Historically, most clinical microbiology laboratories report that 80 to 90% of enterococci are Enterococcus faecalis, whereas E. faecium accounts for 5 to 10% of isolates. At our medical center from 1993 to 2002, we evaluated the percentages of E. faecium among all enterococcal isolates and the percentages of E. faecium isolates that were vancomycin resistant. Over this 10-year period, the percentage of enterococci that were identified as E. faecium increased from 12.7 to 22.2% (P < 0.001) and the proportion of E. faecium that was vancomycin resistant increased from 28.9 to 72.4% (P < 0.001). Both the percentage of E. faecium among the enterococci and the proportion of vancomycin-resistant E. faecium increased significantly over this 10-year period.
Blood stream infections (BSIs) are an important cause of morbidity and mortality in patients with left ventricular assist devices (LVADs). The aim of this study was to examine the correlation between hemorrhagic cerebrovascular accident (CVA) and BSI after implantation of LVAD for advanced heart failure (HF). This was a retrospective descriptive review of 87 patients with end-stage HF, who underwent implantation of HeartMate II continuous-flow LVAD over a 4 year period. Blood stream infections were diagnosed by serial blood cultures, and suspected neurological complications including CVAs were confirmed by neuroimaging. Extensive patient chart review was performed, and descriptive characteristics were analyzed using SPSS statistical software. The mean age of our study population was 62.3 ± 12.8 years, and the majority of our patients were males (n = 75, 86.2%). The baseline characteristics were comparable in the patients with and without CVAs. Patients with BSI had a much greater incidence of CVA compared to patients without BSI (n = 13, 43.3% vs. n = 5, 10.0%; p < 0.0001). There was an increased mortality in patients with BSI than those without (n = 57, 65.5% vs. n = 30, 34.5%; p = 0.003). The risk of all CVAs (hemorrhagic/ischemic) was eightfold (odds ratio [OR] = 7.9; 95% confidence interval [CI] = 2.4-25.5; p = 0.001] in patients with BSI. Patients with BSI had a >20-fold risk of hemorrhagic CVA (OR = 24; 95% CI = 2.8-201.1; p = 0.03). Advanced HF patients with LVAD support who developed BSI need urgent evaluation and close monitoring for suspected neurological complications, particularly hemorrhagic CVA.
PURPOSE: Sepsis is the body's overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure, and death. It is also associated with a significant financial impact on healthcare systems. As sepsis is known as a prominent cause of deaths in the United States (US), a regional state wise incidence of this disease could provide additional information and insight with regards to its geographical distribution. Over the past decade, reimbursement and lack of trained physicians have been cited as major challenges in the battle against sepsis. METHODS: We conducted a descriptive analysis using mortality data from the National Center for Health Statistics' (NCHS), Compressed Mortality File (CMF), which contains descriptive data on the age, race, sex, year and causes of all deaths in the US. We used this data set as it is the only one which aggregates US death incidence with regards to geographical distribution. We defined sepsis death as death attributed to an infection. The location of current Critical Care fellowships was obtained from the National Residency Matching Program (NRMP) public data. We mapped this data using Google fusion tables and studied them in relation to deaths attributed to infection in the continental US, after running algorithms through the NCHS software, selecting deaths from infections, in age groups 20 years and older, in all races, and both sexes, with state wise charting of the data. RESULTS: A total of 150 Critical Care fellowship programs were identified. Our results indicate that Critical Care fellowship programs tend to be more concentrated in the Northeast and metropolitan areas in the Western regions of the US, which parallel similar patterns noted in other specialties. Survival rates for sepsis were also noted to be higher in these locations. Several previous studies have indicated that physicians often tend to practice in geographic areas close to their training sites. A cluster extending from the Southeastern to the mid-Atlantic US encompassed states with the highest sepsis mortality, whereas relatively, the west coast had a significantly lower crude mortality rate as compared to the south eastern regions. CONCLUSIONS: The use of this novel mapping approach to assess the Critical Care physician workforce has the potential of providing real time data regarding their geographical spread. CLINICAL IMPLICATIONS: The discrepancies between supply and demand could be addressed by targeted rebalancing interventions that may include additional fellowship spots, in Critical Care Medicine, in 'underserved' areas as well as financial and practice incentives.
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