BACKGROUND Despite a reported worldwide increase, the incidence of extended-spectrum β-lactamase (ESBL) Escherichia coli and Klebsiella infections in the United States is unknown. Understanding the incidence and trends of ESBL infections will aid in directing research and prevention efforts. OBJECTIVE To perform a literature review to identify the incidence of ESBL-producing E. coli and Klebsiella infections in the United States. DESIGN Systematic literature review. METHODS MEDLINE via Ovid, CINAHL, Cochrane library, NHS Economic Evaluation Database, Web of Science, and Scopus were searched for multicenter (≥2 sites), US studies published between 2000 and 2015 that evaluated the incidence of ESBL-E. coli or ESBL-Klebsiella infections. We excluded studies that examined resistance rates alone or did not have a denominator that included uninfected patients such as patient days, device days, number of admissions, or number of discharges. Additionally, articles that were not written in English, contained duplicated data, or pertained to ESBL organisms from food, animals, or the environment were excluded. RESULTS Among 51,419 studies examined, 9 were included for review. Incidence rates differed by patient population, time, and ESBL definition and ranged from 0 infections per 100,000 patient days to 16.64 infections per 10,000 discharges and incidence rates increased over time from 1997 to 2011. Rates were slightly higher for ESBL-Klebsiella infections than for ESBL-E. coli infections. CONCLUSION The incidence of ESBL-E. coli and ESBL-Klebsiella infections in the United States has increased, with slightly higher rates of ESBL-Klebsiella infections. Appropriate estimates of ESBL infections when coupled with other mechanisms of resistance will allow for the appropriate targeting of resources toward research, drug discovery, antimicrobial stewardship, and infection prevention. Infect Control Hosp Epidemiol 2017;38:1209-1215.
Objectives: The presence of squamous epithelial cells (SECs) has been advocated to identify urinary contamination despite a paucity of evidence supporting this practice. We sought to determine the value of using quantitative SECs as a predictor of urinalysis contamination. Methods:Retrospective cross-sectional study of adults (≥18 years old) presenting to a tertiary academic medical center who had urinalysis with microscopy and urine culture performed. Patients with missing or implausible demographic data were excluded (2.5% of total sample). The primary analysis aimed to determine an SEC threshold that predicted urine culture contamination using receiver operating characteristics (ROC) curve analysis. The a priori secondary analysis explored how demographic variables (age, sex, body mass index) may modify the SEC test performance and whether SECs impacted traditional urinalysis indicators of bacteriuria.Results: A total of 19,328 records were included. ROC curve analysis demonstrated that SEC count was a poor predictor of urine culture contamination (area under the ROC curve = 0.680, 95% confidence interval [CI] = 0.671 to 0.689). In secondary analysis, the positive likelihood ratio (LR+) of predicting bacteriuria via urinalysis among noncontaminated specimens was 4.98 (95% CI = 4.59 to 5.40) in the absence of SECs, but the LR+ fell to 2.35 (95% CI = 2.17 to 2.54) for samples with more than 8 SECs/lowpowered field (lpf). In an independent validation cohort, urinalysis samples with fewer than 8 SECs/lpf predicted bacteriuria better (sensitivity = 75%, specificity = 84%) than samples with more than 8 SECs/lpf (sensitivity = 86%, specificity = 70%; diagnostic odds ratio = 17. 5 [14.9 to 20.7] vs. 8.7 [7.3 to 10.5 ]).Conclusions: Squamous epithelial cells are a poor predictor of urine culture contamination, but may predict poor predictive performance of traditional urinalysis measures.ACADEMIC EMERGENCY MEDICINE 2016;23:323-330
BackgroundThe relationship between competitive sports and atrial fibrillation (AF) is controversial. We aimed to systematically evaluate and summarize all published observational data on the association between competitive sports and AF.Methods and resultsWe searched PubMed, EMBASE, Scopus and SportDiskus for all observational studies that assessed the risk of AF among athletes involved in competitive sports. Data were extracted and pooled odds ratios (OR) were calculated using random effects models. Six cohort studies and 2 case-control studies with a total of 9113 subjects were included in our meta-analysis. Pooled analyses showed an increased risk of incident and prevalent AF among athletes compared to the general population (OR = 1.64 [95% confidence interval (CI): 1.10–2.43]). Age-stratified analysis revealed an effect modification with age. Studies enrolling younger adults (<54 years) had an increased risk of AF among athletes compared to controls (OR = 1.96 [95% CI: 1.06–3.65]), but this association was not seen among older adults ≥54 years (OR = 1.41 [95% CI: 0.81–2.44], p = 0.23).ConclusionAthletes have an increased risk of AF compared to the general population. Age appears to modify the risk of AF in athletes.
standard, both in the full population and after stratification by sex. Negative predictive value (NPV) was the proportion of patients with a low-risk urinalysis who had a negative culture. The false omission rate (FOR), calculated as 1-NPV, was the proportion of patients with a low-risk urinalysis who had a positive culture. Positive predictive value (PPV) was the proportion of patients with a high-risk urinalysis who had a positive culture.Results: Among 4,859 patients included in the study, 1,140 (23.5%) had a positive urine culture. Among positive cultures, the most common pathogens were Escherichia coli (48.3%), Klebsiella pneumoniae (12.6%), and Enterococcus faecalis (9.0%). A total of 1,677 (34.5%) patients had a low-risk urinalysis. Diagnostic test characteristics of the low-risk urinalysis definition compared to culture results are summarized in the Table . If urine samples with a low risk urinalysis had not undergone culturing, there would have been a 34.5% absolute reduction in urine cultures performed with a FOR of 4.7% (95% CI 3.6%, 5.7%) in the full population. After stratification by sex, the FOR was significantly higher in women (6.9%, 95% CI: 5.3%, 8.8%) compared to men (2.3, 95% CI: 1.4%, 3.6%) (P < .01).Conclusion: A reflex cancellation protocol in which urine cultures are not performed on samples with low-risk urinalysis features (negative nitrites, negative leukocyte esterase, negative bacteria, and 10 urinary WBCs/HPF) would have led to a substantial reduction in urine cultures performed while maintaining a low rate of missed positive cultures, particularly in men. Given the higher FOR in women, more accurate tools to identify urine samples at low risk for infection in women are still needed.
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