Access of upper airway bacteria to the surgical wound, host factors as expressed by the American Society of Anesthesiologists score, and duration of device-related postoperative communication of the cerebrospinal fluid and the environment are major risk factors for postoperative meningitis after craniotomy.

OBJECT The authors performed a prospective study to define the prevalence and microbiological characteristics of infections in patients undergoing craniotomy and to clarify the risk factors for post-craniotomy meningitis. METHODS Patients older than 18 years who underwent nonstereotactic craniotomies between January 2006 and December 2008 were included. Demographic, clinical, laboratory, and microbiological data were systemically recorded. Patient characteristics, craniotomy type, and pre- and postoperative variables were evaluated as risk factors for meningitis RESULTS Three hundred thirty-four procedures were analyzed (65.6% involving male patients). Traumatic brain injury was the most common reason for craniotomy. Almost 40% of the patients developed at least 1 infection. Ventilatorassociated pneumonia (VAP) was the most common infection recorded (22.5%) and Acinetobacter spp. were isolated in 44% of the cases. Meningitis was encountered in 16 procedures (4.8%), and CSF cultures were positive for microbial growth in 100% of these cases. Gram-negative pathogens (Acinetobacter spp., Klebsiella spp., Pseudomonas aeruginosa, Enterobacter cloaceae, Proteus mirabilis) represented 88% of the pathogens. Acinetobacter and Klebsiella spp. demonstrated a high percentage of resistance in several antibiotic classes. In multivariate analysis, the risk for meningitis was independently associated with perioperative steroid use (OR 11.55, p = 0.005), CSF leak (OR 48.03, p < 0.001), and ventricular drainage (OR 70.52, p < 0.001). CONCLUSIONS Device-related postoperative communication between the CSF and the environment, CSF leak, and perioperative steroid use were defined as risk factors for meningitis in this study. Ventilator-associated pneumonia was the most common infection overall. The offending pathogens presented a high level of resistance to several antibiotics.

Among patients with RA, biologic agents are associated with a small but significant risk of specific OIs. This increase is associated with mycobacterial diseases and does not seem to affect overall mortality. Because OIs are a relatively rare complication of biologic agents, large registries are needed to identify the exact effect in different OIs and to compare the different biologic agents.

Traumatic brain injury (TBI) victims are considered to be at high risk for infection. The purpose of this cohort study was to delineate the rates, types and risk factors for infection in TBI patients. Retrospective surveillance of infections was conducted for all TBI patients, aged ≥18 years, cared for at the Department of Neurosurgery of the University Hospital of Heraklion, Greece, between 1999 and 2005. A total of 760 patients (75% men) with a median age of 41 years were included. Most (59%) were injured in a motor vehicle accident. One third of them underwent a surgical procedure. Two hundred and fourteen infections were observed. The majority were infections of the lower respiratory tract (47%), followed by surgical site infections (SSI) (17%). Multivariate analysis showed that SSI development was independently associated with the performance of ≥2 surgical procedures (OR 16.7), presence of concomitant infections, namely VAP (OR 5.7) and UTI (OR 8.8), insertion of lumbar (OR 34.5) and ventricular drains (OR 4.0), and cerebrospinal fluid (CSF) leak (OR 3.8). Development of meningitis was associated with prolonged hospitalization (OR 1.02), especially >7 days ICU stay (OR 25.5), and insertion of lumbar (OR 297) and ventricular drains (OR 9.1). There was a notable predominance of Acinetobacter spp. as a VAP pathogen; gram-positive organisms remained the most prevalent in SSI cases. Respiratory tract infections were the most common among TBI patients. Device-related communication of the CSF with the environment and prolonged hospitalization, especially in the ICU setting, were independent risk factors for SSIs and meningitis cases.

Prompt diagnosis is essential in spinal infections. Early surgical intervention is required in patients with neurological deficits. Further research should clarify the appropriate duration of antimicrobial treatment and the overall role of surgery.

The 81-kDa malate synthase (MS; Rv 1837c) and the 27-kDa MPT51 (Rv 3803c) of Mycobacterium tuberculosis are immunodominant antigens recognized by serum antibodies from ϳ80% of human immunodeficiency virus-negative smear-positive tuberculosis patients from India. We now provide evidence that the use of the MS/MPT51-based serodiagnostic assay can serve as an adjunct to sputum microscopy in the rapid diagnosis of pulmonary tuberculosis.Approximately 50% of the pulmonary tuberculosis (PTB) cases in the United States are smear negative for acid-fast bacilli (AFB), leading to a diagnostic delay of several weeks due to the low growth rate of Mycobacterium tuberculosis (2a). Delayed recognition of smear-negative PTB is estimated to be responsible for ϳ20% of the cases of TB transmission (2). Nucleic acid amplification assays can detect ϳ50% of these cases but are too expensive for routine screening for smearnegative PTB (1,13,20). Diagnostic tests that can enhance the early recognition of paucibacillary TB are therefore urgently required.Our earlier studies have delineated a subset of ϳ10 to 12 culture filtrate proteins of M. tuberculosis that are recognized by antibodies (Abs) in patients with human immunodeficiency virus-negative (HIV Ϫ ) multibacillary as well as paucibacillary TB and in HIV-infected (HIV ϩ ) TB patients (19). Two of these, the 81-kDa protein malate synthase (MS; Rv 1837c) and the 27-kDa protein MPT51 (Rv3803c) are recognized by Abs in ϳ80% of HIV Ϫ , smear-positive TB patients from India (21). Our studies have shown that paucibacillary TB patients have low titers of Abs compared to multibacillary patients (19). The goal of the present study was to determine the presence of Abs to MS and/or MPT51 in culture-confirmed patients from the United States, who tend to present at an early stage of TB, and to assess the ability of the serodiagnostic assay to serve as an adjunct to AFB smears for the rapid diagnosis of PTB.Approval for human subject research was obtained from the institutional review boards of the New York University School of Medicine, Bellevue Hospital, and the Manhattan Veterans Administration, and written informed consent was obtained from all individuals prior to the drawing of blood samples and review of medical records. Patients clinically suspected of having PTB were enrolled, and their sera were frozen. Only specimens from patients later confirmed to be M. tuberculosis culture positive (TB ϩ ; n ϭ 53) were included in the studies (Table 1). Subjects treated for TB for Ͼ14 days were excluded. Serum specimens from 55 healthy controls with no risk factors for HIV infection (36 with tuberculin skin test [TST]-positive results and 19 with TST-negative results) were also obtained. The TST-positive subjects had indurations of Ͼ10 mm and included volunteers who had been vaccinated with Mycobacterium bovis BCG and/or had a history of TB exposure. Sera from 40 asymptomatic HIV ϩ patients, all of whom were on highly active antiretroviral therapy, were also included; 36/40 (90%) had undetectable...

IntroductionDirect oral anticoagulants (DOAC) have gained an increased share over warfarin for prevention and treatment of thromboembolic disease. We studied DOAC adoption across providers and medical specialties.MethodsRetrospective, cross-sectional analysis of Medicare Part D public use files (PUF), 2013 to 2015. We summarized prescription data for claims and drug payment, stratified by drug class, specialty and calendar year. We treated DOAC claims as a count outcome and explored patterns of expansion across prescribers via a truncated negative binomial regression. We described dispersion and spread in DOAC prescribing, across hospital referral regions (HRRs), including the p90/p10 ratios, and the median absolute deviation from the median.ResultsIn 2015 part D PUF, oral anticoagulant claims have climbed to approximately 24.4 million with a payment cost of approximately $3.3 billion. DOAC claims comprised 31.0% of oral anticoagulant claims, showing a relative increase of approximately 127% compared to 2013. The upper decile of prescribers accounted for half of the oral anticoagulant prescriptions and the resulting cost. The median cost per DOAC claim in 2015 was $367.4 (interquartile range 323.9 to 445.9), as opposed to $12.3 (interquartile range 9.2 to 16.5) for warfarin. The median cost per standardized (30-day supply) prescription was $317.0 (interquartile range 303.8 to 324.3) and $8.0 (6.7 to 9.8) for DOACs and warfarin, respectively. DOAC adoption differs by specialty. Cardiologists, cardiac electrophysiologists and orthopedics had the highest predicted DOAC share per 100 claims (53.8, 72.9 and 71.5, respectively in 2015); nephrologists, family practitioners and geriatricians the lowest (22.3, 21.5 and 20.7, respectively in 2015). The p90/p10 ratio and the median absolute deviation from the median varied across HRRs and correlated positively with the prevalence of stroke and atrial fibrillation in the Medicare population.ConclusionsDOACs have been increasing their share year-over-year, but adoption varies across specialties. In prevalent areas for stroke and atrial fibrillation, prescription dispersion magnifies, and this may signify a rapid adoption by top providers.

It is unclear what effect automated systems for monitoring sepsis have on any of the outcomes included in this review. Very low-quality evidence is only available on automated alerts, which is only one component of automated monitoring systems. It is uncertain whether such systems can replace regular, careful review of the patient's condition by experienced healthcare staff.