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Among patients with out-of-hospital cardiac arrest (OHCA) and ventricular fibrillation, more than half present with refractory ventricular fibrillation unresponsive to initial standard advanced cardiac life support (ACLS) treatment. We did the first randomised clinical trial in the USA of extracorporeal membrane oxygenation (ECMO)-facilitated resuscitation versus standard ACLS treatment in patients with OHCA and refractory ventricular fibrillation. For this phase 2, single centre, open-label, adaptive, safety and efficacy randomised clinical trial, we included adults aged 18–75 years presenting to the University of Minnesota Medical Center (MN, USA) with OHCA and refractory ventricular fibrillation, no return of spontaneous circulation after three shocks, automated cardiopulmonary resuscitation with a Lund University Cardiac Arrest System, and estimated transfer time shorter than 30 min. Patients were randomly assigned to early ECMO-facilitated resuscitation or standard ACLS treatment on hospital arrival by use of a secure schedule generated with permuted blocks of randomly varying block sizes. Allocation concealment was achieved by use of a randomisation schedule that required scratching off an opaque layer to reveal assignment. The primary outcome was survival to hospital discharge. Secondary outcomes were safety, survival, and functional assessment at hospital discharge and at 3 months and 6 months after discharge. All analyses were done on an intention-to-treat basis. The study qualified for exception from informed consent (21 Code of Federal Regulations 50.24). The ARREST trial is registered with ClinicalTrials.gov, NCT03880565. Between Aug 8, 2019, and June 14, 2020, 36 patients were assessed for inclusion. After exclusion of six patients, 30 were randomly assigned to standard ACLS treatment (n=15) or to early ECMO-facilitated resuscitation (n=15). One patient in the ECMO-facilitated resuscitation group withdrew from the study before discharge. The mean age was 59 years (range 36–73), and 25 (83%) of 30 patients were men. Survival to hospital discharge was observed in one (7%) of 15 patients (95% credible interval 1·6–30·2) in the standard ACLS treatment group versus six (43%) of 14 patients (21·3–67·7) in the early ECMO-facilitated resuscitation group (risk difference 36·2%, 3·7–59·2; posterior probability of ECMO superiority 0·9861). The study was terminated at the first preplanned interim analysis by the National Heart, Lung, and Blood Institute after unanimous recommendation from the Data Safety Monitoring Board after enrolling 30 patients because the posterior probability of ECMO superiority exceeded the prespecified monitoring boundary. Cumulative 6-month survival was significantly better in the early ECMO group than in the standard ACLS group. No unanticipated serious adverse events were observed. Early ECMO-facilitated resuscitation for patients with OHCA and refractory ventricular fibrillation significantly improved survival to hospital discharge compared with standard ACLS treatment. National Heart, Lung, and Blood Institute.

Purpose To investigate whether early coronary angiography (CAG) after out-of-hospital cardiac arrest of a presumed cardiac cause is associated with improved outcomes in patients without acute ST elevation. Methods The target temperature management after out-of-hospital cardiac arrest (TTM) trial showed no difference in all-cause mortality or neurological outcome between an intervention of 33 and 36 °C. In this post hoc analysis, 544 patients where the admission electrocardiogram did not show acute ST elevation were included. Early CAG was defined as being performed on admission or within the first 6 h after arrest. Primary outcome was mortality at the end of trial. A Cox proportional hazard model was created to estimate hazard of death, adjusting for covariates. In addition, a propensity score matched analysis was performed. Results A total of 252 patients (46 %) received early CAG, whereas 292 (54 %) did not. At the end of the trial, 122 of 252 patients who received an early CAG (48 %) and 159 of 292 patients who did not (54 %) had died. The adjusted hazard ratio for death was 1.03 in the group that received an early CAG; 95 % CI 0.80–1.32, p  = 0.82. In the propensity score analysis early CAG was not significantly associated with survival. Conclusions In this post hoc observational study of a large randomized trial, early coronary angiography for patients without acute ST elevation after out-of-hospital cardiac arrest of a presumed cardiac cause was not associated with improved survival. A randomized trial is warranted to guide clinical practice.

National estimates of methicillin-resistant Staphylococcus aureus (MRSA) infection rates in hospitalized surgical patients and outcomes are lacking. We sought to estimate the prevalence, identify the predictors, and describe the outcomes of MRSA infections in hospitalized patients undergoing major surgical procedures (MSPs) in the United States. We performed a retrospective analysis of the Nationwide Inpatient Sample, the largest all-payer hospital discharge database in the United States, for the years 2009 to 2010. Of the 22,932,948 hospitalizations that had an MSP, MRSA infection occurred in 235,636 (1.03%) patients. Factors associated with “significantly” lower risk of MRSA occurrence include women (odds ratio [OR] .68), elective procedure (OR .38), teaching institutes (OR .94), and large hospital size (OR .87). Blacks (OR 1.19), native Americans (OR 1.27), increased comorbid burden (OR 1.38), and uninsured patients were associated with higher risk of MRSA occurrence. Outcomes in MSPs “with” MRSA versus “without” MRSA include mean length of stay (14 vs 5 days) and in-hospital mortality (IHM) rate (3.7% vs 1.2%). Occurrence of an MRSA was associated with significantly longer length of stay and higher odds of IHM (OR 1.39, 95% confidence interval 1.30 to 1.48). Although the occurrence of MRSA infections complicating MSPs was low, it is associated with worse outcomes. Certain predictors of MRSA infection are identified. •Of the 22.9 million hospitalizations that had a MSP in the USA, MRSA infection occurred in 235,636 (1.03%).•MRSA was associated with Blacks, native Americans, comorbidity and uninsured were associated with higher risk of MRSA occurrence.•Females, elective surgeries, & patient’s in teaching/large hospitals had lower risk of MRSA occurrence.

The 'chain of survival'-including early call for help, early cardiopulmonary resuscitation (CPR) and early defibrillation-represents the most beneficial approach for favourable patient outcome after out-of-hospital cardiac arrest (OHCA). Despite increasing numbers of publicly accessible automated external defibrillators (AED) and interventions to increase public awareness for basic life support (BLS), the number of their use in real-life emergency situations remains low. In this prospective population-based cross-sectional study, a total of 501 registered inhabitants of Vienna (Austria) were randomly approached via telephone calls between 08/2014 and 09/2014 and invited to answer a standardized questionnaire in order to identify public knowledge and awareness of BLS and AED-use. We found that more than 52 percent of participants would presume OHCA correctly and would properly initiate BLS attempts. Of alarming importance, only 33 percent reported that they would be willing to perform CPR and 50 percent would use an AED device. There was a significantly lower willingness to initiate BLS attempts (male: 40% vs. female: 25%; OR: 2.03 [95%CI: 1.39-2.98]; p<0.001) and to use an AED device (male: 58% vs. female: 44%; OR: 1.76 [95%CI: 1.26-2.53]; p = 0.002) in questioned female individuals compared to their male counterparts. Interestingly, we observed a strongly decreasing level of knowledge and willingness for BLS attempts (-14%; OR: 0.72 [95%CI: 0.57-0.92]; p = 0.027) and AED-use (-19%; OR: 0.68 [95%CI: 0.54-0.85]; p = 0.001) with increasing age. We found an overall poor knowledge and awareness concerning BLS and the use of AEDs among the Viennese population. Both female and elderly participants reported the lowest willingness to perform BLS and use an AED in case of OHCA. Specially tailored programs to increase awareness and willingness among both the female and elderly community need to be considered for future educational interventions.

Background We aimed to investigate the diagnostic performance of S100 as an outcome predictor after out-of-hospital cardiac arrest (OHCA) and the potential influence of two target temperatures (33 °C and 36 °C) on serum levels of S100. Methods This is a substudy of the Target Temperature Management after Out-of-Hospital Cardiac Arrest (TTM) trial. Serum levels of S100 were measured a posteriori in a core laboratory in samples collected at 24, 48, and 72 h after OHCA. Outcome at 6 months was assessed using the Cerebral Performance Categories Scale (CPC 1–2 = good outcome, CPC 3–5 = poor outcome). Results We included 687 patients from 29 sites in Europe. Median S100 values were higher in patients with a poor outcome at 24, 48, and 72 h: 0.19 (IQR 0.10–0.49) versus 0.08 (IQR 0.06–0.11) μg/ml, 0.16 (IQR 0.10–0.44) versus 0.07 (IQR 0.06–0.11) μg/L, and 0.13 (IQR 0.08–0.26) versus 0.06 (IQR 0.05–0.09) μg/L ( p  < 0.001), respectively. The ability to predict outcome was best at 24 h with an AUC of 0.80 (95% CI 0.77–0.83). S100 values were higher at 24 and 72 h in the 33 °C group than in the 36 °C group (0.12 [0.07–0.22] versus 0.10 [0.07–0.21] μg/L and 0.09 [0.06–0.17] versus 0.08 [0.05–0.10], respectively) ( p  < 0.02). In multivariable analyses including baseline variables and the allocated target temperature, the addition of S100 improved the AUC from 0.80 to 0.84 (95% CI 0.81–0.87) ( p  < 0.001), but S100 was not an independent outcome predictor. Adding S100 to the same model including neuron-specific enolase (NSE) did not further improve the AUC. Conclusions The allocated target temperature did not affect S100 to a clinically relevant degree. High S100 values are predictive of poor outcome but do not add value to present prognostication models with or without NSE. S100 measured at 24 h and afterward is of limited value in clinical outcome prediction after OHCA. Trial registration ClinicalTrials.gov identifier: NCT01020916 . Registered on 25 November 2009.

Background Targeted temperature management is recommended after out-of-hospital cardiac arrest and may be achieved using a variety of cooling devices. This study was conducted to explore the performance and outcomes for intravascular versus surface devices for targeted temperature management after out-of-hospital cardiac arrest. Method A retrospective analysis of data from the Targeted Temperature Management trial. N  = 934. A total of 240 patients (26%) managed with intravascular versus 694 (74%) with surface devices. Devices were assessed for speed and precision during the induction, maintenance and rewarming phases in addition to adverse events. All-cause mortality, as well as a composite of poor neurological function or death, as evaluated by the Cerebral Performance Category and modified Rankin scale were analysed. Results For patients managed at 33 °C there was no difference between intravascular and surface groups in the median time taken to achieve target temperature (210 [interquartile range (IQR) 180] minutes vs. 240 [IQR 180] minutes, p  = 0.58), maximum rate of cooling (1.0 [0.7] vs. 1.0 [0.9] °C/hr, p  = 0.44), the number of patients who reached target temperature (within 4 hours (65% vs. 60%, p  = 0.30); or ever (100% vs. 97%, p  = 0.47), or episodes of overcooling (8% vs. 34%, p  = 0.15). In the maintenance phase, cumulative temperature deviation (median 3.2 [IQR 5.0] °C hr vs. 9.3 [IQR 8.0] °C hr, p  = <0.001), number of patients ever out of range (57.0% vs. 91.5%, p  = 0.006) and median time out of range (1 [IQR 4.0] hours vs. 8.0 [IQR 9.0] hours, p  = <0.001) were all significantly greater in the surface group although there was no difference in the occurrence of pyrexia. Adverse events were not different between intravascular and surface groups. There was no statistically significant difference in mortality (intravascular 46.3% vs. surface 50.0%; p  = 0.32), Cerebral Performance Category scale 3–5 (49.0% vs. 54.3%; p  = 0.18) or modified Rankin scale 4–6 (49.0% vs. 53.0%; p  = 0.48). Conclusions Intravascular and surface cooling was equally effective during induction of mild hypothermia. However, surface cooling was associated with less precision during the maintenance phase. There was no difference in adverse events, mortality or poor neurological outcomes between patients treated with intravascular and surface cooling devices. Trial registration TTM trial ClinicalTrials.gov number https://clinicaltrials.gov/ct2/show/NCT01020916 NCT01020916; 25 November 2009

Urinary catheter replacement prior to urinary tract infection assessment, introduced as a quality improvement recommendation in two surgical intensive care units, was associated with (88% and 84%) reduction in catheter-associated urinary tract infections and significant reductions in urine cultures performed.

Bacterial antibiotic resistance (AMR) is a significant threat to public health, with the sentinel ‘ESKAPEE’ pathogens, being of particular concern. A cohort study spanning 5.5 years (2016–2021) was conducted at a provincial general hospital in Crete, Greece, to describe the epidemiology of ESKAPEE-associated bacteraemia regarding levels of AMR and their impact on patient outcomes. In total, 239 bloodstream isolates were examined from 226 patients (0.7% of 32 996 admissions) with a median age of 75 years, 28% of whom had severe comorbidity and 46% with prior stay in ICU. Multidrug resistance (MDR) was lowest for Pseudomonas aeruginosa (30%) and Escherichia coli (33%), and highest among Acinetobacter baumannii (97%); the latter included 8 (22%) with extensive drug-resistance (XDR), half of which were resistant to all antibiotics tested. MDR bacteraemia was more likely to be healthcare-associated than community-onset (RR 1.67, 95% CI 1.04–2.65). Inpatient mortality was 22%, 35% and 63% for non-MDR, MDR and XDR episodes, respectively (P = 0.004). Competing risks survival analysis revealed increasing mortality linked to longer hospitalisation with increasing AMR levels, as well as differential pathogen-specific effects. A. baumannii bacteraemia was the most fatal (14-day death hazard ratio 3.39, 95% CI 1.74–6.63). Differences in microbiology, AMR profile and associated mortality compared to national and international data emphasise the importance of similar investigations of local epidemiology.

Norovirus outbreaks in hospital settings are a common challenge for infection prevention teams. Given the high burden of norovirus in most communities, it can be difficult to distinguish between ongoing in-hospital transmission of the virus and new introductions from the community, and it is challenging to understand the long-term impacts of outbreak-associated viruses within medical systems using traditional epidemiological approaches alone. Real-time metagenomic sequencing during an ongoing norovirus outbreak associated with a retrospective cohort study. We describe a hospital-associated norovirus outbreak that affected 13 patients over a 27-day period in a large, tertiary, pediatric hospital. The outbreak was chronologically associated with a spike in self-reported gastrointestinal symptoms among staff. Real-time metagenomic next-generation sequencing (mNGS) of norovirus genomes demonstrated that 10 chronologically overlapping, hospital-acquired norovirus cases were partitioned into 3 discrete transmission clusters. Sequencing data also revealed close genetic relationships between some hospital-acquired and some community-acquired cases. Finally, this data was used to demonstrate chronic viral shedding by an immunocompromised, hospital-acquired case patient. An analysis of serial samples from this patient provided novel insights into the evolution of norovirus within an immunocompromised host. This study documents one of the first applications of real-time mNGS during a hospital-associated viral outbreak. Given its demonstrated ability to detect transmission patterns within outbreaks and elucidate the long-term impacts of outbreak-associated viral strains on patients and medical systems, mNGS constitutes a powerful resource to help infection control teams understand, prevent, and respond to viral outbreaks.

Background Hospital-onset bacteraemia and fungaemia (HOB) has emerged as a novel surveillance metric in recent years and a prime target for automation of surveillance of healthcare-associated infections. However, real-life HOB data from European institutions remain scarce. This study explores the epidemiology of HOB at a German university hospital and describes characteristics of HOB cases. Methods A retrospective single-centre study was conducted by applying an extended version of the Providing a Roadmap for Infection Surveillance in Europe (PRAISE) automated HOB algorithm to data from the electronic health records of all in-hospital patients admitted to Charité university hospital between 2018 and 2022. HOB rates per 1,000 patient days were calculated for different groups of wards. Furthermore, the distribution of microorganisms, share of antimicrobial resistance, and source of possible secondary HOB (defined as HOB-causing pathogens detected in relevant clinical samples other than blood) were analysed. Additionally, patient characteristics and outcomes were investigated. Results A total of 3,648,254 patient days and 7,256 HOB with 8,357 microorganisms were included. The pooled HOB rate was 6.0 per 1,000 patient days in intensive care units, and between 0.9 and 2.0 in the various groups of non-intensive care units. Around 34.5% (n = 2,505) of HOB were deemed potentially secondary, with respiratory tract (37.6%, n = 943) being the most common source. A total of 1,106 of 8,357 (13.2%) microorganisms were classified as multidrug-resistant, including 60.5% (23 of 38) of Acinetobacter baumannii with resistance to carbapenems. Case fatality within 14 days of HOB onset was 16.2% (990 of 6,093 patients). Conclusions Analysis of electronic health record data provides important insights into the epidemiology and characteristics of HOB cases. Substantial rates of antimicrobial resistance and case fatality underscore the relevance of HOB as an IPC metric. Results from this study may inform refinement of algorithms for automated HOB surveillance.