-adjusted creatinine clearance (CrCl) during receipt of vancomycin, vancomycin serum trough concentrations, duration of vancomycin therapy, and Acute Physiology and Chronic Health Evaluation II scores. Renal toxicity was defined as either a 0.5-mg/dL increase from baseline in SCr or a ≥50% increase in SCr based on serial SCr measurements. Data for patients who met the definition of renal toxicity were compared with data for those who did not. Results: Ninety-four patients (mean [SD] age, 59.0 [15.6] years; 59 [62.8%] men; 73 (77.7%) white; mean baseline CrCl, 70.3 [23.0] mL/min) were identified as having MRSA HCAP. Forty (42.6%) patients developed renal toxicity. Patients who developed renal toxicity were significantly more likely than patients who did not develop renal toxicity to have greater mean vancomycin serum trough concentrations (20.8 [9.9] µg/mL vs 14.3 [6.7] µg/mL, respectively; P < 0.001), vancomycin serum trough concentrations ≥15 µg/mL (67.5% vs 40.7%; P = 0.01), and a prolonged duration (≥14 days) of vancomycin treatment (45.0% vs 20.4%; P = 0.011). Logistic regression analysis identified a maximum vancomycin serum trough concentration of ≥15 µg/mL as being independently associated with renal toxicity (adjusted odds ratio = 2.82; 95% CI, 1.02‐7.74; P = 0.045). The overall mean change in CrCl for the study population was ‐13.5 (‐16.0) mL/min (range, 0.0 to ‐62.6 mL/min). Patients with maximum measured vancomycin serum trough concentrations ≥15 µg/mL (n = 49) had significantly greater absolute changes in CrCl compared with patients with maximum measured vancomycin serum trough concentrations

Objective To determine the financial impact of a sepsis protocol designed for use in the emergency department. Design Retrospective analysis of a before-after study testing the implications of sepsis protocol. Setting Academic, tertiary care hospital in the United States. Patients Persons with septic shock presenting to the emergency department. Interventions A multifaceted protocol developed from recent scientific literature on sepsis and the Surviving Sepsis Campaign. The protocol emphasized identification of septic patients, aggressive fluid resuscitation, timely antibiotic administration, and appropriateness of antibiotics, along with other adjunctive, supportive measures in sepsis care. Measurements and main results We compared patients treated before the protocol with those cared for after the protocol was implemented. Overall hospital costs represented the primary end point, whereas hospital length of stay served as a secondary end point. All hospital costs were calculated based on charges after conversion to costs based on department-specific cost-to-charge ratios. We also attempted to measure the independent impact of the protocol on costs through linear regression. We conducted a sensitivity analysis assessing these end points in the subgroup of subjects who survived their hospitalization. The total cohort included 120 subjects (evenly divided into the before and after cohorts) with a mean age of 64.7 +/- 18.2 yrs and median Acute Physiology and Chronic Health Evaluation II score of 22.5 +/- 8.3. There were more survivors following the protocol's adoption (70.0% vs. 51.7%, p = .040). Median total costs were significantly lower with use of the protocol ($16,103 vs. $21,985, p = .008). The length of stay was also on average 5 days less among the postintervention population (p = .023). A Cox proportional hazard model indicated that the protocol was independently associated with less per-patient cost. Restricting the analysis to only survivors did not appreciably change our observations. Conclusions Use of a sepsis protocol can result not only in improved mortality but also in substantial savings for institutions and third party payers. Broader implementation of sepsis treatment protocols represents a potential means for enhancing resource use while containing costs.

To identify predictors of 28-day mortality among patients with refractory septic shock treated with norepinephrine with or without vasopressin.Prospective observational cohort study.A 1,200-bed academic medical center.One hundred thirty-seven patients with septic shock treated with norepinephrine with or without vasopressin.None.The 28-day mortality rate was 37.2% (n = 51). By multivariate analysis, significant predictors of death were norepinephrine plus vasopressin administration (adjusted odds ratio [AOR], 13.96; 95% confidence interval [CI] 6.47, 30.08; p = 0.001), lack of goal-directed fluid administration during initial resuscitation (AOR 15.82; 95% CI 6.16, 40.61; p = 0.003), inappropriate initial antimicrobial therapy (AOR 8.95; 95% CI 2.93, 27.33; p = 0.05), and higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (AOR 1.14; 95% CI 1.07, 1.21; p = 0.033). Patients who received norepinephrine plus vasopressin (n = 68) had a significantly higher mortality rate than patients managed with norepinephrine alone (n = 69) 28 days after the initiation of vasopressors (54.4% vs. 20.3%; p0.001). This finding was confirmed in patients matched optimally across treatment groups.Our study found an association between the use of norepinephrine plus vasopressin and 28-day mortality in refractory septic shock. In view of its known mechanism of action, vasopressin contributed to this excess mortality. Further recommendations regarding the use of vasopressin await the results of large randomized trials evaluating its efficacy and safety for septic shock.

Study Objective. To identify predictors of in-hospital mortality among patients with bacteremia caused by Enterobacter cloacae, Enterobacter aerogenes, or Citrobacter freundii. Design. Retrospective cohort study. Setting. 1300-bed tertiary academic medical center. Patients. One hundred twenty-four patients who had bloodstream infections caused by E. cloacae (3), E. aerogenes (71), or C. freundii (50) between 1998 and 2004. Measurements and Main Results. Data from patients with bloodstream infections caused by Enterobacter sp or C. freundii were retrospectively segregated according to hospital survival (98 survivors, 26 nonsurvivors). Multiple patient characteristics and processes of care were evaluated to identify factors contributing to in-hospital mortality. Multiple logistic regression was performed based on univariate comparisons to determine independent risk factors for in-hospital mortality. Among the 124 cases of bacteremia, the crude in-hospital mortality rate was 21% (26 cases). Univariate analysis revealed that survivors were more likely to receive an aminoglycoside as part of their empiric antimicrobial regimen (40% [39/98]) compared with nonsurvivors (19% [5/26], p=0.05). Other factors related to antimicrobial therapy including choice and number of agents used did not differ between survivors and nonsurvivors (p>0.05). Vasopressor use (31% [30/98] vs 62% [16/26]), care in an intensive care unit (19% [19/98] vs 54% [14/26]), and acute renal failure (13% [13/98] vs 31% [8/26]) occurred more frequently in nonsurvivors (p

Introduction Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in pneumonia. Bacteremia may secondarily complicate MRSA pneumonia. The epidemiology and outcomes associated with bacteremia in the setting of MRSA pneumonia are unknown. We sought to describe the prevalence of bacteremia in MRSA pneumonia and its impact on hospital mortality and length of stay (LOS). Methods We conducted a single-center retrospective cohort study (2008–2013) including adult patients hospitalized with pneumonia caused by MRSA. We defined pneumonia based on clinical criteria and all cases were culture confirmed. MRSA bacteremia was identified based on positive blood cultures. Pneumonia was categorized as either community-onset (CO, occurring at presentation or within 2 days of admission) or hospital-onset (HO, occurring > 2 days after admission). We compared bacteremic and non-bacteremic groups with respect to their demographic and clinical characteristics and outcomes. A logistic regression and a generalized linear model (GLM) were constructed to examine the impact of bacteremia on hospital mortality and post-pneumonia onset LOS, respectively. Results Among the 765 patients with MRSA pneumonia (33.1 % CO), 93 (12.2 %) had concurrent bacteremia (37.6 % CO). Patients with bacteremia were similar to non-bacteremic subjects based on demographic and clinical characteristics with the exception of frequency of a hospitalization within prior 180 days (48.4 % bacteremic and 37.7 % non-bacteremic, p = 0.047), prevalence of chronic liver disease (17.2 % vs. 9.5 %, p = 0.030), and the mean APACHE II score at the onset of pneumonia (17.5 ± 6.0 vs. 16.1 ± 6.0, p = 0.045). Both unadjusted mortality (33.7 % vs. 23.8 %, p = 0.067) and median post-pneumonia LOS (18.2 vs. 12.2 days, p < 0.001) were greater in the bacteremic than the non-bacteremic group. In a logistic regression, bacteremia showed a trend toward an association with increased mortality (odds ratio 1.56, 95 % confidence interval 0.93 to 2.61). Concomitant bacteremia was independently associated with a 10.3-day increase in the post-pneumonia hospital LOS (95 % confidence interval 6.7 to 13.9 days). Conclusions Concurrent bacteremia occurred with moderate frequency in the setting of hospitalization with MRSA pneumonia. Although bacteremia did not appear to independently impact mortality, this was likely due to our study’s limited sample size. However, bacteremia complicating MRSA pneumonia added between 1 and 2 weeks to the hospital LOS.

This was a randomized controlled pilot study of Lactobacillus rhamnosus GG versus standard of care to prevent gastrointestinal multidrug-resistant organism colonization in intensive care unit patients. Among 70 subjects, there were no significant differences in acquisition or loss of any multidrug-resistant organisms (P>.05) and no probiotic-associated adverse events.Infect. Control Hosp. Epidemiol. 2015;36(12):1451–1454

Infections with multidrug-resistant organisms (MDROs) are common in critically ill patients and are challenging to manage appropriately. Strategies that can be used in the treatment of MDRO infections in the intensive care unit (ICU) include combination therapy, adjunctive aerosolized therapy, and optimization of pharmacokinetics with higher doses or extended-infusion therapy as appropriate. Rapid diagnostic tests could assist in improving timely appropriate antimicrobial therapy for MDRO infections in the ICU.

Background Hospital readmission occurs often and is difficult to predict. Polypharmacy has been identified as a potential risk factor for hospital readmission. However, the overall impact of the number of discharge medications on hospital readmission is still undefined. Methods To determine whether the number of discharge medications is predictive of thirty-day readmission using a retrospective cohort study design performed at Barnes-Jewish Hospital from January 15, 2013 to May 9, 2013. The primary outcome assessed was thirty-day hospital readmission. We also assessed potential predictors of thirty-day readmission to include the number of discharge medications. Results The final cohort had 5507 patients of which 1147 (20.8 %) were readmitted within thirty days of their hospital discharge date. The number of discharge medications was significantly greater for patients having a thirty-day readmission compared to those without a thirty-day readmission (7.2 ± 4.1 medications [7.0 medications (4.0 medications, 10.0 medications)] versus 6.0 ± 3.9 medications [6.0 medications (3.0 medications, 9.0 medications)]; P

OBJECTIVETo describe and compare the mortality associated with nosocomial pneumonia due to Pseudomonas aeruginosa (Pa-NP) according to pneumonia classification (community-onset pneumonia [COP], hospital-acquired pneumonia [(HAP], and ventilator-associated pneumonia [VAP]).DESIGNWe conducted a retrospective cohort study of adults with Pa-NP. We compared mortality for Pa-NP among patients with COP, HAP, and VAP and used logistic regression to identify risk factors for hospital mortality and inappropriate initial antibiotic therapy (IIAT).SETTINGTwelve acute care hospitals in 5 countries (United States, 3; France, 2; Germany, 2; Italy, 2; and Spain, 3).PATIENTS/PARTICIPANTSA total of 742 patients with Pa-NP.RESULTSHospital mortality was greater for those with VAP (41.9%) and HAP (40.1%) compared with COP (24.5%) (PCONCLUSIONSAmong patients with Pa-NP, pneumonia classification identified patients with different risks for hospital mortality. Specific risk factors for hospital mortality also differed by pneumonia classification and multidrug resistance appeared to be an important risk factor for IIAT. These findings suggest that pneumonia classification for P. aeruginosa identifies patients with different mortality risks and specific risk factors for outcome and IIAT.Infect Control Hosp Epidemiol 2015;36(10):1190–1197

BACKGROUND Acinetobacter baumannii (AB) has evolved a variety of resistance mechanisms and exhibits unpredictable susceptibility patterns, making it difficult to select empiric therapy. OBJECTIVE To examine US secular trends in the resistance of AB in respiratory infections and blood stream infections (BSI) to antimicrobial agents whose effectiveness is supported in the literature DESIGN Survey. METHODS We analyzed 3 time periods (2003–2005, 2006–2008, 2009–2012) in Eurofins' The Surveillance Network for resistance of AB to the following antimicrobials: carbapenems (imipenem, meropenem, doripenem), aminoglycosides (tobramycin, amikacin), tetracyclines (minocycline, doxycycline), polymyxins (colistin, polymyxin B), ampicillin-sulbactam, and trimethoprim-sulfamethoxazole. Resistance to ≥3 drug classes defined multidrug resistance (MDR). RESULTS We identified 39,320 AB specimens (81.1% respiratory, 18.9% BSI). The highest prevalence of resistance was to doripenem (90.3%) followed by trimethoprim-sulfamethoxazole (55.3%), and the lowest to colistin (5.3%). Resistance to carbapenems (21.0% in 2003–2005 and 47.9% in 2009–2012) and colistin (2.8% in 2006–2008 to 6.9% in 2009–2012) more than doubled. Prevalence of MDR AB rose from 21.4% in 2003 to 2005 to 33.7% in 2006 to 2008, and remained stable at 35.2% in 2009 to 2012. In contrast, resistance to minocycline diminished from 56.5% (2003–2005) to 30.5% (2009–2012). MDR organisms were most frequent in nursing homes (46.5%), followed by general ward (29.2%), intensive care unit (28.7%), and outpatient setting (26.2%). CONCLUSIONS Resistance rates among AB to such last-resort antimicrobials as carbapenems and colistin are on the rise, whereas that to minocycline has declined. Nursing homes are a reservoir of resistant AB. These trends should inform not only empiric treatment of serious infections, but also approaches to infection control. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine.

With decreasing mortality in sepsis, attention has shifted to longer-term consequences associated with survivorship. Thirty-day readmission as a component of healthcare utilization is an important outcome.To examine the frequency of and risk factors for 30-day readmission among patients surviving sepsis.Single-center retrospective cohort.We examined 30-day readmission risk among survivors of hospitalization with culture-positive severe sepsis or septic shock. Extended spectrum β-lactamase (ESBL) organisms were identified via molecular laboratory testing. Healthcare-associated (HCA) was defined by 1 of the following: (1) recent hospitalization, (2) immune suppression, (3) nursing home residence, (4) hemodialysis, (5) prior antibiotics, and (6) index bacteremia hospital-acquired (onset2 days following admission). Acute kidney injury (AKI) was defined according to the RIFLE (Risk, Injury, Failure, Loss, End-stage) criteria. Logistic regression modeled predictors of 30-day readmission.Among 1697 sepsis survivors, 543 (32.0%) required 30-day readmission. Readmitted patients had a higher chronic (median Charlson score 5 vs 4, P0.001) but not acute (median APACHE [Acute Physiology and Chronic Health Evaluation] II score 15 and 15, P = 0.275) illness burden, and higher prevalence of HCA sepsis (94.2% vs 90.2%, P = 0.014) than nonreadmitted survivors. In logistic regression, 3 factors increased (Organism: ESBL [odds ratio {OR}: 4.50, 95% confidence interval {CI}: 1.43-14.19], RIFLE: Injury or RIFLE: Failure [OR: 1.95, 95% CI: 1.300-2.93], and Organism: Bacteroides spp [OR: 2.04, 95% CI: 1.06-3.95]) and 2 reduced (Urine [OR: 0.58, 95% CI: 0.35-0.98], Organism: Escherichia coli [OR: 0.49, 95% CI: 0.27-0.90]) the odds of 30-day readmission.One-third of survivors of severe sepsis/septic shock required 30-day readmission. Mild-to-moderate AKI nearly doubled its risk.

There are few data regarding mechanical ventilation and ARDS in the ED. This could be a vital arena for prevention and treatment.This study was a multicenter, observational, prospective, cohort study aimed at analyzing ventilation practices in the ED. The primary outcome was the incidence of ARDS after admission. Multivariable logistic regression was used to determine the predictors of ARDS.We analyzed 219 patients receiving mechanical ventilation to assess ED ventilation practices. Median tidal volume was 7.6 mL/kg predicted body weight (PBW) (interquartile range, 6.9-8.9), with a range of 4.3 to 12.2 mL/kg PBW. Lung-protective ventilation was used in 122 patients (55.7%). The incidence of ARDS after admission from the ED was 14.7%, with a mean onset of 2.3 days. Progression to ARDS was associated with higher illness severity and intubation in the prehospital environment or transferring facility. Of the 15 patients with ARDS in the ED (6.8%), lung-protective ventilation was used in seven (46.7%). Patients who progressed to ARDS experienced greater duration in organ failure and ICU length of stay and higher mortality.Lung-protective ventilation is infrequent in patients receiving mechanical ventilation in the ED, regardless of ARDS status. Progression to ARDS is common after admission, occurs early, and worsens outcome. Patient- and treatment-related factors present in the ED are associated with ARDS. Given the limited treatment options for ARDS, and the early onset after admission from the ED, measures to prevent onset and to mitigate severity should be instituted in the ED.ClinicalTrials.gov; No.: NCT01628523; URL: www.clinicaltrials.gov.

To highlight the clinical importance of ventilator-associated pneumonia (VAP) in an era of escalating antimicrobial resistance.VAP continues to be an important infection in the critically ill. The development of rapid microbiologic diagnostics and new antimicrobial agents offer opportunities for improved treatment strategies for VAP balancing the need to treat effectively in a timely manner and antimicrobial stewardship. Additionally, the new surveillance definitions for assessing the quality of care in critically ill patients (ventilator-associated events, ventilator-associated conditions, and infection-related ventilator-associated conditions) do not appear to be adequate surrogates for the identification of VAP.Clinicians caring for critically ill patients should be aware of the importance of correctly treating VAP. As new diagnostic technologies and antimicrobials become available for VAP, their incorporation into routine patient management should occur in a way that optimizes patient outcomes wherein minimizing further emergence of antimicrobial resistance.

Introduction Pseudomonas aeruginosa nosocomial pneumonia (Pa-NP) is associated with considerable morbidity, prolonged hospitalization, increased costs, and mortality. Methods We conducted a retrospective cohort study of adult patients with Pa-NP to determine 1) risk factors for multidrug-resistant (MDR) strains and 2) whether MDR increases the risk for hospital death. Twelve hospitals in 5 countries (United States, n = 3; France, n = 2; Germany, n = 2; Italy, n = 2; and Spain, n = 3) participated. We compared characteristics of patients who had MDR strains to those who did not and derived regression models to identify predictors of MDR and hospital mortality. Results Of 740 patients with Pa-NP, 226 patients (30.5%) were infected with MDR strains. In multivariable analyses, independent predictors of multidrug-resistance included decreasing age (adjusted odds ratio [AOR] 0.91, 95% confidence interval [CI] 0.96-0.98), diabetes mellitus (AOR 1.90, 95% CI 1.21-3.00) and ICU admission (AOR 1.73, 95% CI 1.06-2.81). Multidrug-resistance, heart failure, increasing age, mechanical ventilation, and bacteremia were independently associated with in-hospital mortality in the Cox Proportional Hazards Model analysis. Conclusions Among patients with Pa-NP the presence of infection with a MDR strain is associated with increased in-hospital mortality. Identification of patients at risk of MDR Pa-NP could facilitate appropriate empiric antibiotic decisions that in turn could lead to improved hospital survival.

Antimicrobial-resistant organisms are an emerging problem in the ICU. Therapy cycling empiric antibiotics between various classes may influence bacterial resistance patterns. Understanding the impact of cycling on the appropriate treatment of suspected Gram-negative infections is important.Data were prospectively collected on patients who were admitted to a 19-bed medical ICU (MICU). A total of 1,172 patients were admitted to the MICU for48 h and were evaluated during a 28.5-month period. After 4.5 months of baseline data collection, an antibiotic-cycling protocol was implemented, using four different antibiotic classes with Gram-negative activity that were cycled every 3 to 4 months. Therapy was considered to be inappropriate if the subsequent bacterial isolate was resistant to the empiric drug used.There were 59 bloodstream infections (BSIs), 17 ventilator-associated pneumonias (VAPs), and 101 urinary tract infections (UTIs) involving Gram-negative bacteria among 139 patients. Fifty-five infections (31%) were due to Gram-negative bacteria resistant to one or more antibiotic agents (BSIs, 18 [30%]; VAPs, 4 [23%]; and UTIs, 33 [33%]). Fifteen patients received inappropriate empiral therapy for 18 resistant Gram-negative infections (BSIs, 7 [39%]; VAPs, 3 [75%]; UTIs, 8 [24%]). Patients receiving inappropriate therapy were more likely to die (10 patients [67%] vs 40 patients [32%], respectively; p0.01). There was no difference in the receipt of appropriate empirical antibiotic therapy during the baseline compared to cycling (infectious episodes, 15% vs 10%, respectively; p = 0.4).Antimicrobial resistance occurred in almost 30% of ICU infections involving Gram-negative bacteria. Antibiotic cycling was not associated with significant changes in the receipt of appropriate empirical antimicrobial therapy for the treatment of ICU infections.

To evaluate a standardized hospital order set for the management of septic shock in the emergency department.Before-after study design with prospective consecutive data collection.Emergency department of a 1,200-bed academic medical center.A total of 120 patients with septic shock.Implementation of a standardized hospital order set for the management of septic shock.A total of 120 consecutive patients with septic shock were identified. Sixty patients (50.0%) were managed before the implementation of the standardized order set, constituting the before group, and 60 (50.0%) were evaluated after the implementation of the standardized order set, making up the after group. Demographic variables and severity of illness measured by the Acute Physiology and Chronic Health Evaluation II were similar for both groups. Patients in the after group received statistically more intravenous fluids while in the emergency department (2825 +/- 1624 mL vs. 3789 +/- 1730 mL, p = .002), were more likely to receive intravenous fluids of20 mL/kg body weight before vasopressor administration (58.3% vs. 88.3%, p.001), and were more likely to be treated with an appropriate initial antimicrobial regimen (71.7% vs. 86.7%, p = .043) compared with patients in the before group. Patients in the after group were less likely to require vasopressor administration at the time of transfer to the intensive care unit (100.0% vs. 71.7%, p.001), had a shorter hospital length of stay (12.1 +/- 9.2 days vs. 8.9 +/- 7.2 days, p = .038), and a lower risk for 28-day mortality (48.3% vs. 30.0%, p = .040).Our study found that the implementation of a standardized order set for the management of septic shock in the emergency department was associated with statistically more rigorous fluid resuscitation of patients, greater administration of appropriate initial antibiotic treatment, and a lower 28-day mortality. These data suggest that the use of standardized order sets for the management of septic shock should be routinely employed.