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Biomedical subjects

R A Weinstein

Publications and source records attributed to R A Weinstein.

At least 73 records · Page 4Linked to original sources
PubMed1996

Predictors of resource utilization for hospitalized patients with Pneumocystis carinii pneumonia (PCP): a summary of effects from the multi-city study of quality of PCP care.

To determine whether patient and hospital characteristics were significantly associated with variations in Pneumocystis carinii (PCP) care and outcomes, we analyzed the use of diagnostic tests, intensive care units (ICUs), anti-PCP medications for persons hospitalized with human immunodeficiency virus (HIV)-related PCP, and hospital discharge status. We conducted retrospective chart reviews of a cohort of 2,174 patients with PCP hospitalized in 1987-1990. Outcomes included process of care for PCP and in-hospital mortality rates. Persons with PCP who were more severely ill at admission were more likely to have early medical care, to receive care in an intensive care unit, and to die in hospital. After we adjusted for differences in this severity of illness, we noted that Medicaid patients, injection drug users (IDUs), and patients treated at VA or county hospitals were significantly less likely than others to have diagnostic bronchoscopies and that persons covered by Medicaid, with a previous diagnosis of acquired immunodeficiency syndrome (AIDS), who did not receive prior zidovudine (AZT) or who received care in a VA hospital had the highest chances of in-hospital death. Insurance and risk group characteristics, severity of illness, and hospital characteristics appear to be the most important determinants of the intensity and timing of medical care and outcomes among patients hospitalized with PCP.

AIDS-Related Opportunistic Infections↗
PubMed1996

Strategies to Prevent and Control the Emergence and Spread of Antimicrobial-Resistant Microorganisms in Hospitals. A challenge to hospital leadership.

OBJECTIVE: To provide hospital leaders with strategic goals or actions likely to have a significant impact on antimicrobial resistance, outline outcome and process measures for evaluating progress toward each goal, describe potential barriers to success, and suggest countermeasures and novel improvement strategies. PARTICIPANTS: A multidisciplinary group of experts was drawn from the following areas: hospital epidemiology and infection control, infectious diseases (including graduate training programs), clinical practice (including nursing, surgery, internal medicine, and pediatrics), pharmacy, administration, quality improvement, appropriateness evaluation, behavior modification, practice guideline development, medical informatics, and outcomes research. Representatives from appropriate federal agencies, the Joint Commission on Accreditation of Healthcare Organizations, and the pharmaceutical industry also participated. EVIDENCE: Published literature, guidelines, expert opinion, and practical experience regarding efforts to improve antibiotic utilization and prevent and control the emergence and dissemination of antimicrobial-resistant microorganisms in hospitals. CONSENSUS PROCESS: Participants were divided into two quality improvement teams: one focusing on improving antimicrobial usage and the other on preventing and controlling transmission of resistant microorganisms. The teams modeled the process a hospital might use to develop and implement a strategic plan to combat antimicrobial resistance. CONCLUSIONS: Ten strategic goals and related process and outcome measures were agreed on. The five strategic goals to optimize antimicrobial use were as follows: optimizing antimicrobial prophylaxis for operative procedures; optimizing choice and duration of empiric therapy; improving antimicrobial prescribing by educational and administrative means; monitoring and providing feedback regarding antibiotic resistance; and defining and implementing health care delivery system guidelines for important types of antimicrobial use. The five strategic goals to detect, report, and prevent transmission of antimicrobial resistant organisms were as follows: to develop a system to recognize and report trends in antimicrobial resistance within the institution; develop a system to rapidly detect and report resistant microorganisms in individual patients and ensure a rapid response by caregivers; increase adherence to basic infection control policies and procedures; incorporate the detection, prevention, and control of antimicrobial resistance into institutional strategic goals and provide the required resources; and develop a plan for identifying, transferring, discharging, and readmitting patients colonized with specific antimicrobial-resistant pathogens.

Anti-Bacterial Agents↗
PubMed1996

AIDS-related Pneumocystis carinii pneumonia in older patients.

MAIN RESULTS: Compared with younger patients, patients aged 50 years or older were less likely to have acquired HIV via intravenous drug use or homosexual contact (p = .0001). Older patients were more likely to have comorbid diseases (12% vs 4%; p = .0001), had more frequent neurologic findings on admission (19% vs 9%; p = .0001), and scored higher on a PCP-specific severity-of-illness scale indicating more severe disease (p = .0001). Older patients had more intensive care unit admissions and intubations (p = .0001). Patients aged 50 years or older were less likely to have a diagnosis of HIV mentioned in their progress notes during the first 2 days of admission (75% vs 85%; p = .0001), less likely to receive PCP-specific therapy within the first 2 hospital days (58% vs 76%; p = .0001), and more likely to receive steroids (32% vs 22%; p = .0001). Older patients had a greater in-hospital mortality (32% vs 18%; p = .0001). However, in logistic regression analysis with mortality as the outcome, the effect of older age was diminished when adjustments were made for insurance status, severity of illness, comorbidity, timely PCP therapy, and inpatient use of steroids. CONCLUSIONS: Age differences in mortality for AIDS-related PCP may be explained by increased severity of presenting illness, underrecognition of HIV, and delay in initiation of PCP-specific therapy. Physicians may need to consider HIV-related infections for persons aged 50 years or older at risk of HIV infection.

AIDS-Related Opportunistic Infections↗
PubMed1996

The role of colonization in the pathogenesis of nosocomial infections.

The close relationship between colonization and the development of nosocomial infections has been demonstrated. Patient-related factors, such as underlying illness for all major sites of infection and advanced age, and pathogen-related factors, such as the ability of bacteria to adhere to epithelial cells, play the major roles in the pathogenesis of colonization. However, exact mechanisms of colonization have not been elucidated, and modulation of bacterial adherence as a method of infection prevention remains experimental. Current methods of infection prevention, therefore, focus either on preventing growth of colonizing microorganisms or on preventing patient-pathogen contact. Topical antibiotics have been used as a method of colonization prevention. However, their effectiveness may be limited by increases in antibiotic resistance; moreover, the effects of patient outcome are controversial. Maintenance of the physiologic mucosal environment using nonantimicrobial agents seems a promising approach, but only a few studies demonstrating efficacy have been published. Prevention of colonization still must rely heavily on basic infection control measures to prevent contact between patient and pathogen.

Bacterial Adhesion↗
PubMed1996

Nosocomial infection caused by antibiotic-resistant organisms in the intensive-care unit.

Resistance to antimicrobial agents is an evolving process, driven by the selective pressure of heavy antibiotic use in individuals living in close proximity to others. The intensive care unit (ICU), crowded with debilitated patients who are receiving broad-spectrum antibiotics and being cared for by busy physicians, nurses, and technicians, serves as an ideal environment for the emergence of antibiotic resistance. Problem pathogens presently include multiply resistant gram-negative bacilli, methicillin-resistant Staphylococcus aureus, and the recently emerged vancomycin-resistant enterococci. The prevention of antimicrobial resistance in ICUs should focus on recognition via routine unit-based surveillance, improved compliance with handwashing and barrier precautions, and antibiotic-use policies tailored to individual units within hospitals.

Cross Infection↗
PubMed1996

Infective endocarditis in injection drug users: importance of human immunodeficiency virus serostatus and degree of immunosuppression.

Human immunodeficiency virus (HIV)-infected patients are at increased risk for serious and recurrent bacterial infections. We hypothesized that the degree of immunosuppression may play an important role in outcomes for HIV-seropositive patients with infective endocarditis (IE). To test our hypothesis, we retrospectively reviewed 144 cases of IE in injection drug users. One hundred two patients with documented HIV status (45 HIV-seropositive patients and 57 HIV-seronegative patients) were included in the analysis. Eleven patients (6 HIV-seropositive patients and 5 HIV-seronegative patients) died in the hospital. Staphylococcus aureus, the most common etiologic pathogen causing IE in our series, was isolated from 32 HIV-seropositive patients (71.1%) and 32 HIV-seronegative patients (56.1%). A clear inverse correlation between mortality rate and CD4 cell count was demonstrated (r = -.625; P < .001). Both univariate and multivariate analyses supported the finding of significantly higher mortality rates among patients with CD4 cell counts of < 200/mm3 than among patients with CD4 cell counts of > 500/mm3 (OR, 14.7; 95% CI, 2.64-81.9).

Adult↗
PubMed1996

The new era of hospital epidemiology: what you need to succeed.

Managed care and competition are creating pressures to control costs and prevent adverse outcomes in health care. These forces are also creating a new era in hospital epidemiology, one in which there are many opportunities for the infectious disease physician. The ability to create and administer a hospital epidemiology program is a valuable asset in this environment. Included in hospital epidemiology programs are activities such as infection control, quality management, employee health, risk management, and microbiology and clinical pharmacy consultations. The hospital epidemiologist must be prepared to take advantage of the opportunities created.

Epidemiology↗
PubMed1996

"Curbside" consultation and informal communication in medical practice: a medicolegal perspective.

In assessing whether a consulting physician is liable as a result of an informal ("curbside") communication, courts examine all of the facts and circumstances to determine if a physician-patient relationship existed. Merely answering a colleague's question or performing a curbside consultation may not give rise to a physician-patient relationship; hence, there is no liability. When duty of care can be established, a physician may be liable for medical malpractice. Infectious diseases physicians with contractual managed-care roles may have an unrecognized duty of care and may actually be at increased risk of liability. Physicians are also under duty to act as any reasonably prudent person would act on the basis of any foreseeable risk of injury to others. In general, physicians should encourage formal consultation when expert advice is sought because a more reliable and complete exchange of information occurs before an opinion is rendered in this setting. While informal interchange between colleagues is often of educational benefit, consultants should avoid giving specific advice about a patient whom they have not examined, answer queries in general terms, and consider keeping a written record of the interaction.

Communication↗
PubMed1996

Antimicrobial resistance rates among aerobic gram-negative bacilli recovered from patients in intensive care units: evaluation of a national postmarketing surveillance program.

We assessed the rates of antimicrobial resistance between 1990 and 1993 in intensive care units in the United States. A standardized microtiter minimal inhibitory concentration panel was used to test approximately 100 consecutive gram-negative aerobic isolates that were recovered primarily from blood, wounds, urine, and pulmonary sites in patients treated in each of 396 intensive care units in 45 states. Amikacin and imipenem were the agents most active against the 33,869 nonduplicate isolates (those recovered only once) tested. Resistance of aerobic gram-negative bacilli to third-generation cephalosporins was found to be an emerging problem. Increases in rates of resistance to ceftazidime among isolates of Klebsiella pneumoniae (from 3.6% to 14.4%; P << .01) and Enterobacter species (from 30.8% to 38.3%; P = .0004) were noted from 1990 to 1993; rates of resistance among Pseudomonas aeruginosa isolates remained stable. Ceftazidime-resistant bacteria were frequently resistant to aminoglycosides and ciprofloxacin. Risk factors for ceftazidime resistance included the number of beds in the hospital, the teaching status of the hospital, and specific body sites from which the isolates were recovered.

Amikacin↗
PubMed1996

Ceftazidime-resistant Klebsiella pneumoniae and Escherichia coli bloodstream infection: a case-control and molecular epidemiologic investigation.

In a molecular, microbiologic, and case-control study to describe the epidemiology of ceftazidime-resistant Klebsiella pneumoniae and Escherichia coli bloodstream infection, 32 unique isolates were recovered over 31 months from the blood of patients hospitalized in a 900-bed hospital in Chicago. Multivariate analysis revealed cases occurred more frequently in debilitated nursing home patients with central venous catheters than in younger, healthier patients. Mortality rates were similar for cases and controls. Case-patients were less likely to die if they received appropriate antibiotic treatment within 3 days of bacteremia onset (P = .02). Pulsed-field gel electrophoresis analysis indicated a polyclonal outbreak, with strain-specific temporal and geographic clustering. Isoelectric focusing results suggested that a predominant enzyme, TEM-10, was responsible for the ceftazidime resistance. The resistance gene was usually carried on a large conjugative plasmid. The polyclonality of the resistant strains suggests that ceftazidime resistance due to TEM-10 is now endemic in Chicago.

Adolescent↗
PubMed1995

Patterns of care for and outcomes of Pneumocystis carinii pneumonia among persons with transfusion-acquired AIDS.

BACKGROUND: The most common human immunodeficiency virus (HIV)-related cause of death in persons with transfusion-acquired (TA) AIDS has been Pneumocystis carinii pneumonia (PCP). While better treatment for PCP accounts for improved survival among HIV-infected homosexual or bisexual men, the extent to which others have benefitted from these developments is unknown. STUDY DESIGN AND METHODS: Patterns of PCP care among persons with TA-AIDS, intravenous drug users, and homosexual or bisexual men are compared. RESULTS: TA-AIDS patients were older (mean, 46 years vs. < 40 for others, p < 0.05), more severely ill (59% had an alveolar-arterial oxygen gradient > 48.5 torr vs. 41% of others, p < 0.05), and less likely to have received PCP prophylaxis (16% of TA-AIDS patients versus 24-41% of others, p < 0.05). PCP care and outcomes also differed: TA-AIDS patients were less than half as likely to have early use of PCP medications (relative odds ratio = 0.45; 95% CI, 70% vs. > 80% for others, p < 0.05), more likely to be intubated (22% vs. 9-13% of others, p < 0.05), and more likely to die in-hospital (26% vs. 13-22% of others, p < 0.05). After controlling for differences in severity of illness, insurance, age, and hospital characteristics, TA-AIDS patients were 45 percent as likely to have early PCP therapy (95% CI, 22%, 91%) as were persons in high-risk groups. CONCLUSION: For persons whose only risk factor was transfusion, recognition of the HIV infection and its complications appears to be problematic, which may help explain poorer outcomes in persons with HIV-related PCP.

Acquired Immunodeficiency Syndrome↗
PubMed1995

A randomized, double-blind, placebo-controlled trial of selective digestive decontamination in a medical-surgical intensive care unit.

A randomized, double-blind, placebo-controlled trial of selective decontamination of the oropharynx and gastrointestinal tract was conducted on 61 intubated patients in a medical-surgical intensive care unit (ICU) to determine the impact on nosocomial pneumonia, other infections, and emergence of colonization or infection with antibiotic-resistant bacteria. Over 8 months, 30 patients received an oral paste and solution containing polymyxin, gentamicin, and nystatin; 31 patients received a placebo paste and solution. At study entry, patients in both groups were seriously ill (mean acute physiologic score, 27.2), frequently had pulmonary infiltrates (73.8%), and were likely to be receiving systemic antibiotics (86.9%). There were no differences between study patients and control patients in these characteristics or in frequency of any nosocomial infection (50% vs. 55%), nosocomial pneumonia (27% vs. 26%), febrile days (2.3 vs. 2.0), duration of antibiotic therapy (14.0 vs. 13.4), or mortality rates (37% vs. 48%). There was no difference in infections caused by antibiotic-resistant gram-negative bacilli, although a trend towards more frequent infection with gentamicin-resistant enterococci was found for study patients. Selective decontamination did not appear to be effective in our very ill medical-surgical ICU patients, although the number of patients in our trial was sufficient to detect only a 50% or greater reduction in pneumonia rates.

Colistin↗
PubMed1995

Control of nosocomial infections in an intensive care unit in Guatemala City.

We tested the effectiveness of specific vs. general infection control interventions in a teaching hospital in Guatemala City. After 3 months of prospective surveillance, we implemented targeted interventions (i.e., modification of respiratory tract care and use of a closed urinary catheter drainage system), an educational program focused on respiratory intervention, and general interventions (i.e., aseptic technique). The rate of nosocomial pneumonia, the most common nosocomial infection, decreased from 33% (41 of 123 patients) before intervention to 16% (21 of 130 patients) after intervention (P = .001). Although the frequency of hand washing increased from 5% to 63% (P < .001), the rates of other types of nosocomial infections did not change significantly. The combination of targeted respiratory intervention and an intense, focused educational campaign reduced the rate of nosocomial pneumonia. General improvements in hygiene and hand washing rates, or even implementation of a closed urinary drainage system without focused education, may not be sufficient to reduce infection rates in intensive care units in developing countries.

Adult↗
PubMed1995

Reactive hemophagocytic syndrome: a new presentation of disseminated histoplasmosis in patients with AIDS.

We report the cases of six patients with AIDS in whom reactive hemophagocytic syndrome (RHPS) secondary to disseminated histoplasmosis was diagnosed. RHPS was diagnosed by established criteria, including fever (duration of > or = 7 days, with peak temperatures of > 38.5 degrees C), unexplained thrombocytopenia with anemia and/or neutropenia, and bone marrow biopsy findings of hemophagocytic histiocytosis. Disseminated Histoplasma capsulatum infection was diagnosed on the basis of the results of cultures of the bone marrow sample. The serum lactate dehydrogenase (LDH) level was elevated (> 1,000 IU/L) in all patients, and five of six patients had hyperferritinemia (range of ferritin level, 15,848-425,984 ng/mL). Five patients had features resembling severe sepsis with multiorgan dysfunction. Three patients recovered, and the findings of RHPS resolved following therapy with amphotericin B. In patients with AIDS, the combination of fever, cytopenia, elevated serum LDH level (> 1,000 IU/L), and/or hyperferritinemia (ferritin level of > 10,000 ng/mL) is a clue to the diagnosis of RHPS and disseminated histoplasmosis; bone marrow biopsy is valuable in establishing the diagnosis.

AIDS-Related Opportunistic Infections↗
PubMed1995

Empirically treated Pneumocystis carinii pneumonia in Los Angeles, Chicago, and Miami: 1987-1990.

Many patients infected with the human immunodeficiency virus (HIV) with symptoms suggestive of pneumonia are treated empirically for Pneumocystis carinii pneumonia (PCP), although other bacterial infections (e.g., tuberculosis) and pulmonary Kaposi's sarcoma may cause identical symptoms. Empiric treatment for PCP may result in misdiagnosis and mistreatment. When the outcomes of cytologically confirmed versus empirically treated PCP cases were evaluated, the most important predictors of in-hospital mortality were severity of illness and use of bronchoscopy. Persons who did not undergo bronchoscopy had higher mortality rates than patients negative by bronchoscopy or cytologically confirmed as positive for PCP (22% vs. 11% vs. 14%, P < .01), although severity of illness and timing of anti-PCP medications did not differ significantly. Compared with cytologically confirmed cases, persons who did not have bronchoscopy were more likely to die than were bronchoscopy-negative patients (P < .05), after adjusting for severity of illness. Bronchoscopy use may have contributed to better outcomes for persons treated for HIV-related PCP.

AIDS-Related Opportunistic Infections↗
PubMed1995

Relationship between procedures and health insurance for critically ill patients with Pneumocystis carinii pneumonia.

The objective of the present study was to assess the association between type of health insurance coverage and use of diagnostic tests and therapies among patients with AIDS-related Pneumocystis carinii pneumonia (PCP). Fifty-six private, public, and community hospitals in Chicago, Los Angeles, and Miami were selected for the study, and the charts of 890 patients with empirically treated or cytologically confirmed PCP, hospitalized during 1987 to 1990 were retrospectively reviewed. Patients were classified by insurance status: self-pay (n = 56), Medicaid (n = 254), or private insurance, including health maintenance organizations and Medicare (n = 580). Primary outcomes were the use and timing of bronchoscopy, the type and timing of PCP therapy, and in-hospital mortality. The results indicate that Medicaid patients were less likely than privately insured patients to undergo bronchoscopy (relative odds = 0.61; 95% CI = 0.40, 0.93; p = 0.02) or to have their diagnosis of PCP confirmed (relative odds = 0.51; 95% CI = 0.33, 0.77), after adjusting for patient, severity of illness, and hospital characteristics. Medicaid patients were approximately three-fourths more likely than privately insured patients (relative odds = 1.73; 95% CI = 1.01, 2.96; p = 0.04) to die in-hospital, after adjusting for patient, severity of illness, and hospital characteristics. However, with further adjustment for confirmation of PCP, Medicaid patients no longer had a significantly higher likelihood of dying in-hospital. We conclude that Medicaid patients are less likely to receive diagnostic bronchoscopy than privately insured or self-insured patients, more likely to be empirically treated for PCP, and more likely to die in-hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Related Opportunistic Infections↗
PubMed1994

A rapid preadmission method for predicting inpatient course of disease for patients with HIV-related Pneumocystis carinii pneumonia.

Pneumocystis carinii pneumonia (PCP) has been the most common reason for hospitalization and the most common cause of death for persons with HIV infection. Hospital mortality rates for PCP range from 10 to 60%. Studies that evaluate differences in hospital mortality rates must control for differences in patient severity of illness. We developed a simple staging system for categorizing severity of illness in patients with PCP. We analyzed the relation between clinical factors and in-hospital mortality for 576 hospitalized patients with HIV-related PCP treated at 56 hospitals for the years 1987 to 1990. Four stages of PCP could be identified based on three routinely measured clinical variables: alveolar-arterial oxygen difference, total lymphocyte count, and body mass index. The mortality rate increased by stage: 1% for Stage 1, 8% for Stage 2, 23% for Stage 3, and 48% for Stage 4. The four-stage severity system compared well with previous models developed for AIDS and for PCP, and is easier to use in clinical practice. Our staging system identifies patients with a high and low risk of in-hospital death upon admission. Physicians may benefit from consideration of PCP stage in deciding on management strategies. In addition, researchers involved in clinical trials of new agents for PCP might consider stratification by PCP stage in order to define homogenous groups.

AIDS-Related Opportunistic Infections↗