Catheter removal versus retention in the management of catheter-associated enterococcal bloodstream infections

It is unclear whether CVC removal is necessary to successfully manage enterococcal CA-BSI. MEthoDs: A 12-month retrospective cohort study of adults with enterococcal CA-BSI was conducted at a tertiary care hospital; clinical, microbiological and outcome data were collected. rEsuLts: A total of 111 patients had an enterococcal CA-BSI. [37.9]; P=0.03), but similar rates of recurrent bacteremia (nine [11.0%] versus two (7.0%); P=0.7) and a similar post-BSI length of hospital stay (median days [range]) (11.1 [1.7 to 63.1 days] versus 9.3 [1.9 to 31.8 days]; P=0.3). Catheter retention was an independent predictor of mortality (OR 3.34 [95% CI 1.21 to 9.26]). ConCLusIons: To the authors' knowledge, the present article describes the largest enterococcal CA-BSI series to date. Mortality was increased among patients who had their catheter retained. Additional prospective studies are necessary to determine the optimal management of enterococcal CA-BSI. [37, Catheter removal versus retention in the management of catheter-associated enterococcal bloodstream infections The aim of the present study was to examine the epidemiology, treatment and subsequent outcomes of patients with enterococcal CA-BSI, comparing patients with retained versus removed catheters. Our hypothesis was that catheter management does not affect patient outcomes. MEthoDs setting Barnes-Jewish Hospital (BJH), a 1250-bed teaching hospital, is the largest hospital in Missouri (USA), and has a referral base that includes the St Louis Metropolitan area, eastern Missouri and western Illinois. It houses all medical specialties, including a stem cell transplantation unit. BJH is affiliated with the Washington University School of Medicine (St Louis, Missiouri, USA). study design A retrospective cohort study of patients with enterococcal CA-BSIs during their hospital stay was performed. CA-BSI was defined as enterococcal bacteremia in a patient with a central venous catheter (CVC) in place for at least 48 h and no alternative source of infection. The hospital's medical informatics database was queried for blood cultures positive for any Enterococcus species; this dataset was merged with a manually collected dataset of CVC usage in the hospital, which is part of the hospital infection control database. Inclusion and exclusion criteria Adult patients admitted to BJH between January 1, 2006 and December 31, 2006, who presented with, or developed, an enterococcal bloodstream infection and had a CVC present at the time of detection of this infection were included. All types and locations of CVCs were included. Blood cultures were obtained during routine care either peripherally and/or from the CVC. Patients who presented to the hospital with a CVC already in place were included. Patient history and physical examination as well as admitting diagnosis and microbiology results were reviewed to determine whether the catheter was the primary focus of the bacteremia. Patients with a primary focus of bacteremia other than the catheter, patients with a CVC in place for <48 h, and patients who died on the day of the positive blood culture were excluded. Polymicrobial infections were included except concurrent Staphylococcus aureus bacteremia or candidemia within ±3 days of the enterococcal bacteremia (n=20) because both entities are established indications for catheter removal. Data collection Demographic characteristics, medical history, clinical presentation, diagnostic and therapeutic procedures, antibiotic treatment and key markers of outcome (recurrence of bloodstream infection, length of hospital stay after the bloodstream infection, crude mortality) were abstracted from the medical records. Admission Charlson comorbidity and McCabe severity of illness scores were determined. Duration of catheter retention time after the bacteremia was recorded. Information on antibiotic lock therapy was collected; however, this treatment modality was not used in patients from this cohort. Postdischarge mortality at both 30 days and three months after bacteremia was obtained from the Social Security Death Index (www. ssdi-search.com). Definitions Renal insufficiency was defined by a serum creatinine level >132.6 μmol/L. Sepsis and sepsis-induced hypotension were defined using established criteria (13). Appropriate therapy was defined as pathogen-directed treatment with antibiotics matching susceptibilities. A catheter was considered to be retained if it was present for the duration of the hospitalization after the first positive blood culture. Recurrence of bacteremia (used here synonymously with intermittent bacteremia) was defined as a second positive blood culture after ≥1 negative blood culture and an interval of ≥1 day during their hospitalization. Community-onset enterococcal bloodstream infection was defined as having the first positive blood culture drawn within 48 h of hospital admission. Data analysis and statistical methods Data entry was performed using Access and Excel (Microsoft Corporation, USA). Data analysis was performed using SPSS 17 (IBM Corporation, USA). Univariate comparisons among categorical variables and outcome measures were performed using the χ 2 test or Fisher's exact test. A two-sided P <0.05 was considered to be statistically significant. Also calculated was the absolute difference in proportion (∆ p ) of rates of outcome measures including the 95% CI of this difference to describe the precision of this point estimate. Analysis of the difference in proportions and 95% CI enabled the interpretation of statistical significance (if the 95% CI did not cross zero) as well as clinical significance (if the upper limit of the 95% CI exceeded a predefined difference). An absolute difference in recurrence of bacteremia and mortality rates of 15% was considered to represent a clinically significant difference; this estimate was chosen based on previous literature regarding catheter management and clinical experience (14,15). Comparisons among continuous independent variables were performed using the Student's t test or Mann-Whitney U test as appropriate. Variables found to have P<0.1 in univariate testing were considered for entry into a forward, stepwise multivariate logistic regression model. The study was approved by the Washington University Human Research Protection Office (#07-0690). rEsuLts Demographics, comorbidities and clinical presentation There were 111 patients with enterococcal CA-BSI who met inclusion criteria. The mean (± SD) age was 58.2±15.3 years; 56 (50.5%) patients were male; and 77 (69.4%) were white. There were 36 (32%) patients admitted to the oncology/bone marrow transplant service. The most frequent comorbidities were malignancies (n=62 [55.9%]), diabetes (n=35 [31.5%]) and renal insufficiency (n=31 [27.9%]). Twenty-five (22.5%) patients had metastatic solid tumours, 28 (25.2%) had leukemia, six (5.4%) had lymphomas and three (2.7%) had nonmetastatic solid tumours. There were 20 (18%) patients who were neutropenic at the time of bloodstream infection. Of all bloodstream infections, 90 (81%) were hospital-acquired. None of the patients were diagnosed with infective endocarditis during the admission. Microbiology Of the enterococcal bloodstream infections, 45 (40.5%) were caused by E faecalis and 61 (55.0%) by E faecium. Of the bacteremias caused by E faecalis, 10 (22.2%) were due to vancomycin-resistant isolates while 57 (93.4%) of the bacteremias caused by E faecium were vancomycin resistant. An additional five (4.5%) infections were caused by other Enterococcus species. A total of 37 patients (33.3%) had polymicrobial infections in which the most common polymicrobial organism was coagulase-negative Staphylococcus (n=26 [23.4%]). There were 24 (34.9%) polymicrobial E faecalis bacteremias and 10 (27.0%) polymicrobial E faecium bacteremias. Additionally, there was no difference in polymicrobial bacteremias among patients who had their catheter removed versus retained (28 [34.1%] versus nine [31.0%]; P=0.8). Vancomycin-susceptible E faecalis caused 30 (36.6%) of 82 infections in which catheters were removed during the hospitalization and five (17.2%) of 29 infections in which they were retained (P=0.09). Vancomycin-resistant E faecium (VRE) caused 42 (51.2%) of infections in which catheters were removed and 15 (51.7%) in which they were retained (P=0.9). Overall, there was no difference in the number of vancomycin-resistant isolates regardless of whether a catheter was removed Catheter management The CVC was retained during the hospitalization in 29 (26.1%) patients. In univariate analysis, patients with removed CVCs were similar to patients whose CVC was retained DIsCussIon Removal of an intravascular catheter is, with few exceptions, considered to be an essential part of managing CA-BSI. However, robust data to support this approach are only available for a limited number of pathogens responsible for these infections. Despite the lack of sufficient data to provide an evidence-based recommendation with regard to CA-BSI caused by Enterococcus species, national guidelines recommend removing the involved catheters (9). To our knowledge, the present study represents the largest investigation into catheter management and outcomes of enterococcal bloodstream infections. The main finding of the present study was increased mortality in patients whose catheters were retained during the hospitalization. Our findings suggest that catheter removal should be considered to improve patient survival. Also, the difference in the two outcome proportions exceeded the predetermined clinically meaningful difference of 15%, which gives us a quantitative estimate of the impact of catheter removal. The patient groups were very similar with respect to demographic characteristics and comorbidities, including adjunctive antibiotic treatment with the aminoglycoside gentamicin. These findings are congruent with the single study encountered in the scientific literature that scrutinized outcomes of enterococcal CA-BSI and specifically investigated catheter management, albeit in a smaller number of patients (11). There, the authors retrospectively examined 61 enterococcal CA-BSI, with 82% of the episodes due to E faecalis and polymicrobial infections found in 18% of the study population. Of note, they did not exclude patients with concurrent Staphylococcus aureus or yeast bloodstream infections, although these infections likely guided catheter management significantly more than the detection of enterococci. Sandoe et al (11) evaluated whether successful treatment of a bloodstream infection was possible without removal of the catheter, which was achieved in five of 13 cases (38%). If the catheter was removed, the chance for cure was higher (40 of 48 [83%]). They found a combination of a cell wall-active agent with an aminoglycoside to be significantly more effective than monotherapy when the catheter was retained. The authors concluded that, although the removal of the catheter was performed in the majority of cases, it did not appear to be a necessary part of the management as long as antimicrobial treatment was optimized. In our study, even though we did not set cure as an end point, 67 (81.7%) of 82 patients with catheters removed survived the hospital admission and 61 (74.4%) survived at 30 days postbacteremia. These rates were much lower for patients with retained catheters. In summary, these data suggest that although enterococcal CA-BSI are not an absolute indication for catheter removal, removal should be favoured over catheter retention. Reasons for catheter retention may have been that the treating physicians of patients who were severely ill at the time of enterococcal bloodstream infection were reluctant to remove the catheter because it was essential for nonantibiotic medications; that the patients had limited options for alternative intravenous access; or that their comorbidities increased the risk of catheter removal and replacement. Catheter management may have been driven by reasons other than the infection alone, and removing the catheter could have been a lower priority or higher risk in the patients' overall medical management. Because we collected crude mortality data, it is also conceivable that patients died from causes not related to the CA-BSI. Of note, we did not observe a difference in recurrence of infection depending on catheter management; it is possible that the size of the cohort prevented us from noting a statistically significant difference. Our patients are notable for a high percentage of comorbid conditions, including metastatic solid tumours (23%) and leukemia (25%); accordingly, the crude in-hospital mortality rate was high in our study population. An independent factor associated with death was the detection of VRE in the stool, which may be a marker for frequent health care exposure. Despite this finding, CA-BSIs with vancomycinresistant E faecium did not result in increased mortality compared with non-VRE infections. This is different from an earlier prospective study and a more recent meta-analysis, in which vancomycin resistance was found to be associated with increased mortality Limitations of the present study include its retrospective design, the fact that the diagnosis of recurrent infection depended on the treating physician ordering blood cultures and that postdischarge outcomes, including completion of planned antibiotic therapy, follow-up blood cultures, and catheter removal postdischarge, were not studied. In addition, catheter management is potentially influenced by other reasons for retention (difficulty of finding alternative access, bleeding diathesis) and we did not report outcomes for different catheter types. Finally, changes in the usage of daptomycin and linezolid have occurred since the time of the study. Although this was the largest study of enterococcal CA-BSI to date, it is still a relatively small sample to detect rare outcomes. ConCLusIons Based on our study findings, catheter removal is preferable to retention in patients with enterococcal CA-BSI. A large prospective or multicentre study should be performed to identify patients at highest risk for mortality and to add strength to our results. DECLArAtIons: None of the following authors has a conflict of interest to declare: J Marschall, ML Piccirillo, J Doherty

Trigger Finger Release Performed Wide Awake: Prospective Comparison of Local Anesthetics

Introduction: Trigger fi­nger (TF) is one of the most common conditions treated by hand surgeons with a lifetime risk up to 10% in patients with diabetes. If conservative management fails, surgical treatment is undertaken, with or without sedation and a tourniquet, via a small incision to release the A1 pulley. A number of local anesthetics are readily available including Lidocaine, Ropivacaine and Marcaine as well as encapsulated formulations thereof such as Exparel. Since it’s approval in 2011, there have been numerous reports of successfully achieving prolonged pain relief with locally injected Exparel after various procedures, but to the best of our knowledge there have been no reports of its use in ambulatory hand surgery. In this study we prospectively evaluated the efficacy of Lidocaine, Marcaine, or bupivacaine with post-operative Exparel in controlling pain, opioid usage, and adverse reactions following TF surgery

Extragalactic Radio Continuum Surveys and the Transformation of Radio Astronomy

Next-generation radio surveys are about to transform radio astronomy by discovering and studying tens of millions of previously unknown radio sources. These surveys will provide new insights to understand the evolution of galaxies, measuring the evolution of the cosmic star formation rate, and rivalling traditional techniques in the measurement of fundamental cosmological parameters. By observing a new volume of observational parameter space, they are also likely to discover unexpected new phenomena. This review traces the evolution of extragalactic radio continuum surveys from the earliest days of radio astronomy to the present, and identifies the challenges that must be overcome to achieve this transformational change.Comment: To be published in Nature Astronomy 18 Sept 201

Advances in the role of sacral nerve neuromodulation in lower urinary tract symptoms

Sacral neuromodulation has been developed to treat chronic lower urinary tract symptoms, resistant to classical conservative therapy. The suspected mechanisms of action include afferent stimulation of the central nervous system and modulation of activity at the level of the brain. Typical neuromodulation is indicated both in overactivity and in underactivity of the lower urinary tract. In the majority of patients, a unilateral electrode in a sacral foramen and connected to a pulse generator is sufficient to achieve significant clinical results also on long term. In recent years, other urological indications have been explored

A module-based analytical strategy to identify novel disease-associated genes shows an inhibitory role for interleukin 7 Receptor in allergic inflammation

<p>Abstract</p> <p>Background</p> <p>The identification of novel genes by high-throughput studies of complex diseases is complicated by the large number of potential genes. However, since disease-associated genes tend to interact, one solution is to arrange them in modules based on co-expression data and known gene interactions. The hypothesis of this study was that such a module could be a) found and validated in allergic disease and b) used to find and validate one ore more novel disease-associated genes.</p> <p>Results</p> <p>To test these hypotheses integrated analysis of a large number of gene expression microarray experiments from different forms of allergy was performed. This led to the identification of an experimentally validated reference gene that was used to construct a module of co-expressed and interacting genes. This module was validated in an independent material, by replicating the expression changes in allergen-challenged CD4⁺cells. Moreover, the changes were reversed following treatment with corticosteroids. The module contained several novel disease-associated genes, of which the one with the highest number of interactions with known disease genes, <it>IL7R</it>, was selected for further validation. The expression levels of <it>IL7R </it>in allergen challenged CD4⁺cells decreased following challenge but increased after treatment. This suggested an inhibitory role, which was confirmed by functional studies.</p> <p>Conclusion</p> <p>We propose that a module-based analytical strategy is generally applicable to find novel genes in complex diseases.</p

AGT M235T Genotype/Anxiety Interaction and Gender in the HyperGEN Study

BACKGROUND. Both anxiety and elevated heart rate (HR) have been implicated in the development of hypertension. The HyperGen cohort, consisting of siblings with severe and mild hypertension, an age-matched random sample of persons from the same base populations, and unmedicated adult offspring of the hypertensive siblings (N=1,002 men and 987 women), was analyzed for an association of the angiotenisinogen AGTM235T genotype (TT, MT, MM) with an endophenotype, heart rate (HR) in high and low anxious groups. METHODOLOGY. The interaction of AGTM genotype with anxiety, which has been independently associated with hypertension, was investigated adjusting for age, hypertension status, smoking, alcohol consumption, beta blocker medication, body mass index, physical activity and hours of television viewing (sedentary life style). PRINCIPAL FINDINGS. Although there was no main effect of genotype on HR in men or women, high anxious men with the TT genotype had high HR, whereas high anxious men with the MM genotype had low HR. In women, HR was inversely associated with anxiety but there was no interaction with genotype. CONCLUSION/SIGNIFICANCE. The results suggest that high anxiety in men with the TT genotype may increase risk for hypertension whereas the MM genotype may be protective in high anxious men. This type of gene x environment interaction may be one reason why genome wide association studies sometimes fail to replicate. The locus may be important only in combination with certain environmental factors.National Heart, Lung and Blood Institute (UT FC, HL54472, HL54473, HL54495, HL54496, HL54497, HL54509, HL54515

The Association between Hypertension and Depression and Anxiety Disorders: Results from a Nationally-Representative Sample of South African Adults

OBJECTIVE:Growing evidence suggests high levels of comorbidity between hypertension and mental illness but there are few data from low- and middle-income countries. We examined the association between hypertension and depression and anxiety in South Africa. METHODS:Data come from a nationally-representative survey of adults (n = 4351). The Composite International Diagnostic Interview was used to measure DSM-IV mental disorders during the previous 12-months. The relationships between self-reported hypertension and anxiety disorders, depressive disorders and comorbid anxiety-depression were assessed after adjustment for participant characteristics including experience of trauma and other chronic physical conditions. RESULTS:Overall 16.7% reported a previous medical diagnosis of hypertension, and 8.1% and 4.9% were found to have a 12-month anxiety or depressive disorder, respectively. In adjusted analyses, hypertension diagnosis was associated with 12-month anxiety disorders [Odds ratio (OR) = 1.55, 95% Confidence interval (CI) = 1.10-2.18] but not 12-month depressive disorders or 12-month comorbid anxiety-depression. Hypertension in the absence of other chronic physical conditions was not associated with any of the 12-month mental health outcomes (p-values all <0.05), while being diagnosed with both hypertension and another chronic physical condition were associated with 12-month anxiety disorders (OR = 2.25, 95% CI = 1.46-3.45), but not 12-month depressive disorders or comorbid anxiety-depression. CONCLUSIONS:These are the first population-based estimates to demonstrate an association between hypertension and mental disorders in sub-Saharan Africa. Further investigation is needed into role of traumatic life events in the aetiology of hypertension as well as the temporality of the association between hypertension and mental disorders

Ethnicity, sleep, mood, and illumination in postmenopausal women

BACKGROUND: This study examined how ethnic differences in sleep and depression were related to environmental illumination and circadian rhythms. METHODS: In an ancillary study to the Women's Health Initiative, 459 postmenopausal women were recorded for one week in their homes, using wrist monitors. Sleep and illumination experience were estimated. Depression was self-rated with a brief adjective check list. Affective diagnoses were made using the SCID interview. Sleep disordered breathing was monitored with home pulse oximetry. RESULTS: Hispanic and African-American women slept less than European-American women, according to both objective recordings and their own sleep logs. Non-European-American women had more blood oxygen desaturations during sleep, which accounted for 26% of sleep duration variance associated with ethnicity. Hispanic women were much more depressed. Hispanic, African-American and Native-American women experienced less daily illumination. Less daily illumination experience was associated with poorer global functioning, longer but more disturbed sleep, and more depression. CONCLUSIONS: Curtailed sleep and poor mood were related to ethnicity. Sleep disordered breathing was a factor in the curtailed sleep of minority women. Less illumination was experienced by non-European-American women, but illumination accounted for little of the contrasts between ethnic groups in sleep and mood. Social factors may be involved