Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.

This study compares the proportions of surgical intensive care unit (ICU) patients with delirium detected using the Confusion Assessment Method for the ICU (CAM-ICU) who received administrative documentation for delirium using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, stratified by delirium motoric subtypes. This retrospective cohort study was conducted at a surgical ICU from 06/2012 to 05/2013. Delirium was assessed twice daily and was defined as having ≥1 positive CAM-ICU rating. Delirious patients were categorized into hyperactive/mixed and hypoactive subtypes using corresponding Richmond Agitation Sedation Scales. Administrative documentation of delirium was defined as having ≥1 of 32 unique ICD-9-CM codes. Proportions were compared using Pearson's Chi-square test. Of included patients, 40 % (423/1055) were diagnosed with delirium, and 17 % (183/1055) had an ICD-9-CM code for delirium. The sensitivity and specificity of ICD-9-CM codes for delirium were 36 and 95 %. ICD-9-CM codes for delirium were available for 42 % (95 % CI 35-48 %; 105/253) of patients with hyperactive/mixed delirium and 27 % (95 % CI 20-34 %; 46/170) of patients with hypoactive delirium (relative risk = 1.5; 95 % CI 1.2-2.0; p = 0.002). ICD-9-CM codes yielded a low sensitivity for identifying patients with CAM-ICU positive delirium and were more likely to identify hyperactive/mixed delirium compared with hypoactive delirium.

BACKGROUND Conflicting reports have been published on the association between Clostridium difficile ribotypes and severe disease outcomes in patients with C. difficile infection (CDI); several so-called hypervirulent ribotypes have been described. We performed a multicenter study to assess severe disease presentation and severe outcomes among CDI patients infected with different ribotypes. METHODS Stool samples that tested positive for C. difficile toxin were collected and cultured from patients who presented to any of 7 different hospitals in Houston, Texas (2011–2013). C. difficile was characterized using a fluorescent PCR ribotyping method. Medical records were reviewed to determine clinical characteristics and ribotype association with severe CDI presentation (ie, leukocytosis and/or hypoalbuminemia) and severe CDI outcomes (ie, ICU admission, ileus, toxic megacolon, colectomy, and/or in-hospital death). RESULTS Our study included 715 patients aged 61 ± 18 years (female: 63%; median Charlson comorbidity index: 2.5 ± 2.4; hospital-onset CDI: 45%; severe CDI: 36.7%; severe CDI outcomes: 12.3%). The most common ribotypes were 027, 014-020, FP311, 002, 078-126, and 001. Ribotype 027 was a significant independent predictor of severe disease (adjusted odds ratio [aOR], 2.24; 95% confidence interval [CI], 1.53–3.29; P < .001) and severe CDI outcomes (aOR, 1.71; 95% CI, 1.02–2.85; P = .041) compared with all other ribotypes in aggregate. However, in an analysis using all common ribotypes as individual variables, ribotype 027 was not associated with severe CDI outcomes more often than other ribotypes. CONCLUSION Ribotype 027 showed virulence equal to that of other ribotypes identified in this endemic setting. Clinical severity markers of CDI may be more predictive of severe CDI outcomes than a particular ribotype.

Consensus on the optimal treatment of Clostridium difficile infection (CDI) is rapidly changing. Treatment with metronidazole has been associated with increased clinical failure rates; however, the reasons for this are unclear. The purpose of this study was to assess age-related treatment response rates in hospitalized patients with CDI treated with metronidazole. This was a retrospective, multicenter cohort study of hospitalized patients with CDI. Patients were assessed for refractory CDI, defined as persistent diarrhea after 7 days of metronidazole therapy, and stratified by age and clinical characteristics. A total of 242 individuals, aged 60 ؎ 18 years (Charlson comorbidity index, 3.8 ؎ 2.4; Horn's index, 1.7 ؎ 1.0) were included. One hundred twenty-eight patients (53%) had severe CDI. Seventy patients (29%) had refractory CDI, a percentage that increased from 22% to 28% and to 37% for patients aged less than 50 years, for patients from 50 to 70 years, and for patients aged >70 years, respectively (P ‫؍‬ 0.05). In multivariate analysis, Horn's index (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.50 to 2.77; P < 0.001), severe CDI (OR, 2.25; 95% CI, 1.15 to 4.41; P ‫؍‬ 0.018), and continued use of antibiotics (OR, 2.65; 95% CI, 1.30 to 5.39; P ‫؍‬ 0.0072) were identified as significant predictors of refractory CDI. Age was not identified as an independent risk factor for refractory CDI. Therefore, hospitalized elderly patients with CDI treated with metronidazole had increased refractory CDI rates likely due to increased underlying severity of illness, severity of CDI, and concomitant antibiotic use. These results may help identify patients that may benefit from alternative C. difficile treatments other than metronidazole.I n the United States, Clostridium difficile is the most commonly reported pathogen for health setting-acquired infections, causing approximately 500,000 infections and 29,000 deaths (1, 2) annually. Oral metronidazole is a treatment option for C. difficile infection (CDI) and is recommended in the guidelines for the treatment of mild-to-moderate disease (3). However, observational (4) and randomized controlled (5, 6) studies have demonstrated high clinical failure rates in patients with CDI given metronidazole. Colonic concentrations of metronidazole are relatively low and not predictable, and this drug is not considered by many to be an optimal pharmacologic agent for CDI (7). However, the reason for increased clinical failure rates in patients treated with metronidazole is unknown. Mortality rates due to CDI increase in the elderly (8). We hypothesized that metronidazole response rates would also decrease in the elderly. The purpose of this study was to assess age-related treatment response rates in hospitalized patients with CDI treated with metronidazole. MATERIALS AND METHODSStudy design and study sites. This was a retrospective, multicenter cohort study of patients with CDI admitted to three large tertiary care academic institutions in Houston, TX, from January 2009 to August ...

Learning Objectives: Incidence of new onset postoperative atrial fibrillation (POAF) ranges from 9-20% of non-cardiac major thoracic and vascular surgeries and is associated with worse postoperative outcomes. A CHADS2 score of ≥ 2 has previously been associated with new onset POAF in cardiac surgery patients. The objective of the present study was to determine whether CHADS2 score alone and in the context of other clinical risk factors would be predictive of new onset POAF in non-cardiac major thoracic and vascular surgical patients. Methods: After IRB approval, 1,566 patients undergoing major non-cardiac thoracic and vascular surgery without known atrial fibrillation from 2006 through 2013 who were admitted to a surgical intensive care unit postoperatively were retrospectively identified. Baseline CHADS2 and clinical variables including daily fluid balance, electrolyte values, intra-and postoperative vasopressor and inotrope requirements, operation length, blood transfusion, and resumption of home cardiac medications were collected. The primary endpoint was correlation of CHADS2 with incidence of POAF. A multivariable Cox proportional hazards model was used to assess association between risk factors and POAF. Results: Two hundred twenty-one (14.1%) patients developed POAF at a median of 55 hours (IQR 30-93.7) after surgery. On univariate analysis, CHADS2 was significantly associated with POAF (HR 1.22 [95% CI 1.08-1.37] for every unit increase in score). This association persisted after multivariate adjustment (HR 1.17 [95% CI 1.04-1.31]). Intraoperative fluid administration (HR 1.03 [95% CI 1.01-1.06] per 1000 ml), preoperative beta blocker use (HR 2.04 [95% CI 1.44-2.90]), calcium channel blocker use (HR 0.67 [95% CI 0.49-0.93])and postoperative day 1 SOFA score (HR 1.08 [95% CI 1.03-1.12] for every unit increase in score) were also significantly associated. Model R2 was 0.76. Conclusions: CHADS2, when used in combination with baseline and clinical variables, is predictive of new POAF after major thoracic or vascular surgery and maybe useful in identifying at risk patients.