492
Table 1. Duration of Antimicrobials Among Patients Who Did and Did Not Change Their Code Status
Variable
Discharged on antimicrobials, no. (%)
Total duration (days) of
antimicrobials (inpatient þ outpatient), median (IQR)
Duration (days) of inpatient antimicrobials, median (IQR)
6(4–12.8) Note. IQR, interquartile range; NS, not significant. 5 (4–9.5) NS
Patients Not Changing Code Status (n = 96)
36 (37.5) 9 (4.3–22.3) Patients
ChangingCode Status (n = 36)
6 (16.7) P
Value .022
6.5 (4–12) .044
Jussimara Monteiro et al
in reducing antimicrobial consumption in patients at the end of life. Antimicrobial stewardship programs should consider engaging palliative-care providers in the development of end- of-life antimicrobial stewardship efforts.
Author ORCIDs. Jason Burnham, Acknowledgments.
0000-0002-4777-3006
Financial support. Dr. Kollef was supported by the Barnes-Jewish Hospital Foundation. This publication was made possible by the NIH-National Center for Advancing Translational Sciences (NCATS), components of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research (grant no. UL1 TR002345, subaward KL2 TR002346). Its contents are solely the respon- sibility of the authors and do not necessarily represent the official view of NCATS or NIH.
interquartile range [IQR], 3–7) than patients not discharged to hos- pice (n = 109; median, 7 days; IQR, 4–12).When analyzing by ran- domization arm, we found no statistically significant difference in discharge on antimicrobial therapy (P = .14). However, patients in the control armof the study were assigned to usual care, in which they could undergo palliative-care consultation.
Discussion
In a cohort of patients enrolled in a randomized controlled trial of early palliative-care consultation, patients who changed their code status were less likely to be discharged on antimicrobials and to receive overall shorter courses of antimicrobials. This difference was primarily driven by patients transitioning to hospice (n = 23) with 0 of 23 patients discharged on antimicrobials, a number sub- stantially lower than in previous studies.4 Palliative care consultants help clarify resuscitation pref-
erences and discuss the risks and benefits of many different therapies for patients at the end of life; antimicrobials are among these. Antimicrobials in patients at the end of life are frequently used but with uncertain benefit.5,7 Our study suggests that early palliative-care consultation, even when not designed as an anti- microbial stewardship intervention, may nonetheless be effective
Conflicts of interest. All authors have no conflicts of interest to report.
References 1. Vincent JL, Rello J, Marshall J, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009;302: 2323–2329.
2. Antibiotic resistance threats in the United States, 2013. Centers for Disease Control and Prevention website.
https://www.cdc.gov/drugresistance/pdf/ar- threats-2013-508.pdf. Published 2013. Accessed February 12, 2019.
3. Thorpe KE, Joski P, Johnston KJ. Antibiotic-resistant infection treatment costs have doubled since 2002, now exceeding $2 billion annually. Health Affairs 2018;37:662–669.
4. Thompson AJ, Silveira MJ, Vitale CA, Malani PN. Antimicrobial use at the end of life among hospitalized patients with advanced cancer. Am J Hosp Palliat Care 2012;29:599–603.
5. Reinbolt RE, Shenk AM, White PH, Navari RM. Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. J Pain Symptom Manage 2005;30:175–182.
6. Ma J, Chi S, Buettner B, et al. Early palliative care consultation in the medical ICU: a cluster randomized crossover trial. Crit Care Med 2019 (in review).
7. Rosenberg JH, Albrecht JS, FrommeEK, et al. Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review. J Palliat Med 2013;16:1568–1574.
A major monoclonal hospital outbreak of NDM-1–producing Klebsiella pneumoniae ST340 and the first report of ST2570 in Brazil
Jussimara Monteiro1
1Department of Research and Development, Associação Fundo de Incentivo a Pesquisa (AFIP – Medicina Diagn´ Section, Associação Fundo de Incentivo a Pesquisa (AFIP – Medicina Diagn´
, Fernanda M. Inoue1, Ana Paula T. Lobo2, Aline S. Ibanes3, Sergio Tufik1 and Carlos R. V. Kiffer4 ostica), São Paulo, Brazil, 2Clinical Microbiology
de São Caetano do Sul, São Paulo, Brazil and 4Division of Infectious Diseases, Department of Internal Medicine, Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil
To the Editor Author for correspondence: Jussimara Monteiro, Email:
jussimara.nurmberger@afip.
com.br PREVIOUS PRESENTATION: This report was presented in part at session 229 as
poster no. 487 at the ASM MICROBE conference on May 9, 2018, in Atlanta, Georgia. Cite this article: Monteiro J, et al. (2019). A major monoclonal hospital outbreak of
NDM-1–producing Klebsiella pneumoniae ST340 and the first report of ST2570 in Brazil. Infection Control&Hospital Epidemiology, 40: 492–494,
https://doi.org/10.1017/ice.2018.333
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved.
ostica), São Paulo, Brazil, 3Infection Control Service, Complexo Hospitalar Municipal —
New Delhi metallo-β-lactamase (NDM) is one of
the main globally described carbapenemases. It was first reported in 2009 in India.1 Providencia rettgeri was first reported in Brazil in 2013.2NDMemergence has been described in Brazil among gram- negative bacteria related to infection or the environment.3–5 Here,we describe an outbreak of NDM-1–producing Klebsiella pneumoniae (KPN) strains ST340 and ST2570 in 50 single isolates from 2 Brazilian hospitals between May 2017 and July 2018 (Figure 1).
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