Hospital practice (1995)
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Ventilator-associated pneumonia (VAP) is the most common infection seen in intensive care units (ICUs); it accounts for one-fourth of the infections occurring in critically ill patients and is the reason for half of antibiotic prescriptions in mechanically ventilated patients. In addition to being a financial burden on ICUs, it continues to contribute significantly to the morbidity and mortality of ICU patients, with an estimated attributable mortality rate of 8% to 15%. ⋯ Important messages that the reader should take away include: 1) There is no gold standard for the diagnosis of VAP; whenever VAP is suspected, if feasible, a quantitative culture should be obtained by invasive or noninvasive methods (whichever is more readily available before initiation of antibiotics); 2) Suspicion based on clinical features should prompt the initiation of a broad spectrum of antibiotics depending on suspected pathogens; 3) Close attention should be paid to de-escalation of antibiotics once microbiological results become available or as the patient starts responding clinically; the ideal duration of treatment should be 8 days instead of the conventional 10 to 14 days, except in situations where Pseudomonas may be suspected or the patient's comorbidities dictate otherwise; and 4) Prevention remains the key to reducing the burden of VAP. We promote the proven preventive measures of using noninvasive ventilation when possible, semirecumbent patient positioning, continuous aspiration of subglottic secretions, and oral chlorhexidine washes along with stress ulcer prophylaxis only after careful assessment of the risks versus benefits.
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Clostridium difficile has become an increasingly important nosocomial pathogen and is one of the most common causes of hospital-acquired diarrhea. The incidence of C difficile infection (CDI) is increasing worldwide. ⋯ The increasing incidence of CDI has a major impact on increasing health care costs. This article will summarize the epidemiology, pathogenesis, clinical manifestations, laboratory diagnosis, and treatment options for CDI, as well as infection-control measures for the prevention of CDI.
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In the postoperative pain setting, the use of opioid analgesics remains essential in achieving effective analgesia and in avoiding the deleterious sequelae of uncontrolled pain that can worsen patient outcomes. However, postoperative pain remains undertreated in many patients. Choosing the most appropriate use of opioids in the postoperative setting, especially for patients undergoing ongoing opioid treatment for chronic pain, can pose daunting challenges for many clinicians. In this article, we examine the pitfalls that may be encountered when implementing postoperative pain management strategies with opioid analgesics, especially in patients receiving chronic opioid therapy prior to admission, and the critical steps for appropriate and effective analgesia in this setting.
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Hospital practice (1995) · Feb 2012
Evaluation of costs associated with tolvaptan-mediated hospital length of stay reduction among US patients with the syndrome of inappropriate antidiuretic hormone secretion, based on SALT-1 and SALT-2 trials.
Two randomized clinical trials, the Study of Ascending Levels of Tolvaptan in Hyponatremia 1 and 2 (SALT-1 and SALT-2), showed that tolvaptan was an efficacious and safe therapy for the treatment of hyponatremic patients with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). ⋯ Based on the SALT-1 and SALT-2 trials, tolvaptan usage is associated with a shorter hospital LOS than placebo among patients with the SIADH. Including the drug cost for 4 days of inpatient tolvaptan therapy, tolvaptan is associated with an estimated mean hospital cost reduction of $694 per admission in the United States.
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Hospital practice (1995) · Feb 2012
ReviewPrevention and management of central line-associated bloodstream infections in hospital practice.
In this article aimed at hospitalists, we examine the literature on preventive measures for central line-associated bloodstream infections (CLABSIs) and optimal management once a CLABSI has been established. We focus on a number of core preventive measures and the contemporary approach of bundling these measures for maximal impact in reducing infection rates. We then discuss empiric and pathogen-specific antibiotic therapy, including the role of newer antimicrobial agents, as well as the management of an infected central venous catheter.