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Aspiration pneumonia is a common cause of community-acquired and hospital-acquired pneumonias, with a higher mortality rate compared to other types of pneumonia. It is diagnosed based on clinical history and radiographic features, with risk factors including dysphagia and altered level of consciousness. Suggestive radiographic features include a right lower lobe infiltrate on chest radiography, and computed tomography may show bronchopneumonia or bronchiolitis. Routine anaerobic coverage is not necessary, as anaerobic bacteria are not major pathogens in aspiration pneumonia. Treatment should follow the same antibiotic regimen as community or hospital-acquired pneumonia, with additional anaerobic-specific coverage only given to patients with empyema, abscess, or necrosis. Aspiration pneumonitis, which is an acute chemical lung injury, is managed differently and does not require antibiotic therapy. Measures to prevent aspiration pneumonia include swallowing assessments, proper positioning during feeding, texture modification of diet, and mouth care. Gastric tube feeding does not decrease the risk of aspiration or pneumonia.

Background. We assessed the impact of infectious disease (ID) consultation on management and outcome in patients with Staphylococcus aureus bacteremia (SAB). Methods. A retrospective cohort study examined consecutive SAB patients from 6 academic and community hospitals between 2007 and 2010. Quality measures of management including echocardiography, repeat blood culture, removal of infectious foci, and antibiotic therapy were compared between ID consultation (IDC) and no ID consultation (NIDC) groups. A competing risk model with propensity score adjustment was used to compare in-hospital mortality and time to discharge. Results. Of 847 SAB patients, 506 (60%) patients received an ID consultation and 341 (40%) patients did not. Echocardiography was done for 371 (73%) IDC and 191 (56%) NIDC patients (P < .0001) in hospital. Blood cultures were repeated within 2–4 days of bacteremia in 207 (41%) IDC and 107 (31%) NIDC patients (P = .0058). The infectious foci removal rate was not statistically different between the 2 groups. For empiric therapy, 474 (94%) IDC and 297 (87%) NIDC patients received appropriate antibiotics (P = .0013). For patients who finished the planned course of antibiotics, 285 of 422 (68%) IDC and 141 of 262 (54%) NIDC patients received the appropriate duration of antibiotic therapy (P = .0004). In hospital, 204 (24%) patients died: 104 of 506 (21%) IDC and 100 of 341 (29%) NIDC patients. Matched by propensity score, ID consultation had a subdistribution hazard ratio of 0.72 (95% confidence interval [CI], .52–.99; P = .0451) for in-hospital mortality and 1.28 (95% CI, 1.06–1.56; P = .0109) for being discharged alive. Conclusions. ID consultation is associated with better adherence to quality measures, reduced in-hospital mortality, and earlier discharge in patients with SAB.

Background Hospitalized patients are designated alternate level of care (ALC) when they no longer require hospitalization but discharge is delayed while they await alternate disposition or living arrangements. We assessed hospital costs and complications for general internal medicine (GIM) inpatients who had delayed discharge. In addition, we developed a clinical prediction rule to identify patients at risk for delayed discharge. Methods We conducted a retrospective cohort study of consecutive GIM patients admitted between 1 January 2015 and 1 January 2016 at a large tertiary care hospital in Canada. We compared hospital costs and complications between ALC and non-ALC patients. We derived a clinical prediction rule for ALC designation using a logistic regression model and validated its diagnostic properties. Results Of 4311 GIM admissions, 255 (6%) patients were designated ALC. Compared to non-ALC patients, ALC patients had longer median length of stay (30.85 vs. 3.95 days p  < 0.0001), higher median hospital costs ($22,459 vs. $5003 p  < 0.0001) and more complications in hospital (25.5% vs. 5.3% p  < 0.0001) especially nosocomial infections (14.1% vs. 1.9% p  < 0.0001). Sensitivity analyses using propensity score and pair matching yielded similar results. In a derivation cohort, seven significant risk factors for ALC were identified including age > =80 years, female sex, dementia, diabetes with complications as well as referrals to physiotherapy, occupational therapy and speech language pathology. A clinical prediction rule that assigned each of these predictors 1 point had likelihood ratios for ALC designation of 0.07, 0.25, 0.66, 1.48, 6.07, 17.13 and 21.85 for patients with 0, 1, 2, 3, 4, 5, and 6 points respectively in the validation cohort. Conclusions Delayed discharge is associated with higher hospital costs and complication rates especially nosocomial infections. A clinical prediction rule can identify patients at risk for delayed discharge.

It is unclear if a local audit would be useful in providing guidance on how to improve local practice of empiric antibiotic therapy. We performed an audit of antibiotic therapy in bacteremia to evaluate the proportion and risk factors for inadequate empiric antibiotic coverage. This retrospective cohort study included patients with positive blood cultures across 3 hospitals in Hamilton, Ontario, Canada during October of 2019. Antibiotic therapy was considered empiric if it was administered within 24 hours after blood culture collection. Adequate coverage was defined as when the isolate from blood culture was tested to be susceptible to the empiric antibiotic. A multivariable logistic regression model was used to predict inadequate empiric coverage. Diagnostic accuracy of a clinical pathway based on patient risk factors was compared to clinician's decision in predicting which bacteria to empirically cover. Of 201 bacteremia cases, empiric coverage was inadequate in 56 (27.9%) cases. Risk factors for inadequate empiric coverage included unknown source at initiation of antibiotic therapy (adjusted odds ratio (aOR) of 2.76 95% CI 1.27-6.01, P = 0.010) and prior antibiotic therapy within 90 days (aOR of 2.46 95% CI 1.30-4.74, P = 0.006). A clinical pathway that considered community-associated infection as low risk for Pseudomonas was better at ruling out Pseudomonas bacteremia with a negative likelihood ratio of 0.17 (95% CI 0.03-1.10) compared to clinician's decision with negative likelihood ratio of 0.34 (95% CI 0.10-1.22). An audit of antibiotic therapy in bacteremia is feasible and may provide useful feedback on how to locally improve empiric antibiotic therapy.

In this article, five things to know about management of staphylococcus aureus bacteremia in adults are presented. These are the following: 1. Cases in which a blood culture grows Staphylococcus aureus should always be treated as a true bloodstream infection; 2. Expert consultation is suggested for all patients with S. aureus bacteremia; 3. Initial antibiotic therapy for S. aureus bacteremia should be intravenous and tailored to susceptibility once known; 4. All patients with S. aureus bacteremia should undergo thorough evaluation for infectious source and secondary infectious foci; and 5. Patients with S. aureus bacteremia should be treated with at least 2 weeks of antibiotic therapy.

In 2022, the Ontario Ministry of Health recommended preoperative nasal mupirocin and chlorhexidine body wash for Staphylococcus aureus decolonization. This 2025 cross-sectional study of 61 Ontario hospitals showed heterogeneity in decolonization protocols prior to hip and knee arthroplasty. Only 6.6% of hospitals indicated both recommended measures, highlighting an evidence-practice gap.

Background In non-inferiority trials, there is a concern that intention-to-treat (ITT) analysis, by including participants who did not receive the planned interventions, may bias towards making the treatment and control arms look similar and lead to mistaken claims of non-inferiority. In contrast, per protocol (PP) analysis is viewed as less likely to make this mistake and therefore preferable in non-inferiority trials. In a systematic review of antibiotic non-inferiority trials, we compared ITT and PP analyses to determine which analysis was more conservative. Methods In a secondary analysis of a systematic review, we included non-inferiority trials that compared different antibiotic regimens, used absolute risk reduction (ARR) as the main outcome and reported both ITT and PP analyses. All estimates and confidence intervals (CIs) were oriented so that a negative ARR favored the control arm, and a positive ARR favored the treatment arm. We compared ITT to PP analyses results. The more conservative analysis between ITT and PP analyses was defined as the one having a more negative lower CI limit. Results The analysis included 164 comparisons from 154 studies. In terms of the ARR, ITT analysis yielded the more conservative point estimate and lower CI limit in 83 (50.6%) and 92 (56.1%) comparisons respectively. The lower CI limits in ITT analysis favored the control arm more than in PP analysis (median of − 7.5% vs. -6.9%, p  = 0.0402). CIs were slightly wider in ITT analyses than in PP analyses (median of 13.3% vs. 12.4%, p  < 0.0001). The median success rate was 89% (interquartile range IQR 82 to 93%) in the PP population and 44% (IQR 23 to 60%) in the patients who were included in the ITT population but excluded from the PP population ( p  < 0.0001). Conclusions Contrary to common belief, ITT analysis was more conservative than PP analysis in the majority of antibiotic non-inferiority trials. The lower treatment success rate in the ITT analysis led to a larger variance and wider CI, resulting in a more conservative lower CI limit. ITT analysis should be mandatory and considered as either the primary or co-primary analysis for non-inferiority trials. Trial registration PROSPERO registration number CRD42020165040 .

Background It is important to understand clinical features of bacteremic urinary tract infection (bUTI), because bUTI is a serious infection that requires prompt diagnosis and antibiotic therapy. Escherichia coli is the most common and important uropathogen. The objective of our study was to characterize the clinical presentation of E coli bUTI. Methods Retrospective cohort study of consecutive adult patients admitted for community acquired E. coli bacteremia from January 1, 2015 to December 31, 2016 was conducted at 4 acute care academic and community hospitals in Toronto, Ontario, Canada. Logistic regression models were developed to identify E coli bUTI cases without urinary symptoms. Results Of 462 patients with E. coli bacteremia, 284 (61.5%) patients had a urinary source. Of these 284 patients, 161 (56.7%) had urinary symptoms. In a multivariable model, bUTI without urinary symptoms were associated with older age (age < 65 years as reference, age 65–74 years had OR of 2.13 95% CI 0.99–4.59 p  = 0.0523; age 75–84 years had OR of 1.80 95% CI 0.91–3.57 p  = 0.0914; age > =85 years had OR of 2.95 95% CI 1.44–6.18 p  = 0.0036) and delirium (OR of 2.12 95% CI 1.13–4.03 p  = 0.0207). Sepsis by SIRS criteria was present in 274 (96.5%) of all bUTI cases and 119 (96.8%) of bUTI cases without urinary symptoms. Conclusion The majority of patients with E. coli bacteremia had a urinary source. A significant proportion of bUTI cases had no urinary symptoms elicited on history. Elderly and delirious patients were more likely to have bUTI without urinary symptoms. In elderly and delirious patients with sepsis by SIRS criteria but without a clear infectious source, clinicians should suspect, investigate, and treat for bUTI.