The Journal of hospital infection
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Invasive candidiasis is associated with high mortality rates, ranging from 35% to 60%, in the range reported for septic shock. The epidemiology and pathogenesis of invasive candidiasis differ according to the patient's immune status; the majority of cases in immunocompromised hosts are candidaemia, whereas non-candidaemic systemic candidiasis accounts for the majority of cases in critically ill patients. In contrast to candidaemia, non-candidaemic systemic candidiasis is difficult to prove, especially in critically ill patients. ⋯ This continuum from colonization of mucosal surfaces to local invasion and then invasive infection makes it difficult to identify those critically ill patients likely to benefit most from antifungal prophylaxis or early empirical antifungal treatment. Early empirical treatment of non-candidaemic systemic candidiasis currently relies on the positive predictive value of risk assessment strategies, such as the colonization index, candida score, and predictive rules based on combinations of risk factors such as candida colonization, broad-spectrum antibiotics, and abdominal surgery. Although guidelines recently scored these strategies as being supported by limited evidence, they are widely used at bedside and have substantially decreased the incidence of invasive candidiasis.
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Infants in neonatal intensive care units (NICUs) are highly susceptible to infection due to the immaturity of their immune systems. Healthcare-associated infections (HCAIs) are associated with prolonged hospital stay, and represent a significant risk factor for neurological development problems and death. ⋯ Prevention is based on improving neonatal management, avoiding unnecessary use of central venous catheters, restricting use of antibiotics and H2 blockers, and introducing antifungal prophylaxis if necessary. Quality improvement interventions to reduce HCAIs in neonates seem to be the cornerstone of infection control.
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Ventriculitis is an important complication following neurosurgery and is often associated with the use of an external ventricular drain (EVD). The incidence varies from <5% to 20%, partly due to variations in the definitions used for diagnosis. Staphylococci are the most important causes but the isolation of coagulase-negative staphylococci from a cerebrospinal fluid (CSF) sample needs to be interpreted with caution as it may represent contamination. ⋯ Antimicrobial treatment is challenging as many widely used agents do not penetrate into the CSF and causative bacteria are increasingly multidrug resistant. Often a combination of high-dose intravenous and intraventricular agents is required, especially for Gram-negative infections. Large trials in this area are challenging to conduct; therefore, to better inform preventive strategies and to optimize management of this important condition, ongoing national surveillance and pooling of data on treatment approaches and outcomes are needed.
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Airborne transmission occurs only when infectious particles of <5 μm, known as aerosols, are propelled into the air. The prevention of such transmission is expensive, requiring N95 respirators and negative pressure isolation rooms. This lecture first discussed whether respiratory viral infections are airborne with reference to published reviews of studies before 2008, comparative trials of surgical masks and N95 respirators, and relevant new experimental studies. ⋯ Modelling studies by ventilation engineers were then summarized to explain why these results were not unexpected. Second, the systematic review commissioned by the World Health Organization on what constituted aerosol-generating procedures was summarized. From the available evidence, endotracheal intubation either by itself or combined with other procedures (e.g. cardiopulmonary resuscitation or bronchoscopy) was consistently associated with increased risk of transmission by the generation of aerosols.