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接觸TB後，TST大抵上2-12週轉陽，IGRA大抵上6-10週，但IGRA可以長到3個月以上 TB Tests Can Have a Lengthy Window Period Two studies suggest that interferon- release assay conversion sometimes occurs more than 3 months after exposure to active tuberculosis. Increasingly, interferon- release assays (IGRAs) are being used for diagnosing latent tuberculosis (TB). Although the tuberculin skin test (TST) traditionally used for this purpose converts to positive within 2 to 12 weeks after an individual is exposed to someone with active TB, the interval for IGRA conversion has remained unclear. Current guidelines recommend repeating an initially negative IGRA after 6 to 10 weeks, but this recommendation is not based on controlled studies. Two recent investigations address this issue. Anibarro and colleagues conducted a longitudinal prospective analysis among contacts of TB patients in Spain. The 152 contacts received a TST and an IGRA at first visit; for individuals with negative or conflicting results, t...

Can We Prevent Transmission of Drug-Resistant Bacteria in Hospitals? Two large studies on active screening for drug-resistant bacteria produced strikingly different results. How to limit the spread of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) in the healthcare environment remains unclear. This issue was recently addressed in two large clinical studies. In a cluster-randomized trial involving 18 U.S. adult intensive care units (ICUs), Huskins and colleagues (with partial industry support) examined the effect of MRSA and VRE surveillance. In the 10 intervention ICUs, patients known or found to have MRSA or VRE colonization or infection were managed with contact precautions; all other patients received care with universal gloving pending the results of the screening studies. In the eight control ICUs, standard institutional protocols for managing MRSA and VRE were followed. Routinely scheduled surveillance cultures wer...

有趣的問題 白袍頂多一個星期換一次吧… 如果不用解釋病情 當然是穿手術衣趴趴走最輕鬆 一天換一件就丟…… 過去會認為白袍最髒 看來還好…… What Should Physicians Wear? After 8 hours of wear, physicians' white coats and freshly laundered short-sleeved uniforms showed similar levels of bacterial contamination. Evidence that physicians' white coats and other long-sleeved garments can be contaminated with bacteria including methicillin-resistant Staphylococcus aureus (MRSA) has led British health authorities to ban such attire for clinicians. To examine the appropriateness of this action, researchers conducted a prospective trial in which they assessed bacterial contamination of physicians' clothing. The study involved 100 internal medicine physicians at a Denver hospital in 2008 and 2009. These physicians were randomized to wear either their own white coats or newly laundered short-sleeved uniforms. Eight hours after the start of the workday, cultures were collected from multiple sites, including breast pockets, s...

IHI 的幾個bundle裏，最立竿見影的就是CVP bundle CVP bundle>VAP bundle>> stop sepsis bundle 以下截自「詹廖明義醫師的blog」 CR=Catheter-related; CLA=Central Line-Associated; BSI=Blood Stream Infection。 而全球的最佳典範，即是在密西根州(Michigan)的Keystone ICU，醫護團隊在運用由Atul Gawande等人設計的Checklist後，有效控制感染的創新突破。 這些轟動醫界的作為，統稱為CVP Bundle。 在IHI的網站上，數年前就有詳細資料可供下載。 根據美國醫院評鑑(JC)，2011年的新規定，NPSG.07.04.01強調受評者，要有Checklist且預防CLABSI的方法，必需要有科學論證(Cited in Scientific Literature或專科學會的背書)，因此要有好成績，務必遵循IHI及AHRQ所建議的各種條件。 CDC的Guidelines， Johns Hopkins的Central Line Insertion Care Team Checklist及www.dr.carondelet.org的Central Line Bundle 都很值得參考。 構成與中心導管相關的血流感染，有很多複雜的因素，多年來學者們為了克服這些問題，曾做過很多統計與研究報告，因此以CRBSI或CLABSI可以找到很龐大(光是英文就有數百篇)的文獻資料，可見它是一門大學問！ 不僅有置入時的技術問題、制度問題(如SOP，知情告知，手部衛生，執行者的資格條件，協助者及督導者的職責)、消毒液的成分問題、使用導管的種類含材質問題(如Lumen腔數，Hickman,Broviac,Port-A等forTPN及化療)，置入後短期與中長期的照護問題(如在OR，ICU及一般病房，多少還是有些不同)。 連輸液的管理不當，如注入孔及3-way stopcock的操作不當，也可能影響病菌的播種途徑......總而言之，很複雜！ 以下只簡單重複幾項最受注目的Major Elements: 1、高度的無菌遮斷預防對策(Maximal Barrier Precaution)，即戴手術帽及口罩，身穿無菌衣並戴無菌...

severe H1N1 infection, 今年冬季大家領教過了吧…… 歐洲的觀察，用steroid trying to decrease cytokine storm是無益的 會增加肺炎機會 個人見解： 這次流感的ARDS 60-70歲以上的病人，除非underlying太差，雖敗不亂，用呼吸器可以徐圖漸進，日日有起色，眼睛烏亮亮，不會讓你想用類固醇 30-40歲的人，一來就撐不住，馬上轉到敏盛/長庚用ECMO，用啥都沒用 either case -> 都用不到 steroid Severe H1N1 Influenza Infection: Hold the Corticosteroids! An observational European study shows that corticosteroids increased risk for pneumonia and conferred no mortality benefit in patients with severe H1N1 infection. Use of corticosteroids to mitigate the cytokine storm that might contribute to poor outcomes in otherwise healthy people with pandemic H1N1 influenza infection is controversial, even in those with acute respiratory distress syndrome (ARDS). In a prospective observational study, investigators evaluated the effect of corticosteroids on outcomes in 220 intensive care unit (ICU) patients who were enrolled in the European Society of Intensive Care Medicine H1N1 registry from June 2009 through February 2010. H1N1 influenza A infect...

住院的人，非因infectious diarrhea來住院，32%大便會有mdr-GNB 裏面有10%的人從沒住過院(這種也會…) 全文找不到，不知道MDR的定義 Prevalence of Multidrug-Resistant Gram-Negative Pathogens Fecal carriage of such pathogens was common among patients hospitalized for diarrhea in France, particularly those with recent hospitalization, antibiotic therapy, or nursing home residence. A rapid rise in multidrug-resistant (MDR) gram-negative pathogens has been observed worldwide. Such pathogens can be acquired under common circumstances — for example, during travel (JW Infect Dis Sep 29 2010) — and antibiotic therapy is assumed to be the selective pressure driving further spread of resistant clones. Fecal colonization may be a risk factor for subsequent clinically apparent infections. However, little is known about the prevalence of MDR pathogens in the fecal flora of patients admitted to the hospital. To investigate this issue, researchers collected stool specimens from 303 patients who were hospitalized in France with acute diarrhea during a...

2010-08-22 台大 VAP bundle sepsis bundle CVP bundle ACS bundle https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B278nGJMQBk7YTE4N2M5NzktNGJmZS00MzE2LWEzYjItZjZjNmE0NGRiZGQ0&hl=zh_TW

老人家，住一次院就全垮了(真的目前都是遇到sepsis的病人會這樣，其它的不太會) acute delirium, 失禁，睡眠失常 家人常常會回來抱怨 如果是長期在門診看的病人還好，可以知道抱怨的真假 但有時候是第一次看的病人，那就要看家人的可信度了…… 通常外勞的話比家人可信，孫子/女輩的話比第二代可信…哈哈哈 anyway....只要確定沒有其它問題，通常隨時間會改善，1-2 weeks maybe Cognitive Decline After Sepsis Hospitalization Older patients hospitalized with severe sepsis are at increased risk for new cognitive deficits and functional impairment, highlighting their need for subacute and chronic follow-up. In this observational study, investigators explored the effects of sepsis on cognition and performance of activities of daily living (ADLs). The authors conducted biennial structured interviews of 9223 elders (or their proxies) who were participating in an ongoing cohort study with linked Medicare data. More than 500 were survivors of severe sepsis (defined as new infection with organ failure) and had at least one follow-up interview after sepsis during the 8-year study. According to previously validated, yet not widely used, cognitive screening methods and cu...

疾管局進了一批 peramivir，要用要通過程序申請…… UGI bleeding合併流感重症也許是唯一使用它的時機 但因為FDA尚未正式通過 所以臨床醫師必須要和病人家屬解釋一大堆可能的副作用… Treatment of Influenza with Intravenous Peramivir Intravenous peramivir given within 48 hours of influenza symptom onset was well tolerated, reduced fever, and shortened time to resumption of usual activities. To date, influenza treatments have consisted only of oral (oseltamivir) or topical (zanamivir) neuraminidase inhibitor formulations, but an intravenous option is also being investigated —the selective neuraminidase inhibitor peramivir. This sialic acid analogue is characterized by a strong affinity for influenza neuraminidase and a low off rate. Researchers recently reported the results of a manufacturer-sponsored, phase II, randomized controlled trial investigating the effect of a single dose of intravenous peramivir on the course of community-acquired influenza in previously healthy individuals during the 2007–2008 influenza season in Japan. Within 48 hours after onset of typical...

http://homepage.vghtpe.gov.tw/~cmd/education/Guidelines%20NTM.pdf https://docs.google.com/leaf?id=0B278nGJMQBk7ZmJjMmFjNDctMTE3ZS00ODAyLThiODYtNzBhMjc1YmJhNTVi&hl=zh_TW

意思就是說，健保局想用pay-for-performance，用健保大電腦來看你的performance來給你錢，是不通的 前一陣子寫過一個台大公衛所的問卷，列出很多種infection, 包括VAP, HAP, SSI, CLBSI, UTI等指標，問說，你覺得哪種最能代表一個醫院的照護品質，因為採delphi methods，可看到大家的第一意見都是選CLBSI(還用說),也許哪一天一個報告出來，說「專家們」都認為CLBSI最能代表品質，那我們就開始論質計酬吧! ==> 到時候可以拿這個報告出來給蛋頭學者看一下…記得是賴美淑老師指導的學生 做這個infection survey 是做內部管理用的，有時和同儕比較一下，不是給你秤斤秤兩算錢用的。老子成天收爛病人，是盡社會義務，不是用來給你嫌東嫌西扣錢用的。 Surveillance for Central Line–Associated Bloodstream Infections The correlation between infection preventionist– and algorithm-determined infection rates was weak and varied markedly among the hospitals studied. With pay-for-performance metrics now focusing on healthcare-acquired infections, the accuracy with which such infections are identified will have substantial financial implications for hospitals. Moreover, for interhospital comparisons to be valid, surveillance methods must be uniform and reliable across institutions. The recent development of computer algorithms for central line–associated bloodstream infection (CLABSI) ...

減少42%VAP rate, 這一根管子要價多少? 這個study可以顯示出VAP的減少，但無法顯示出2nd endpoint(mortality, MV days, ICU stay的減少) 作者預期case number夠多，大約可減少ICU mortality 1-3% 划算否? Intermittent Subglottic Suction to Prevent Ventilator-Associated Pneumonia? In a randomized, nonblinded study, intermittent subglottic suction reduced the incidence of microbiologically confirmed VAP by 42%. Ventilator-associated pneumonia (VAP) occurs in 9% to 27% of patients receiving mechanical ventilation in intensive care units (ICUs). Because the condition results in part from leakage of secretions around the endotracheal cuff, subglottic secretion drainage (SSD) using a specially designed endotracheal tube has been used to diminish this risk. However, previous studies of this strategy have produced conflicting results. Now, investigators in France, with partial support from the manufacturer of the endotracheal tube, have conducted a multicenter study to shed light on the issue. A total of 333 adults who were admit...

吃兩個capsule, 一個灌漿到口中，一個灌到NG裏 如果有效，比什麼subglottic suction要來得實際多了 下次來試試看，吃益生菌的人PDRAB會不會消失得比較快…! Probiotics and Ventilator-Associated Pneumonia In a blinded, randomized study involving 138 mechanically ventilated patients, Lactobacillus administered to the oropharynx and gastrointestinal tract significantly reduced VAP incidence. Ventilator-associated pneumonia (VAP) develops in up to 30% of patients receiving mechanical ventilation. The pathogenesis is presumed to involve colonization of the aerodigestive tract and subsequent aspiration of contaminated secretions. Probiotics could potentially have a role in reducing VAP incidence by maintaining the aerodigestive microbial balance, but evidence to support this possibility is limited. To explore the issue further, researchers conducted a randomized, double-blind trial among adult patients at a Nebraska hospital who were receiving mechanical ventilation and were likely to require it for >72 hours. The 146 patients rece...

by Dr. lee https://docs.google.com/leaf?id=0B278nGJMQBk7MTYxZWY2NWQtNWYxMC00MzdiLTg2MTUtNWYzZTI1MzVlMDZi&hl=zh_TW

1950年代做的data是 0.10-0.16 per 100 person-years, which justified LTBI tx 但目前只有0.070-0.099 per 100 person-years, 排除掉HIV病人還更降到0.040-0.058 per 100 person-years, 那我們還做LTBI tx 幹啥? 類似的觀念蘇維鈞主任有講過，台灣似乎花太多資源在LTBI上面，沒有data support LTBI tx 的功效. 應該先有類似baseline data，再說服臨床院所加入LTBI tx 台灣目前的階段，應該還是先抓出病人，治好病人，阻斷感染源為先…特別是越來越沒錢的時候… How Common Is Reactivation Tuberculosis? In a population-based tuberculin skin-test survey, the rate of reactivation TB was 0.070 to 0.099 per 100 person-years. Active tuberculosis (TB) results from recent acquisition of Mycobacterium tuberculosis or, more commonly in the U.S., from reactivation of latent TB infection (LTBI). Knowing the current rate of reactivation TB is important in the drive to implement preventive strategies. The rate was last calculated in the 1950s, when it was found to be 0.10 to 0.16 per 100 person-years. Since then, the epidemiology and management of TB have changed substantially. To calculate today's rate, researchers performed a population-based tu...

老年婦女多(59%)，平均66歲 而且症狀不太一樣 NTMthrive within the biofilm of municipal water systems and likely infect susceptible hosts via aerosolization 最近遇到兩個NTM，一個是天天游泳的老人家，請他莫再游了 is it ok to check the swimming pool water supply? MAC佔多，klaricid + EMB + Rif? Atypical Mycobacterial Infections Might Be on the Rise Pulmonary infections are now more common than pulmonary tuberculosis. Pulmonary infections with "atypical" nontuberculous mycobacteria have been recognized for decades, but reliable estimates of their prevalence are elusive for several reasons: These infections are tricky to diagnose, geographically variable, and untracked by local or federal health departments. Several reports from around the country now suggest that infection rates are rising. Investigators reviewed all clinical isolates of nontuberculous mycobacteria obtained from Oregon residents during 2005 and 2006. Estimated prevalence of pulmonary infection was 8 to 11 cases per 100,000, with a prevalence in older people (ag...

健保資料庫文章 接受牙科手術後一個月，1.5倍 vascular events 六個月後降到baseline 平時吃aspirin的，手術後要吃回去 Invasive Dental Treatment Linked to Vascular Events? Invasive dental treatment might be associated with a short-term increase in vascular risk, according to a self-controlled study in the Annals of Internal Medicine. Using Medicaid databases, researchers identified some 1200 adults who both underwent invasive dental procedures (e.g., periodontal therapy, extractions) and also experienced a myocardial infarction or stroke from 2002 to 2006. They found that vascular events were more common in the month after dental treatment than at other times during the observation period (incidence ratio, 1.5). Risk gradually returned to baseline by 6 months after dental treatment. The authors point to acute inflammation as a potential underlying mechanism. They add that "the absolute risks are minimal, and the long-term benefits on vascular health will probably outweigh the short-lived adverse effects." Meanwhile, ed...

台灣的regimen不太一樣 基本上能不用fluroquinolone就不會用 Treatment of Multidrug-Resistant Tuberculosis In an observational study, a gatifloxacin-containing regimen for at least 9 months had the highest cure rate. Multidrug-resistant tuberculosis (MDRTB) is defined as infection caused by an organism resistant to both isoniazid and rifampin. Currently recommended treatment regimens are long, often poorly tolerated, and difficult to monitor. Treatment standardization has been recommended for MDRTB in low-income areas, which generally have low levels of resistance to second-line drugs. As part of a TB treatment program in Bangladesh, researchers conducted a prospective observational study from May 1997 through December 2007 to examine the effectiveness of this strategy. Patients with laboratory-confirmed MDRTB were treated with one of six regimens based on enrollment date (i.e., without randomization). Each regimen differed from the previous one, usually by a single change. All regimens contained a fluoroq...

競爭壓力改變族群 19A容易造成invasive disease and resistance Explaining the Increase in Pneumococcal Serotype 19A Heptavalent conjugated pneumococcal vaccine is associated with increased carriage of pneumococcal serotype 19A strains. Heptavalent conjugated pneumococcal vaccine (PCV-7) was incorporated into routine U.S. childhood vaccination schedules in 2001. Since then, reports have surfaced about outbreaks or clusters of children with invasive Streptococcus pneumoniae serotype 19A disease (JW Pediatr Adolesc Med May 23 2007 and JW Infect Dis Nov 7 2007). This serotype is known for its tendency to cause invasive disease and its resistance to antibiotics. Is the increase in serotype 19A disease a result of natural fluctuation in serotypes or introduction of the PCV-7 vaccine? To find out, investigators in the Netherlands conducted a post hoc analysis of data from a randomized study of PCV-7 dosing schedules conducted before routine use of the vaccine. Researchers compared the cumulative proportion ...

1/3人類H5N1病例在印尼，所以有理由相信印尼的豬也有問題 是地，豬是健康的帶菌者!! H5N1 Influenza A Infection of Pigs in Indonesia In areas with H5N1 influenza outbreaks in poultry, the virus was isolated from healthy-appearing pigs. About one third of all confirmed human H5N1 infections worldwide have occurred in Indonesia. Because pigs are believed to be "mixing vessels" for avian and human influenza viruses, investigators assessed whether pigs in Indonesia were being infected with H5N1 and whether the virus was changing receptor specificity. The researchers sampled nasal, fecal, and serum samples from healthy-appearing pigs in various districts of the country during three rainy seasons between 2005 and 2009. Among 702 nasal specimens obtained in 2005 and 2007, H5N1 was isolated from 52 (7.4%). Culture-positive pigs showed no signs of influenza-like illness. Among 300 pigs tested in 2008–2009, none were culture positive, although 3 (1%) had neutralizing antibodies to H5N1 virus. Viral sequences of the hemagglut...