Journal of Clinical Infectious Diseases & Practice
Open Access

Antimicrobial use; Clinical teaching units; Infections; Internal medicine

Introduction

Intense administration of traumatic neurological wounds, counting spinal rope harm (SCI), and of nontraumatic neurological occasions has progressed impressively in later a long time. In terms of traumatic wounds, there has been critical enhancement in administration at the mishap location and amid the time of exchange to the healing centre. Wounds that within the past would have caused passing some time recently or amid exchange can presently be overseen so that the quiet comes to the clinic lively. At the healing center, enhancements in ventilatory and cardiovascular back, as well as administration of acute intracranial insuperable within the seriously care setting have too had a striking effect on survival [1].

After stabilization of intense wounds or nontraumatic neurological infection, the tremendous lion's share of patients requires a period of intense inpatient restoration. Be that as it may, since the survival rate is moving forward for patients with traumatic brain harm or SCI, patients exchanged to intense recovery units may be more intensely sick than within the past. For illustration, among 6 governmentally financed demonstrate frameworks for the care of patients with SCI [2], there was a noteworthy diminish from 1973 through 1986 within the number of days of intense care some time recently exchange to a restoration unit. In expansion, the execution of imminent repayment by diagnosisrelated bunches has moreover contributed to the shortening of intense healing center remains.

Prospective infection control surveillance at our hospital has revealed that the largest reservoir of patients with antibiotic-resistant organisms is in the acute inpatient rehabilitation unit. On the basis of these observations, it is hypothesized that acute severity of illness may be an important predictor of the development of nosocomial infection among patients admitted for the first time to an acute rehabilitation unit.

To our information, as it were 3 distributed think about have characterized the study of disease transmission of nosocomial disease in intense recovery units. These consider were worn out the 1980s or early 1990s, and only one consider was performed within the Joined together States. None of them measured intense seriousness of sickness to account for this calculates in distinguishing indicators of nosocomial disease. In expansion, these think about contain small data on the living beings causing nosocomial colonization or disease, counting antibiotic-resistant strains [3].

The study presented in this paper was a prospective study of patients admitted to an acute rehabilitation unit of a public hospital during a 19-month period. For nearly 90% of the patients it was there to begin with affirmation to an intense recovery unit. The destinations of the consider were to depict the study of disease transmission of nosocomial contamination in common and of nosocomial colonization and contamination with antibiotic-resistant life forms. We too wished to pick up an understanding of indicators of nosocomial disease by controlling for useful status and intense seriousness of ailment at the time of confirmation [4].

Methods

This study was performed at the Erie County Medical Center (ECMC), a 300-bed university-affiliated public hospital located in Buffalo, New York. ECMC provides primary and tertiary care facilities for the metropolitan Buffalo region. Although it provides services to the indigent, ECMC has the only level I trauma unit and burn-treatment unit in the area of New York State west of Rochester. The department of rehabilitation medicine is responsible for a 40-bed acute rehabilitation unit at ECMC [5]. This unit is localized in 1 area of the hospital and consists of 2 20-bed wings that share a common nursing station and staff. The unit has single and double rooms, as well as 4-bed rooms.

Nosocomial infection

Nosocomial infection was defined as an infection that was identified >72 h after admission to the rehabilitation unit, in cases in which there was no evidence of incubating infection on admission. Nosocomial infections were identified by use of criteria of the Centers for Disease Control and Prevention, except for urinary tract infection. Definitions for urinary tract infection were those of Gribble and Puterman and were as follows. Significant bacteriuria was defined as growth of an organism in quantities ≥102 cfu/mL in 2 consecutive urine cultures or ≥105 cfu/mL in a single specimen [6]. Definite urinary tract infection was defined as follows: (1) significant bacteriuria in association with fever and suprapubic or flank pain, epididymoorchitis, or periurethral abscess; or (2) bacteremia, with the same organism identified in a urine culture. Possible urinary tract infection was defined as significant bacteriuria with unexplained fever or unexplained autonomic dysreflexia. Asymptomatic bacteriuria was defined as significant bacteriuria in which the criteria for definite or possible urinary tract infection were not met. Patients with asymptomatic bacteriuria were considered to be colonized for the purposes of this study.

Antimicrobial therapy

All patients admitted to the unit during the study were monitored for therapy with antibiotics. The unit amount of an antibiotic was converted into a defined daily dose. Conversion to DDDs allows comparison of agents, even if there is wide disparity in the unit amount prescribed [7]. The number of DDDs of each antibiotic administered was counted, and total antibiotic use for a given patient was the sum of the DDDs. Bacteriologic methods. Cultures ordered by primary care physicians were performed by the ECMC Bacteriology Laboratory, using standard methods to identify all bacteria. Antibiotic susceptibility testing was performed by the disk-diffusion method.

Results

During the 19-month study period, there were 423 admissions to the acute rehabilitation unit; 91of these patients had a primary diagnosis of SCI. Primary causes of SCI were trauma to the spinal cord, spinal stenosis with myelopathy, vertebral osteomyelitis with epidural extension, malignancy involving the spinal cord, spinal cord ischemia, cervical subluxation secondary to rheumatoid arthritis, and other causes [8]. Among the 330 cases without SCI, the most common reasons for admission were traumatic brain injury, acute stroke, multiple traumatic injuries, deconditioning, subarachnoid hemorrhage, cancer, and a miscellaneous group.

Discussion

There are limited data concerning the epidemiology of nosocomial infection among patients admitted for acute rehabilitation after stabilization of an acute medical or neurological event. Nicolle et al. and Henderson et al. identified SCI patients to be at greatest risk for nosocomial infection among patients undergoing treatment in acute rehabilitation units in Canada in the mid-1980s and early 1990s. The most common nosocomial infections were urinary tract infections and skin/soft-tissue infections [9]. However, none of these studies provided specific data on the organisms causing nosocomial infection, and in their analyses none used objective measures of functional status or of acute severity of illness at the time of admission.

Other studies have focused on patients with SCI and specific infections or on specific organisms demonstrating antibiotic resistance. However, the patients evaluated in all of these studies varied from those who were just beginning acute rehabilitation to those who have had chronic disabilities for many years. This variation in characteristics of the patients makes comparisons difficult, especially with patients undergoing acute rehabilitation for the first time, as in the present study.

Finally, it should be noted that the outcome for patients with nosocomial infection in the present study was excellent. Nicolle et al. also found very low mortality among patients with nosocomial infection. It was suggested by these authors that the low mortality was due to the infrequent occurrence of serious infections associated with a poor prognosis, such as pneumonia or bacteremia, and the frequent occurrence of urinary tract infections, for which the prognosis tends to be good. There are also reports of low mortality associated with bacteremia in patients with SCI [10].

Conclusion

In summary, new information about nosocomial colonization and infection in those undergoing acute rehabilitation for the first time has been provided in this report. First, this study clearly defined SCI as an independent risk factor for nosocomial infection, along with acute severity of illness and functional status at the time of admission. Second, gram-positive organisms were the predominant strains causing colonization and infection. Third, MRSA and P. aeruginosa were the resistant organisms most commonly causing nosocomial colonization and infection. Prospective studies of the epidemiology of MRSA in this population are needed, to determine whether eradication of this organism may be justified as a way of reducing the incidence of infection. Nonrandomized studies have indicated that MRSA can be eradicated from some colonized patients with SCI. Fourth; C. difficile was identified as a common cause of nosocomial infection. Last, the findings of this study primarily apply to patients admitted for the first time to an acute rehabilitation unit. This group needs to be distinguished from patients with chronic neurological and nonneurological disabilities. Risk factors for colonization and infection in the latter group may be different from those for patients undergoing their initial acute rehabilitation. Future studies should carefully specify the rehabilitation population being studied.

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