FREE ELECTRONIC LIBRARY - Dissertations, online materials

Pages:     | 1 |   ...   | 8 | 9 || 11 | 12 |


-- [ Page 10 ] --

Severity of illness contributes to risk of HAI development. Based on the multivariate model, every one point increase in APACHE II score there is a 3.4% increase in the risk of developing HAI. APACHE II scores range from 0 to 71 with a higher scores associated with a worse outcome.38 The APACHE II has been correlated with baseline inflammatory response but not HAI development.12 Patients with a higher severity of illness require a higher level of care. These patients are potentially exposed to a higher risk due to the presence of more invasive devices and also have a higher exposure to multiple hospital personnel and equipment needed to provide their care. For each additional invasive device there was a 9.1% reduced risk in the development of HAI. This does not make intuitive sense. It is likely that the format of the invasive device score used in the model is problematic and additional models will be explored using only the number of invasive devices present at the time of HAI, rather than the cumulative score. Table 4-6 provides the cumulative invasive device score at the time of HAI (52.8 ± 26.7) and Table 4-8 provides the cumulative invasive device score at ICU discharge (23.9 ± 23.0) for those who did not develop HAI. More investigation is needed to fully assess these findings.

We found that early antibiotic use prior to ICU stay reduces risk of HAI in patients with sepsis. The importance of early antibiotic use has been incorporated into several guidelines. The surviving sepsis campaign recommends antibiotics within the first hour for septic shock.26 The IDSA recommends antibiotic administration in the ER prior to ICU admission for patients with CAP.55 In this study, we examined whether patients received antibiotics before transfer to the ICU. The early administration of antibiotics reduces morality associated with sepsis and may, according to Zubert, be a “surrogate marker for quality of care in the broader sense”. 129 While early antibiotic use is important, appropriately deescalating therapy based on culture sensitivities is also important.130 The presence of IL6 rs1800795 CC compared to GG and GC compared to GG had a higher risk in the univariate mode, and the risk increased in the multivariate model when controlling for other variables. The final model included only variables that were significant (p 0.05). The higher risk associated with rs1800795 genotypes CG and CC is consistent with higher risk associated with the C allele noted in the literature. The rs1800795 C Allele has also been found to be associated with late blood stream infections in African American infants,128 and has been shown to be more prevalent in coronary artery patients developing myocardial infarction compared to coronary artery patients with stable and unstable angina.131 More analysis is needed to fully explore the relationships of these variables.

–  –  –

Study strengths are summarized below:

1. This study occurred in a teaching hospital where the attending physicians and medical team rotate monthly; however, the MICU team include a PharmD who is present for daily rounds with the team in the morning and afternoon on Monday through Friday. This provides consistency in patient management in regards to the appropriate use, selection, and dosing of antibiotics in the ICU. This PharmD reviewed cultures and antibiotics with me to determine appropriate antibiotics based on current guidelines.

2. This study occurred in one facility, limiting the biases that could occur at multiple sites by multiple data collectors.

3. The inclusion of biomarkers and use in a multivariate model strengthens conclusions about risk factors associated with development of HAI.

–  –  –

Study limitations are summarized below:

1. A potential limitation of this study was the heterogeneous sample. Some patients were not as sick as others and were discharged from the ICU prior to three days.

Since development of HAI has been strongly associated with length of stay, this is a limitation that was accounted for by using Cox regression modeling.

2. Limiting this study to a single site with primarily older male veterans limits generalizability of findings.

3. It was a major assumption that baseline systemic inflammation would be prolonged. Measuring only baseline cytokine levels is a limitation.

4. The usage of corticosteroid therapy may impact the degree and duration of systemic inflammation; thus, potentially limiting the possible impact of systemic inflammation on the development of HAI in participants receiving corticosteroids.

5. The use of corticosteroids may limit fever among participants experiencing HAI, and may result in failure to detect HAI when they occur. It is recommended clinical practice in our ICU to use sepsis surveillance, and thus a high degree of suspicion when steroids are used.

6. There may be other predisposing factors for development of HAI that were not measured.

7. The investigator is a novice bench researcher, and although efforts were made to accurately follow protocols, it is possible that errors could have influenced results.

8. Endpoint genotyping of rs1800896 required manual calls in seven samples.

9. Interleukin 6 was selected as a proinflammatory cytokine; however, it does have some anti-inflammatory properties.


This study provides important insights into risk factors that contribute to the development of HAI in patients presenting to the ICU with sepsis. These findings may impact nursing and other critical care clinician practice first by helping to identify patients at risk, then implementing stricter targeted infection control practices in efforts to prevent development of HAIs (in addition to current standard and recommended practices). JACHO patient safety goals include prevention of HAI.

Since the completion of this study, new processes are in place in the facility where this study occurred. These including daily surveillance of central line sites and implementation of a UTI bundle to reduce UTI. The findings of this study reveal a need to further investigate the cause of Candida in this population and to follow-up on the incidence of Candida in this unit. The use of antibiotic timing and duration should be reviewed. A high percentage (9 of 11, 81.8%) of the Candida infections occurred during corticosteroids use, indicating a need to assure appropriate sepsis surveillance is followed in patients receiving corticosteroids. Specific nursing measures would include a review of standard IV care practices such as tubing changes, site rotation for peripheral lines, duration of central lines, routine site evaluation and care, hub care, cleaning of IV equipment, cleaning of transducer holders, and no re-use of disposable pressure bags.

This may include changing the catheter hub after blood draws when flushing cannot completely clear the hub as well as protocol driven hub care.

Cleaning the environment closest to the patient needs to be considered. The side rails, call light, bed controls, and equipment in use in the room are typically only cleaned when they become soiled. These items could be wiped down with sanitary wipes daily when other areas of the room are cleaned. Cleaning of other environmental areas would include routine cleaning of medication carts, including the front of medication drawers, keyboard, scanner, and the work surface. Routine cleaning of the sink handles and light switches should also be evaluated.


This study provides evidence of a genetic risk for development of HAI. Despite best evidenced based practices some patients will develop HAI. Strict aseptic technique is essential to preventing infection. In addition to eliminating invasive devices as quickly as possible, patients with a high severity of illness may need to be isolated to lower their risk. Early administration of antibiotics not only provides prompt treatment for the initial infection but also lowers risk for subsequent infections.


1. Ylipalosaari P, Ala-Kokko TI, Laurila J, Ohtonen P, Syrjala H. Epidemiology of intensive care unit (ICU)-acquired infections in a 14-month prospective cohort study in a single mixed Scandinavian university hospital ICU. Acta Anaesthesiologica Scandinavica 2006;50:1192-7.

2. Ylipalosaari P, Ala-Kokko TI, Laurila J, Ohtonen P, Syrjala H. Intensive care acquired infection is an independent risk factor for hospital mortality: a prospective cohort study. Critical Care 2006;10:R66.

3. Munford RS. Sepsis and Septic Shock. In: Fauci AS, Braunwald E, Isselbacher

KJ, et al., eds. Harrison's Principles of Internal Medicine. 14 ed. New York, NY:

McGraw-Hill Health Professions Division; 1998:776-80.

4. Tolley E. Causal Modeling of Infection in the Activated Host: Implications for Clinical Investigaton in Sepsis and Acute Respiratory Distress Syndrome. Sepsis 2000;4:21-33.

5. Osmon S, Warren D, Seiler SM, Shannon W, Fraser VJ, Kollef MH. The influence of infection on hospital mortality for patients requiring 48 h of intensive care. Chest 2003;124:1021-9.

6. Darouiche RO. Device-associated infections: a macroproblem that starts with microadherence. Clinical Infectious Diseases 2001;33:1567-72.

7. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infection Control Hospital Epidemiology 2000;21:510-5.

8. Rosenthal VD, Maki DG, Salomao R, et al. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Annals of Internal Medicine 2006;145:582-91.

9. McCusker ME, Perisse AR, Roghmann MC. Severity-of-illness markers as predictors of nosocomial infection in adult intensive care unit patients. American Journal of Infection Control 2002;30:139-44.

10. Fernandez-Crehuet R, Diaz-Molina C, de Irala J, Martinez-Concha D, SalcedoLeal I, Masa-Calles J. Nosocomial infection in an intensive-care unit:

identification of risk factors. Infection Control Hospital Epidemiology 1997;18:825-30.

11. Gogos CA, Drosou E, Bassaris HP, Skoutelis A. Pro- versus anti-inflammatory cytokine profile in patients with severe sepsis: a marker for prognosis and future therapeutic options. Journal Infectious Diseases 2000;181:176-80.

12. Kinasewitz GT, Yan SB, Basson B, et al. Universal changes in biomarkers of coagulation and inflammation occur in patients with severe sepsis, regardless of causative micro-organism [ISRCTN74215569]. Critical Care (London, England) 2004;8:R82-90.

13. Villar J, Maca-Meyer N, Perez-Mendez L, Flores C. Bench-to-bedside review:

understanding genetic predisposition to sepsis. Critical Care (London, England) 2004;8:180-9.

14. Holmes CL, Russell JA, Walley KR. Genetic polymorphisms in sepsis and septic shock: role in prognosis and potential for therapy. Chest 2003;124:1103-15.

15. Stuber F, Klaschik S, Lehmann LE, Schewe JC, Weber S, Book M. Cytokine promoter polymorphisms in severe sepsis. Clinical Infectious Diseases 2005;41 Suppl 7:S416-20.

16. Dahmer MK, Randolph A, Vitali S, Quasney MW. Genetic polymorphisms in sepsis. Pediatric Critical Care Medicine 2005;6:S61-73.

17. Wurfel MM, Gordon AC, Holden TD, et al. Toll-like receptor 1 polymorphisms affect innate immune responses and outcomes in sepsis. American Journal of Respiratory and Critical Care Medicine 2008.

18. Arcaroli J, Fessler MB, Abraham E. Genetic polymorphisms and sepsis. Shock (Augusta, Ga) 2005;24:300-12.

19. Papathanassoglou ED, Giannakopoulou MD, Bozas E. Genomic variations and susceptibility to sepsis. AACN Advanced Critical Care 2006;17:394-422.

20. Segal S, Hill AV. Genetic susceptibility to infectious disease. Trends in Microbiology 2003;11:445-8.

21. Burgner D, Jamieson SE, Blackwell JM. Genetic susceptibility to infectious diseases: big is beautiful, but will bigger be even better? The Lancet Infectious Diseases 2006;6:653-63.

22. van der Poll T, Opal SM. Host-pathogen interactions in sepsis. The Lancet Infectious Diseases 2008;8:32-43.

23. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR.

Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Critical Care Medicine 2001;29:1303-10.

24. Umberger R, Thompson C, Muthiah M, Meduri GU. Patients admitted to ICU with sepsis are more likely to develop nosocomial infections. Chest 2008;134(suppl) e479.

25. Janeway CA, Travers P, Walport M, Shlomchik MJ. Immunobiology - the immune system in health and disease. 6 ed. New York, NY: Garland Science Publishing; 2005.

26. Dellinger RP, Carlet JM, Masur H, et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Critical Care Medicine 2004;32:858-73.

27. Otero RM, Nguyen HB, Huang DT, et al. Early goal-directed therapy in severe sepsis and septic shock revisited: concepts, controversies, and contemporary findings. Chest 2006;130:1579-95.

28. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. The New England Journal of Medicine 2001;345:1368-77.

29. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992;101:1644-55.

30. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Critical Care Medicine 2003;31:1250Angus DC, Burgner D, Wunderink R, et al. The PIRO concept: P is for predisposition. Critical Care (London, England) 2003;7:248-51.

32. Gerlach H, Dhainaut JF, Harbarth S, Reinhart K, Marshall JC, Levy M. The PIRO concept: R is for response. Critical Care (London, England) 2003;7:256-9.

33. Vincent JL, Opal S, Torres A, Bonten M, Cohen J, Wunderink R. The PIRO concept: I is for infection. Critical Care (London, England) 2003;7:252-5.

Pages:     | 1 |   ...   | 8 | 9 || 11 | 12 |

Similar works:

«ITALY 2012 HUMAN RIGHTS REPORT EXECUTIVE SUMMARY Italy is a multiparty parliamentary democracy with a bicameral parliament consisting of the Chamber of Deputies and the Senate. The constitution vests executive authority in the Council of Ministers, headed by the prime minister, who is the president of the council. The president of the republic, who is the head of state, nominates the prime minister after consulting with the leaders of all political forces in parliament. International observers...»

«Detection and Prevention of Melanoma Guest Expert: David Leffell, MD Professor of Dermatology and Surgery CEO, Yale Medical Group www.wnpr.org www.yalecancercenter.org Welcome to Yale Cancer Center Answers with Dr. Ed Chu and Dr. Ken Miller. I am Bruce Barber. Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and Dr. Miller is a medical oncologist specializing in pain and palliative care and he also serves as Director of the Connecticut Challenge Survivorship...»

«KNOW who you’re dealing with. Crime Prevention.starts with you The Interac logo is a registered trade-mark of Interac Inc. Used under licence. THE ONTARIO MESSAGE FROM ASSOCIATION OF CHIEFS OF POLICE Safe and healthy communities play a big part in making Ontario a great place to live. Keeping Ontarians safe requires all of us – law enforcement, governments, businesses, community groups, and individuals – to work together. As Ontario’s police leaders, we strongly believe in community...»

«Multi-centre randomised controlled trial of clinical and cost-effectiveness of drug coated balloons, drug eluting stents and plain balloon angioplasty with bail-out bare metal stent revascularisation strategies for severe limb ischaemia due to femoropopliteal disease BAlloon vs Stenting in Severe Ischaemia of the Leg-3 TRIAL PROTOCOL: Version 2.0, 22nd January 2016 Sponsor: University of Birmingham Chief Investigator: Professor Andrew Bradbury Coordinating Centre: Birmingham Clinical Trials...»

«University of Pécs, Faculty of Health Sciences Head of the Doctoral School: Prof. Dr. József Bódis Rector and Member of the Hungarian Academy of Sciences Limited Forensic Assessability of Soft Tissue Injuries. Contrastive Terminological Analyses of Hungarian, Austrian and German Medical Diagnostic Reports PhD Dissertation Katalin Fogarasi Head of the Doctoral Programme: Prof. Dr. Gábor Kovács L. Regular Member of the Hungarian Academy of Sciences Supervisors: Dr. Gábor Rébék-Nagy, Head...»

«P.E.I. (Personal Efficiency Index): a note to the Good Livers by Giulia Loli Dictating lifestyle, even though on my dark days is a tendency I have to beat back like a brushfire, is not on my agenda. The Personal Efficiency Index can only serve as a gauge and Intervention Guide (to borrow from the World Health Organization), for how can one teach conscience? These two words side by side already negate each other. There is nothing to teach, only to use what already exists, somewhere interred,...»

«European Medicines Agency Evaluation of Medicines for Human Use London, 27 July 2006 Doc.Ref.: EMEA/CHMP/87018/2006 This product was later resubmitted to the EMEA. See here for information on the outcome of the resubmission REFUSAL CHMP ASSESSMENT REPORT FOR Valdoxan International Nonproprietary Name: Agomelatine Procedure No. EMEA/H/C/656 This Assessment Report is the CHMP Assessment Report with all commercially confidential information removed. 7 Westferry Circus, Canary Wharf, London, E14...»

«A brief guide to emerging infectious diseases and zoonoses WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. A brief guide to emerging infectious diseases and zoonoses.1. Communicable Diseases, Emerging 2. Zoonoses – epidemiology – prevention and control.3. Virus Diseases. 4. Bacterial Infections. 5. Parasitic Diseases. 6. Pest Control ISBN 978-92-9022-458-7 (NLM classification: WA 110) © World Health Organization 2014 All rights...»

«COMPANY BACKGROUNDER Over 40 years ago Galaxy Nutritional Foods Inc. created the cheese alternative category and is proud to remain America’s leading provider of great tasting cheese-free products. Today, under Galaxy’s new brand GO VEGGIE, the company continues to innovate and offer consumers with food sensitivities or seeking healthier alternatives more cheese-free choices. Across its product portfolio – Lactose Free, Lactose & Soy Free and Dairy Free & Vegan – GO VEGGIE offers 55...»

«An Investigation of Factors Impacting on the Retention of Radiographers in KwaZulu-Natal Submitted in fulfilment of the requirements of the Master of Health Sciences in Radiography Durban University of Technology. Muchui Julius Thambura Student No. 21143607 March 2016 Supervisor: Mrs Lynda Swindon (MEd HE) BTech: Rad (D)) Date: Co-supervisor: Dr FI Peer (DTech: Rad, MTech: Rad, BTech: Rad (NM)) Date: ABSTRACT An Investigation of Factors Impacting on the Retention of Radiographers in...»

«Get Healthy/Stay Healthy Recipes Created, adapted and taste-tested by Bessie Jo Tillman, MD Five to ten servings of delicious, colorful, nutritious vegetables per day keeps the doctor away! Bessie Jo Tillman, MD http://naturalhealingcookbook.com Page 1 Copyright 2012 Enjoy life promoting recipes to help your body reverse the ravages of degenerative diseases. They also help you maintain optimal health. When it comes to food you either choose life or death, a slow, insidious downward spiral to...»

«8 Elite 8D/Lite Version 8 Zone Controller Arrowhead Alarm Products Ltd Operating Guide Proudly Designed and Manufactured in New Zealand CONTENTS Page No. INTRODUCTION 4 About your Alarm 4 OPERATING YOUR ALARM 5 General Information 5 Arming the Alarm 5 Disarming the Alarm 5 Arming in Stay Mode 6 Disarming Stay Mode 6 Bypassing Zones 7 Manual Panic, Medical & Fire Alarms 8 Resetting Alarms 8 PROGRAMMING YOUR ALARM 9 Getting into Program Mode 9 Exiting Program Mode 9 Adding or Deleting User Codes...»

<<  HOME   |    CONTACTS
2016 www.dissertation.xlibx.info - Dissertations, online materials

Materials of this site are available for review, all rights belong to their respective owners.
If you do not agree with the fact that your material is placed on this site, please, email us, we will within 1-2 business days delete him.