Clinical Impact of the Revised 2019 CLSI Levofloxacin Breakpoints in Patients with Enterobacterales Bacteremia

Background The Clinical and Laboratory Standards Institute (CLSI) revised the fluoroquinolone minimal inhibitory concentration (MIC) breakpoints for Enterobacterales in 2019, based on pharmacokinetic/pharmacodynamic analyses. However, clinical evidence supporting these breakpoints revision is limited. Methods A retrospective cohort was conducted at 3 hospitals in Taiwan between January 2017 and March 2019. Patients treated with levofloxacin for Enterobacterales bacteremia with high-MIC (1 or 2 μg/mL; levofloxacin-susceptible by pre-2019 CLSI breakpoints) were compared with those with low-MIC (≤0.5 μg/mL; levofloxacin-susceptible by 2019 CLSI breakpoints) to assess therapeutic effectiveness in multivariable logistic regression. The primary outcome was 30-day mortality and the secondary outcome was the emergence of levofloxacin-resistant isolates within 90 days after levofloxacin initiation. Results A total of 308 patients were eligible in the study. Kaplan-Meier analysis showed that patients infected with high-MIC isolates (n=63) had a significantly lower survival rate compared with those infected with low-MIC isolates (n=245) (p=0.001). Multivariable logistic regression revealed high levofloxacin MIC was a predictor of 30-day mortality [odds ratio (OR) 6.05, 95% confidence interval (CI) 1.51-24.18, p=0.011]. We consistently found similar result in propensity-score matched cohort (OR 5.38, 95%CI 1.06-27.39, p=0.043). The emergence of levofloxacin-resistant isolates was likely more common in the high-MIC group compared to the low-MIC group (7.5% vs. 25.0%, p=0.065). An estimated AUC/MIC ratio≥ 87 was significantly associated with better survival (p=0.002). Conclusions Patients with high levofloxacin MICs within the pre-2019 CLSI susceptible range of 1 or 2 μg/mL were associated with higher mortality compared to those with MICs ≤0.5 μg/mL.

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Incidence of Secondary Microorganism Infections Following Utilization of Tocilizumab for the Treatment of COVID‑19 - A Matched Retrospective Cohort Study

10.54137/ijiid1782 ◽

2021 ◽

Vol 1 (1) ◽

Author(s):

Joanna L. Moore ◽

Stephanie J. Stroever ◽

Patricia E. Rondain ◽

Robyn N. Scatena

Keyword(s):

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Secondary Infection ◽

World Health ◽

Quantitative Relation ◽

Secondary Outcome ◽

Healthcare Associated Infection ◽

Kaplan Meier ◽

Healthcare Associated

Introduction: immunological disorder agent’s area unit theorized to focus on the protein storm syndrome in COVID‑19. However, the downstream effects concerning susceptibilities to secondary infection risk stay unknown. This study seeks to work out risk variations for secondary infections among COVID‑19 patients World Health Organization did and failed to receive tocilizumab. Methods: we have a tendency to conducted a matched retrospective cohort study from 2 giants, acute care hospitals in Western Connecticut from March 1 to May 31, 2020. we have a tendency to collected variables exploitation manual case history abstraction. the first exposure variable was any dose of tocilizumab. the first outcome was any healthcare‑associated microorganism or mycosis as outlined by the National Care Safety Network. we have a tendency to performed a Kaplan–Meier analysis to assess the crude distinction within the additive likelihood of healthcare‑associated infection (HAI) across exposure teams. we have a tendency to conjointly performed a multivariable Cox multivariate analysis to work out the hazard quantitative relation for HAI by exposure group whereas dominant for potential confounders. Results: The Kaplan–Meier analysis incontestable no distinction within the additive likelihood of HAI across teams. The adjusted hazard of HAI for patients given tocilizumab was zero.85 times that of patients not given tocilizumab (95% confidence interval = zero.29, 2.52, P = 0.780) once dominant for relevant confounders. Conclusions: Tocilizumab failed to increase the incidence of secondary infection among COVID‑19 patients. Larger, irregular trials ought to valuate infection as a secondary outcome to validate this finding.

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Abstract 9086: Sex Differences in the Association Between Bystander CPR and Survival for Patients With Out-of-Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.144.suppl_2.9086 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Kiok Ahn ◽

Bryan McNally ◽

Paul Chan

Keyword(s):

Logistic Regression ◽

Cardiac Arrest ◽

Significant Interaction ◽

National Registry ◽

Republic Of Korea ◽

Secondary Outcome ◽

Multivariable Logistic Regression ◽

Bystander Cpr ◽

The Republic ◽

Hospital Cardiac Arrest

Background: Bystander cardiopulmonary resuscitation (CPR) is associated with a better survival outcome in patients with out-of-hospital cardiac arrest (OHCA). However, there may be cultural barriers in performing high-quality bystander CPR in women in some non-Western countries and the effect of bystander CPR on survival outcomes may differ by patients’ sex. Methods: Using data between 2012-2018 from a national OHCA registry from the Republic of Korea, we identified adult patients with OHCA of presumed cardiac etiology. The main exposures were bystander CPR and patients’ sex. The primary outcome was survival discharge and the secondary outcome was favorable neurological survival. Multivariable logistic regression evaluated the association between bystander CPR and survival, adjusted for patients’ age, sex, socio-economic status, year of arrest, witnessed arrest status, initial OHCA rhythm, location of arrest, urbanization level of arrest location, and type of bystander. The interaction between bystander CPR and sex was explicitly evaluated in the models. Results: Of 101,505 patients with OHCA in the cohort, 34,124 (33.6 %) were women and 67,381 (64.4 %) were men. Bystander CPR was performed on 18,481 (54.2%) women and 35,904 (53.3%) men (p=0.07). Unadjusted rates of survival discharge were 4.5% in women and 9.5 % in men (p<0.001), and rates of favorable neurological survival were 2.5% in women and 6.4% in men (p<0.001). In multivariable logistic regression models, there was a significant interaction (p=0.005) between bystander CPR and sex for survival to discharge, with an adjusted OR for bystander CPR of 1.16 (95% CI: 1.08-1.23) in men and 0.91 (95% CI: 0.80-1.02) in women. For favorable neurological survival, there was also a significant interaction (p=0.01) between sex and bystander CPR, with an adjusted OR for bystander CPR of 1.47 (95% CI: 1.36-1.60) in men and 1.16 (95% CI: 0.98- 1.37) in women. Conclusions: In a national registry of OHCA from the Republic of Korea, men who received bystander CPR were more likely to survive whereas women who received bystander CPR were not.

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ECMO Transport without Physicians or Additional Clinicians

Prehospital and Disaster Medicine ◽

10.1017/s1049023x20001272 ◽

2020 ◽

pp. 1-7

Author(s):

Anna Condella ◽

Jeremy B. Richards ◽

Michael A. Frakes ◽

Christian J. Grant ◽

Jason E. Cohen ◽

...

Keyword(s):

Cohort Study ◽

Adverse Events ◽

Nurse Practitioner ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Primary Outcome ◽

Secondary Outcome ◽

Hub And Spoke ◽

Current Guidelines ◽

Major Adverse Events

Abstract Background: Extracorporeal membrane oxygenation (ECMO) has accelerated rapidly for patients in severe cardiac or respiratory failure. As a result, ECMO networks are being developed across the world using a “hub and spoke” model. Current guidelines call for all patients transported on ECMO to be accompanied by a physician during transport. However, as ECMO centers and networks grow, the increasing number of transports will be limited by this mandate. Objectives: The aim of this study was to compare rates of adverse events occurring during transport of ECMO patients with and without an additional clinician, defined as a physician, nurse practitioner (NP), or physician assistant (PA). Methods: This is a retrospective cohort study of all adults transported while cannulated on ECMO from 2011-2018 via ground and air between 21 hospitals in the northeastern United States, comparing transports with and without additional clinicians. The primary outcome was the rate of major adverse events, and the secondary outcome was minor adverse events. Results: Over the seven-year study period, 93 patients on ECMO were transported. Twenty-three transports (24.7%) were accompanied by a physician or other additional clinician. Major adverse events occurred in 21.5% of all transports. There was no difference in the total rate of major adverse events between accompanied and unaccompanied transports (P = .91). Multivariate analysis did not demonstrate any parameter as being predictive of major adverse events. Conclusions: In a retrospective cohort study of transports of ECMO patients, there was no association between the overall rate of major adverse events in transport and the accompaniment of an additional clinician. No variables were associated with major adverse events in either cohort.

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Predictors of Ustekinumab Failure in Crohn’s Disease After Dose Intensification

Inflammatory Bowel Diseases ◽

10.1093/ibd/izaa282 ◽

2020 ◽

Author(s):

Rahul S Dalal ◽

Cheikh Njie ◽

Jenna Marcus ◽

Sanchit Gupta ◽

Jessica R Allegretti

Keyword(s):

Logistic Regression ◽

Crohn’S Disease ◽

Crohn's Disease ◽

Cox Regression ◽

Laboratory Data ◽

Perianal Disease ◽

Secondary Outcome ◽

Opioid Use ◽

Dose Intensification ◽

Multivariable Logistic Regression

Abstract Background Many patients with Crohn’s disease (CD) who lose response to the standard ustekinumab dose interval of every 8 weeks (q8w) undergo dose intensification to q4w or q6w. However, baseline factors that predict success or failure after dose intensification are unknown. We sought to identify predictors of failure of ustekinumab after dose intensification for patients with CD. Methods This was a retrospective cohort study of adult CD patients undergoing ustekinumab dose intensification at a tertiary referral center between January 1, 2016, and January 31, 2019. Electronic health records were reviewed to obtain patient demographics, CD history, and laboratory data. The primary outcome was failure to achieve corticosteroid-free remission (Harvey-Bradshaw Index <5) within 12 months after intensification. The secondary outcome assessed was time to new biologic therapy after dose intensification. We used multivariable logistic regression and Cox regression to identify predictors of these outcomes. Results We included 123 patients who underwent ustekinumab dose intensification to q4w (n = 64), q5w (n = 1), q6w (n = 55), or q7w (n = 3). Multivariable logistic regression demonstrated that perianal disease, Harvey-Bradshaw Index, and opioid use at time of intensification were associated with failure to achieve remission. Cox regression demonstrated that perianal disease and corticosteroid use at time of intensification were associated with shorter time to a new biologic. Conclusion Perianal disease, Harvey-Bradshaw Index, current opioid use, and current corticosteroid use are associated with ustekinumab failure after dose intensification in CD. Larger, prospective studies are needed to corroborate these findings and guide therapeutic strategies for patients who lose response to standard ustekinumab dosing.

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Prognostic significance of occlusion length in recanalized chronic total occlusion lesion: a retrospective cohort study with 5-year follow-up

BMJ Open ◽

10.1136/bmjopen-2020-038302 ◽

2020 ◽

Vol 10 (7) ◽

pp. e038302

Author(s):

Tao Tian ◽

Changdong Guan ◽

Lijian Gao ◽

Lei Song ◽

Jiansong Yuan ◽

...

Keyword(s):

Cohort Study ◽

Primary Endpoint ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Chronic Total Occlusion ◽

Secondary Outcome ◽

Total Occlusion ◽

Risk Of Death ◽

Kaplan Meier

ObjectivesThis study sought to investigate the relationship between occlusion length and long-term outcomes of patients with recanalised chronic total occlusion (CTO) lesion.DesignA retrospective cohort study.SettingFuwai Hospital, National Center for Cardiovascular Disease, Beijing, ChinaParticipantsConsecutive patients with successfully recanalised CTO were included from January 2010 to December 2013.Primary and secondary outcome measuresThe primary endpoint of the present study was a composite event of all-cause death and myocardial infarction (MI). The secondary endpoints included target lesion revascularisation (TLR) and target vessel revascularisation (TVR).ResultsA total of 1987 patients were included and 1801 (90.6%) subjects completed 5-year follow-up in this study. Based on occlusion length, the patients were divided equally into two groups: short (length <15 mm, n=957) and long (length ≥15 mm, n=1030) CTO group. Kaplan-Meier survival curve showed no significant difference in the risk of the composite primary endpoint between short and long CTO groups (p=0.242). Receiver operating characteristic curve analysis also established occlusion length ≥15 mm as a cut-off value for predicting TLR and TVR, with an area under the curve of 0.604 (95% CI: 0.569 to 0.638, p<0.001) and 0.605 (95% CI: 0.572 to 0.638; p<0.001). Kaplan-Meier analysis revealed that the risks for TLR (p=0.002) and TVR (p=0.002) were higher in a patient with long CTO lesion. Multivariate Cox analysis also identified long CTO lesion as an independent predictor of TLR (HR: 1.539, 95% CI: 1.033 to 2.293; p=0.034) and TVR (HR: 1.476, 95% CI: 1.012 to 2.151; p=0.043).ConclusionPatients with long CTO lesion did not show a higher risk of death and MI after recanalisation, but had higher risks of TLR and TVR. Lesion with occlusion length ≥15 mm should be under close surveillance for restenosis after recanalisation.

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Dose addition of intravenous metronidazole to oral vancomycin improve outcomes in Clostridioides difficile infection?

Clinical Infectious Diseases ◽

10.1093/cid/ciz1115 ◽

2019 ◽

Cited By ~ 7

Author(s):

Ying Wang ◽

Aaron Schluger ◽

Jianhua Li ◽

Angela Gomez-Simmonds ◽

Hojjat Salmasian ◽

...

Keyword(s):

Logistic Regression ◽

Primary Outcome ◽

Time Window ◽

Dual Therapy ◽

Secondary Outcome ◽

Index Test ◽

Oral Vancomycin ◽

Clostridioides Difficile ◽

Improved Outcomes ◽

Clostridioides Difficile Infection

Abstract Background Guidelines recommend adding intravenous (IV) metronidazole to oral vancomycin for fulminant Clostridioides difficile infection (CDI). This study compared dual therapy with IV metronidazole and oral vancomycin versus vancomycin monotherapy. It assessed prevalence of use and effectiveness of dual therapy in non-fulminant and fulminant CDI. Methods This was a two-center retrospective study conducted from 2010 to 2018. Adult inpatients were included if they had a positive C. difficile PCR performed on an unformed stool and received oral vancomycin within two days (either before or after) of testing. Patients were classified as having received dual therapy if IV metronidazole was given within the same time window, and otherwise as having received vancomycin monotherapy. The primary outcome was death or colectomy within 90 days after the index test. Logistic regression modeling was used to adjust for CDI severity and other established predictors of CDI outcomes. CDI recurrence was examined as a secondary outcome, adjusting for death as a competing risk. Results The study included 2,114 patients (dual therapy: 993; monotherapy: 1,121) of whom 23% met the primary outcome. There was no association between dual therapy and the primary outcome (adjusted OR (aOR) 1.07, 95% CI 0.79-1.45) which remained true when the analysis was restricted to patients with fulminant CDI (aOR 1.17, 95% CI 0.65-2.10). There was also no association between dual therapy and CDI recurrence. Conclusions Dual therapy with IV metronidazole and oral vancomycin was common for non-fulminant and fulminant CDI, but was not associated with improved outcomes compared to vancomycin alone.

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Retrospective cohort study of compliance with post-deployment screening in the Canadian Armed Forces

BMJ Open ◽

10.1136/bmjopen-2019-029355 ◽

2019 ◽

Vol 9 (7) ◽

pp. e029355 ◽

Cited By ~ 1

Author(s):

Peter J H Beliveau ◽

David Boulos ◽

Dylan Johnson

Keyword(s):

Mental Health ◽

Retrospective Cohort ◽

Primary Outcome ◽

Mental Health Problems ◽

Armed Forces ◽

Health Problems ◽

Service Members ◽

Canadian Armed Forces ◽

Kaplan Meier ◽

Probabilistic Sample

ObjectiveCanadian Armed Forces (CAF) personnel who return from certain international deployments are required to complete post-deployment screening (PDS) 90 to 180 days post-deployment; the primary goal of PDS is early detection of mental health problems that aims for reduced delays to care provision. We investigated service members’ compliance with the PDS completion requirement and the factors associated with this compliance; a secondary objective was to investigate completion timing.DesignThe study used a retrospective cohort of CAF personnel (n=28 460) who had deployments over 01 January 2009 to 31 December 2014; inferences were based on a probabilistic sample (n=3004).Primary outcomeThe primary outcome was PDS completion. We assessed the timing of PDS completion, comparing non-compliant (early, late or no completion) with compliant completions (90 to 180 days post-deployment) among deployments that required screening. Kaplan-Meier plots summarised time-to-completion and logistic regression assessed the covariate associations with compliant completion. Covariate-adjusted marginal compliance prevalence differences (MPD) were computed.Results67.3% (95% CI65.0 to 69.6) of deployments that required PDS had one completed; 43.3% (95%CI 40.6 to 46.0) were completed within the compliant period. Compliant completion was higher with lower ranks (MPD=10.6%, relative to officers), combat arms occupations (MPD=8.4%), Afghanistan deployments (MPD=19.2%), longer deployments (MPD=10.1%) and among those without a past mental health problem (MPD=9.7%).ConclusionsOur findings suggest that some selective processes may be occurring where those perceived to be at higher risk for post-deployment mental health problems are more compliant with PDS completion. However, PDS completion and compliant completion were lower than expected and this suggests a need to reinforce instruction on the guidelines and objectives of PDS among service members in the CAF.

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Influence of Living Alone or with a Spouse Only on the Short-Term Prognosis in Patients after an Acute Ischemic Stroke

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17218223 ◽

2020 ◽

Vol 17 (21) ◽

pp. 8223

Author(s):

Yohei Ishikawa ◽

Toru Hifumi ◽

Mitsuyoshi Urashima

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Odds Ratio ◽

Retrospective Cohort ◽

Primary Outcome ◽

Living Alone ◽

Secondary Outcome ◽

Cardiovascular Risks ◽

Stroke Patients ◽

Short Term

Background—This study aimed to explore whether living alone or with a spouse only affects the short-term prognosis of acute ischemic stroke patients. Methods—We conducted a retrospective cohort study of patients with a diagnosis of acute ischemic stroke from April 2014 to February 2019 in Japan. The primary outcome was defined as worsening by at least one grade on the modified Rankin Scale (mRS). The secondary outcome was set as the degree of worsening on the mRS. The outcomes were compared between three groups of patients: (1) those living alone (ALONE), (2) those living with their spouse only (SPOUSE), and (3) OTHERs. Results—In total, 365 patients were included in this study: 111 (30%) ALONE, 133 (36%) SPOUSE, and 121 (33%) OTHERs. Cardiogenic embolisms were observed more frequently in ALONE than in OTHERs. The primary outcome occurred in 88 (79.3%) patients in ALONE and in 96 (72.2%) patients in SPOUSE, both of which were higher than the 72 (59.5%) in OTHERs. After adjusting with 19 variables, the risk of worsening was higher in ALONE (odds ratio (OR): 2.90, 95% confidence interval (CI): 1.50–5.58) and SPOUSE (OR: 1.83, 95% CI: 1.00–3.33) compared with OTHERs. Conclusions—In patients with acute ischemic stroke, not only living alone but also living with a spouse only may be associated with a worse short-term prognosis, independent of other cardiovascular risks.

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Heart Rate n-Variability (HRnV) Measures for Prediction of Mortality in Sepsis Patients Presenting at the Emergency Department

10.1101/2020.12.26.20248866 ◽

2021 ◽

Author(s):

Nan Liu ◽

Marcel Lucas Chee ◽

Mabel Zhi Qi Foo ◽

Jeremy Zhenwen Pong ◽

Dagang Guo ◽

...

Keyword(s):

Heart Rate ◽

Logistic Regression ◽

Risk Stratification ◽

Regression Model ◽

Logistic Regression Model ◽

Primary Outcome ◽

Univariable Analysis ◽

Sepsis Mortality ◽

Multivariable Logistic Regression Model ◽

Multivariable Logistic Regression

AbstractBackgroundSepsis is a potentially life threatening condition that requires prompt recognition and treatment for optimal outcomes. There is little consensus on an objective way to assess for sepsis severity and risk for mortality. In recent years, heart rate variability (HRV), a measure of the cardiac autonomic regulation derived from short electrocardiogram tracings, has been found to correlate with sepsis mortality, and its use as a prognostic variable and for risk stratification has been promising. In this paper, we present using novel heart rate n-variability (HRnV) measures for sepsis mortality risk prediction and compare against current mortality prediction scores.MethodsThis study was a retrospective cohort study on a convenience sample of patients presenting to the emergency department (ED) of Singapore General Hospital between September 2014 to April 2017. Patients were included in the study if they were above 21 years old, were suspected to have sepsis by their attending physician, triaged as emergency or urgent cases, and if they met two or more of the Systemic Inflammatory Response Syndrome (SIRS) criteria. Demographic and clinical variables were obtained from the electronic medical records, and HRV and novel HRnV parameters were calculated from five minute ECG tracings. Univariable analysis was conducted on variables obtained, with the primary outcome being 30-day in-hospital mortality (IHM). Variables selected through univariable analysis and stepwise selection were included in a multivariable logistic regression model, the results of which were presented using receiver operating curve (ROC) analysis.ResultsOf 342 patients included for final analysis, 66 (19%) met with the primary outcome. On univariable analysis, 85 out of 142 analysed HRV and HRnV parameters showed statistical difference between groups. The final multivariable logistic regression model comprised of 21 variables including four vital signs, two HRV parameters, and 15 HRnV parameters. The area under the curve (AUC) of the model was 0.86 (95% confidence interval 0.81-0.90), outperforming several established clinical scores.ConclusionThe use of novel HRnV measures can provide adequate power to predictive models in the risk stratification of patients presenting to the ED with sepsis. When included in a multivariable logistic regression model, the HRnV-based model outperformed traditional risk stratification scoring systems. The HRnV measures may have potential to allow for a rapid, objective, and accurate means of patient risk stratification for sepsis severity and mortality.

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Thromboprophylaxis in Adults With Atrio-Pulmonary Fontan

World Journal for Pediatric and Congenital Heart Surgery ◽

10.1177/2150135118772837 ◽

2018 ◽

Vol 9 (5) ◽

pp. 504-508

Author(s):

Adam J. Small ◽

Jamil A. Aboulhosn ◽

Gentian Lluri

Keyword(s):

Primary Outcome ◽

Adult Congenital Heart Disease ◽

Fontan Operation ◽

Primary Prophylaxis ◽

Secondary Outcome ◽

Thromboembolic Prophylaxis ◽

Kaplan Meier ◽

Preventative Strategy ◽

Adult Congenital ◽

Secondary Outcomes

Background: Although aspirin has been compared to warfarin for thromboembolic prophylaxis in the general Fontan population, little is known about the optimal preventative strategy for the atriopulmonary right atrium–pulmonary artery [RA-PA]) Fontan particularly. Methods: A retrospective cohort study was performed including adult patients identified in the Ahmanson/UCLA Adult Congenital Heart Disease Center database with a history of RA-PA Fontan and use of either aspirin or warfarin as most recent primary prophylaxis against thromboembolism. Primary outcome was incident thromboembolism, defined as space-occupying lesion on imaging consistent with thrombus within the Fontan or pulmonary arterial circuit. Secondary outcomes were death, transplantation, Fontan conversion, and bleeding requiring either transfusion or invasive intervention. Follow-up was terminated upon achievement of a primary outcome or achievement of a secondary outcome other than bleeding. Kaplan-Meier analysis of freedom from thrombosis was performed. Results: Twenty-six patients met inclusion criteria. Thirteen (50%) received aspirin as most recent primary prophylaxis and 13 (50%) received warfarin. Tricuspid atresia was the most common underlying diagnosis (42%), followed by double-inlet left ventricle (38%). Median age at Fontan operation was 8.2 years; median age at prophylaxis initiation was 25.9 years. After six years, the aspirin group had 50% ± 35% freedom from thrombosis and the warfarin group 92% ± 8% ( P = .15). Incidences of secondary outcomes were not significantly different between the groups. Conclusion: In this cohort of long-term Fontan survivors with RA-PA Fontan, the risk of thromboembolic complications is high, especially in those taking aspirin rather than warfarin. Larger studies are needed to confirm these findings.

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