Hospital Consult - May 2016
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Managing Vaccine-Preventable Diseases in Antivaxxer Age
SEATTLE – Hospitals need to make sure staff members know how to deal with vaccine-preventable diseases (VPDs) that have re-emerged at least partly because of the antivaxxer movement, according to a new report.
The article published recently in the journal Anesthesia & Analgesia discusses measles, mumps, diphtheria, and other VPDs and how many healthcare providers are encountering the potentially serious and even fatal diseases for the first time because of the high rates of vaccine refusal.
Study authors from Virginia Mason Medical Center in Seattle review and update procedures, especially for operating rooms and ICUs.
"The increasing incidence of VPDs in the United States and Europe and the persistence of VPDs globally means that all clinicians must be prepared to manage infectious diseases previously believed to be controlled or eliminated in order to deliver the highest quality of care to all patients," the study authors stated.
The review cites a variety of factors as contributors to the resurgence of VPDs, including the anti-vaccine movement, the decreasing effectiveness of certain vaccines, adaptation of disease-causing pathogens, and travel to countries where disease rates are higher.
Especially when vaccine refusal rates are high, according to the report, herd immunity might not be achieved, putting entire communities at risk of VPD outbreaks.
The review offers as an example the measles outbreak linked to visits to the Disneyland theme parks in Southern California, stating that those "highlighted vulnerabilities of both vaccinated and unvaccinated individuals when exposed to a highly contagious airborne pathogen and the importance of herd immunity.”
Nine major VPDs are covered in the article, including measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella (chickenpox), and poliomyelitis. The diseases, mostly spread by respiratory transmission, can cause severe cardiovascular, respiratory, or neurological complications, according to study authors.
The authors discuss the use of isolation and, in some cases, personal protective equipment to prevent further transmission when patients with VPDs are hospitalized. They also recommend broader use of immunizations at hospitals that don’t yet require them.
"Hospital-based physicians … should be prepared to diagnose and treat patients with VPDs while protecting themselves, their own families, and other patients from infection," the authors emphasized.
"That these established vaccines, which have reduced once-feared diseases to memories, are now actively avoided makes every case of measles-induced blindness or Varicella pneumonitis more tragic," University of Chicago’s Avery Tung, MD, added in an accompanying editorial.
Tung urges anesthesiologists to take advantage of "teachable moments" during preoperative evaluations to provide patients with accurate information about the benefits and safety of vaccines.
New Information About Antimicrobial Resistance in Oncology Units
ATLANTA -- Antimicrobial-resistant E. coli and E. faecium have become significant pathogens in oncology units in hospitals, according to a recent report.
The article published recently in the journal Clinical Infectious Diseases describes central line-associated bloodstream infection (CLABSI) pathogens and antimicrobial resistance patterns found in oncology locations and reported to the CDC’s National Healthcare Safety Network (NHSN).
The CDC emphasizes that recent antimicrobial resistance data have been lacking from inpatient oncology settings, making it difficult to guide infection prophylaxis and develop treatment recommendations.
Public health officials note that the recent analysis represents the largest set of data from the United States on pathogens and antimicrobial resistance in hospital oncology treatment areas and is the first nationwide evaluation of pathogen patterns and antimicrobial trends among bloodstream infections from a hospitalized oncology patient population in more than a decade.
CDC researchers used CLABSI data reported to NHSN from 2009 to 2012 from adult inpatient oncology locations and compared it to data from non-oncology locations within the same hospitals, calculating pathogen profile, antimicrobial resistance rates, and CLABSI incidence rates per 1,000 central line days.
Results indicate that, from 2009–2012, 4,654 CLABSIs were reported to NHSN from 299 adult oncology units. The most common organisms causing CLABSI in oncology locations were coagulase-negative staphylococci (16.9%), Escherichia coli (11.8%), and Enterococcus faecium (11.4%).
The study also finds that fluoroquinolone resistance was more common among E. coli CLABSI in oncology than non-oncology locations (56.5% vs 41.5% of isolates tested) and increased significantly from 2009–2010 to 2011–2012 (49.5% vs 60.4%).
In addition, rates of CLABSI were significantly higher in oncology compared to non-oncology locations for fluoroquinolone-resistant E. coli (rate ratio, 7.37) and vancomycin-resistant E. faecium (rate ratio, 2.27).
Resistance rates for some organisms, such as Klebsiella species and Pseudomonas aeruginosa, were lower, however, in oncology than in non-oncology locations, the report points out.
“Practices for antimicrobial prophylaxis and empiric antimicrobial therapy should be regularly assessed in conjunction with contemporary antimicrobial resistance data,” study authors concluded.
NICU-Acquired Weakness Can Be Lifelong Disability for Some Discharged Patients
TORONTO – Even if they are cured of the critical illness that sent them to the ICU, discharged patients are at risk of another potentially debilitating condition: ICU-acquired weakness.
That’s according to a report in the American Journal of Respiratory and Critical Care Medicine, which emphasizes that ICU patients can lose muscle mass and function for many reasons, including prolonged immobilization, mechanical ventilation, or even the critical illness that put them there.
The study, led by Canadian researchers from St. Michael’s Hospital in Toronto, points out that the mechanisms of muscle atrophy and function during an ICU stay have been well-studied but relatively little is known about the cellular and molecular mechanisms responsible for recovering muscle strength over the long term.
The article notes that some patients continued to suffer from weakness six months after they were discharged from the ICU, demonstrating persistent muscle wasting even after the biologic functions that commonly cause muscles to atrophy — such as inflammation or the breakdown of proteins in muscle tissue — have returned to normal.
In fact, lead author Jane Batt, MD, PhD, warned that, in some cases, muscle weakness which causes profound disability and reduced quality of life can last the rest of the patients’ lives.
"We know ICU patients lose muscle mass and function. Critical illness literally causes their muscles to dissolve," Batt said in a statement. “Some people grow it back and some don't. Some people can regrow the muscle, but it doesn't function properly."
The novel finding of the study, she said, was that sustained muscle atrophy in the long term is the result of impaired regrowth and is associated with a decrease in the number of satellite cells, the precursors to muscle cells.
"While satellite cells are not required for existing muscle fibres to grow in size, they are essential for the regeneration of injured muscle," Batt explained, adding that decreased number of satellite cells also contribute to age-related muscle loss.
For the small study, 27 patients who had been mechanically ventilated for a week or longer consented to being serially assessed over six months after ICU discharge, although 15 and 11 ended up being assessed at 7 days and 6 months after ICU discharge, respectively. It is the first phase of a larger research program to evaluate patient and caregiver outcomes after prolonged mechanical ventilation with a goal of developing a family-centered rehabilitation program after severe critical illness.
‘Weekend Effect,’ Other Factors Delay Kidney Stone Treatment
CHICAGO – Is the “weekend effect” an issue at your hospital? A new study on kidney stone treatment might prompt you to find out.
The research, published in the Journal of Urology, found that patients with severe cases of kidney stones are 26% less likely to receive timely treatment when they're admitted to the hospital on the weekend.
The study by researchers at Loyola Medicine and Loyola University Chicago Stritch School of Medicine is touted as the first to show how the "weekend effect" affects kidney stone treatment and outcomes.
Study authors note that previous research involving other conditions has found that weekend patients experience delayed treatments, longer hospital stays, higher mortality rates, and more readmissions.
For this study, investigators examined records of 10,301 patients admitted to hospitals in Florida and California from 2007 to 2011. The patients received decompression as urgent kidney stone treatment, with delayed treatment defined as occurring more than 48 hours after admission.
Weekend day admission significantly influenced time to intervention, decreasing patient odds of timely intervention by 26%, according to the study. It indicated that 35% of the kidney stone patients received delayed decompression treatment.
The delay resulted in a 0.47% mortality rate, nearly three times higher than that of patients who received early treatment.
"The implication of these findings is that hospitals and clinicians should strive to deliver the same prompt, high-quality care over the weekend as during the work week," study authors emphasized.
In addition to weekend patients, kidney stone patients more likely to experience delayed treatment were African Americans, Hispanics, and patients who were uninsured or had public insurance such as Medicare and Medicaid, according to the study.
“Delayed operative intervention for acute nephrolithiasis admissions with indications for decompression results in increased patient mortality,” study authors concluded. “Nonmedical factors such as the ‘weekend effect,’ race, and insurance provider exerted the greatest influence on the timing of intervention.”
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