| 61. |
- Gigante, Bruna, et al.
(författare)
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Management of patients on antithrombotic therapy with severe infections : a joint clinical consensus statement of the ESC Working Group on Thrombosis, the ESC Working Group on Atherosclerosis and Vascular Biology, and the International Society on Thrombosis and Haemostasis
- 2023
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Ingår i: European Heart Journal. - : Oxford University Press. - 0195-668X .- 1522-9645. ; 44:32, s. 3040-3058
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Tidskriftsartikel (refereegranskat)abstract
- Patients with severe infections and a pre-existing indication for antithrombotic therapy, i.e. antiplatelet agents, anticoagulant drugs, or their combinations, require integrated clinical counselling among coagulation, infectious disease, and cardiology specialists, due to sepsis-induced coagulopathy that frequently occurs. Bacterial and viral pathogens constitute an increasing threat to global public health, especially for patients with ongoing antithrombotic treatment who have a high risk of thrombotic recurrences and high susceptibility to severe infections with increased morbidity and mortality. Similarly, sepsis survivors are at increased risk for major vascular events. Coagulopathy, which often complicates severe infections, is associated with a high mortality and obligates clinicians to adjust antithrombotic drug type and dosing to avoid bleeding while preventing thrombotic complications. This clinical consensus statement reviews the best available evidence to provide expert opinion and statements on the management of patients hospitalized for severe bacterial or viral infections with a pre-existing indication for antithrombotic therapy (single or combined), in whom sepsis-induced coagulopathy is often observed. Balancing the risk of thrombosis and bleeding in these patients and preventing infections with vaccines, if available, are crucial to prevent events or improve outcomes and prognosis.
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| 62. |
- Gisslén, Magnus, 1962, et al.
(författare)
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Amyloid and tau cerebrospinal fluid biomarkers in HIV infection.
- 2009
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Ingår i: BMC neurology. - : Springer Science and Business Media LLC. - 1471-2377. ; 9:1
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Tidskriftsartikel (refereegranskat)abstract
- ABSTRACT: BACKGROUND: Because of the emerging intersections of HIV infection and Alzheimer's disease, we examined cerebrospinal fluid (CSF) biomarkers related of amyloid and tau metabolism in HIV-infected patients. METHODS: In this cross-sectional study we measured soluble amyloid precursor proteins alpha and beta (sAPPalpha and sAPPbeta), amyloid beta fragment 1-42 (Abeta1-42), and total and hyperphosphorylated tau (t-tau and p-tau) in CSF of 86 HIV-infected (HIV+) subjects, including 21 with AIDS dementia complex (ADC), 25 with central nervous system (CNS) opportunistic infections and 40 without neurological symptoms and signs. We also measured these CSF biomarkers in 64 uninfected (HIV-) subjects, including 21 with Alzheimer's disease, and both younger and older controls without neurological disease. RESULTS: CSF sAPPalpha and sAPPbeta concentrations were highly correlated and reduced in patients with ADC and opportunistic infections compared to the other groups. The opportunistic infection group but not the ADC patients had lower CSF Abeta1-42 in comparison to the other HIV+ subjects. CSF t-tau levels were high in some ADC patients, but did not differ significantly from the HIV+ neuroasymptomatic group, while CSF p-tau was not increased in any of the HIV+ groups. Together, CSF amyloid and tau markers segregated the ADC patients from both HIV+ and HIV- neuroasymptomatics and from Alzheimer's disease patients, but not from those with opportunistic infections. CONCLUSIONS: Parallel reductions of CSF sAPPalpha and sAPPbeta in ADC and CNS opportunistic infections suggest an effect of CNS immune activation or inflammation on neuronal amyloid synthesis or processing. Elevation of CSF t-tau in some ADC and CNS infection patients without concomitant increase in p-tau indicates neural injury without preferential accumulation of hyperphosphorylated tau as found in Alzheimer's disease. These biomarker changes define pathogenetic pathways to brain injury in ADC that differ from those of Alzheimer's disease.
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| 63. |
- Gustafson, Deborah R., et al.
(författare)
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Obesity, vascular disease and frailty in aging women with HIV
- 2021
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Ingår i: Advances in Geriatric Medicine and Research. - : Hapres. - 2632-9921. ; 3:3
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Forskningsöversikt (refereegranskat)abstract
- Women with chronic HIV infection (WWH) living in the United States, experience a disproportionately high rate of obesity compared to uninfected populations. Both overweight and obesity, particularly central obesity, are major contributors to insulin resistance, hypertension, and dyslipidemia—the major components of metabolic syndromes, including type 2 diabetes, and leading to increased cardiovascular risk, including coronary heart disease, and cerebrovascular diseases. Notably, declining physical performance and frailty co-occur with vascular morbidities as well as changes in bone. These factors tend to exacerbate each other and accelerate the aging trajectory, leading to poorer quality of life, cognitive impairments, dementia, and eventually, death. In WWH, persistent HIV infection, sustained treatment for HIV infection, and concomitant obesity, may accelerate aging-related morbidities and poorer aging outcomes. Furthermore, health disparities factors common among some WWH, are independently associated with obesity and higher vascular risk. The purpose of this review is to describe the constellation of obesity, cardio- and cerebrovascular diseases, bone health and frailty among aging WWH, a 21st century emergence.
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| 64. |
- Hagstrand Aldman, Malin, et al.
(författare)
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Treatment outcome with pencillin G or cloxacillin in penicillin susceptible Staphylococcus aureus bactearemi
- 2022
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Ingår i: International Journal of Antimicrobial Agents. - : Elsevier BV. - 0924-8579. ; 59:4
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Tidskriftsartikel (refereegranskat)abstract
- An increasing proportion of penicillin-susceptible Staphylococcus aureus (PSSA) has been reported over the last years. The aim of this retrospective study was to compare penicillin G with cloxacillin in the treatment of PSSA bloodstream infections. The primary outcome was the mortality rate after 90 days and the secondary outcome was the development of treatment complications of varying severity. Medical records from patients with PSSA bacteraemia during 2018–2020 were reviewed. Patient outcome was ranked on an ordinal scale according to severity: (i) alive at 90 days without any complications; (ii) adverse events not requiring treatment; (iii) change or addition of antibiotics owing to treatment failure or adverse events; (iv) relapse within 90 days; and (v) death within 90 days. The outcome ranking scale was dichotomised at every level and was analysed by logistic regression and a propensity score-weighted analysis. A total of 316 patients received cloxacillin and 68 patients received penicillin G as final treatment. Mortality rates did not differ significantly between the treatment groups (cloxacillin 19% vs. penicillin G 13%; P = 0.24), but patients treated with cloxacillin had an increased odds of having any complication compared with patients treated with penicillin G (odds ratio = 2.43, 95% confidence interval 1.30–4.53; P = 0.005). A propensity score analysis confirmed the results. Mortality rates in PSSA bacteraemia did not differ between treatment groups but cloxacillin treatment increased the overall odds of treatment complications.
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| 65. |
- Hartman, E. A. R., et al.
(författare)
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Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries
- 2022
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Ingår i: Age and ageing. - : Oxford University Press (OUP). - 0002-0729 .- 1468-2834. ; 51:6
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Tidskriftsartikel (refereegranskat)abstract
- Background a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions. Objectives (1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults. Methods we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers. Results participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care. Conclusions decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions.
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| 66. |
- Hartman, Esther A R, et al.
(författare)
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Effect of a multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for suspected urinary tract infections in frail older adults (ImpresU): pragmatic cluster randomised controlled trial in four European countries.
- 2023
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Ingår i: BMJ (Clinical research ed.). - : BMJ. - 0959-535X .- 1756-1833. ; 380
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Tidskriftsartikel (refereegranskat)abstract
- To evaluate whether antibiotic prescribing for suspected urinary tract infections in frail older adults can be reduced through a multifaceted antibiotic stewardship intervention.Pragmatic, parallel, cluster randomised controlled trial, with a five month baseline period and a seven month follow-up period.38 clusters consisting of one or more general practices (n=43) and older adult care organisations (n=43) in Poland, the Netherlands, Norway, and Sweden, from September 2019 to June 2021.1041 frail older adults aged 70 or older (Poland 325, the Netherlands 233, Norway 276, Sweden 207), contributing 411 person years to the follow-up period.Healthcare professionals received a multifaceted antibiotic stewardship intervention consisting of a decision tool for appropriate antibiotic use, supported by a toolbox with educational materials. A participatory-action-research approach was used for implementation, with sessions for education, evaluation, and local tailoring of the intervention. The control group provided care as usual.The primary outcome was the number of antibiotic prescriptions for suspected urinary tract infections per person year. Secondary outcomes included the incidence of complications, all cause hospital referrals, all cause hospital admissions, all cause mortality within 21 days after suspected urinary tract infections, and all cause mortality.The numbers of antibiotic prescriptions for suspected urinary tract infections in the follow-up period were 54 prescriptions in 202 person years (0.27 per person year) in the intervention group and 121 prescriptions in 209 person years (0.58 per person year) in the usual care group. Participants in the intervention group had a lower rate of receiving an antibiotic prescription for a suspected urinary tract infection compared with participants in the usual care group, with a rate ratio of 0.42 (95% confidence interval 0.26 to 0.68). No differences between intervention and control group were observed in the incidence of complications (<0.01 v 0.05 per person year), hospital referrals (<0.01 v 0.05), admissions to hospital (0.01 v 0.05), and mortality (0 v 0.01) within 21 days after suspected urinary tract infections, nor in all cause mortality (0.26 v 0.26).Implementation of a multifaceted antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infections in frail older adults.ClinicalTrials.gov NCT03970356.
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| 67. |
- Hartman, E. A. R., et al.
(författare)
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Multifaceted antibiotic stewardship intervention using a participatory-action-research approach to improve antibiotic prescribing for urinary tract infections in frail elderly (ImpresU): study protocol for a European qualitative study followed by a pragmatic cluster randomised controlled trial
- 2021
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Ingår i: Bmj Open. - : BMJ. - 2044-6055. ; 11:10
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Tidskriftsartikel (refereegranskat)abstract
- Introduction Almost 60% of antibiotics in frail elderly are prescribed for alleged urinary tract infections (UTIs). A substantial part of this comprises prescriptions in case of non-specific symptoms or asymptomatic bacteriuria, for which the latest guidelines promote restrictiveness with antibiotics. We aim to reduce inappropriate antibiotic use for UTIs through an antibiotic stewardship intervention (ASI) that encourages to prescribe according to these guidelines. To develop an effective ASI, we first need a better understanding of the complex decision-making process concerning suspected UTIs in frail elderly. Moreover, the implementation approach requires tailoring to the heterogeneous elderly care setting. Methods and analysis First, we conduct a qualitative study to explore factors contributing to antibiotic prescribing for UTIs in frail elderly, using semi-structured interviews with general practitioners, nursing staff, patients and informal caregivers. Next, we perform a pragmatic cluster randomised controlled trial in elderly care organisations. A multifaceted ASI is implemented in the intervention group; the control group receives care as usual. The ASI is centred around a decision tool that promotes restrictive antibiotic use, supported by a toolbox with educational materials. For the implementation, we use a modified participatory-action-research approach, guided by the results of the qualitative study. The primary outcome is the number of antibiotic prescriptions for suspected UTIs. We aim to recruit 34 clusters with in total 680 frail elderly residents >= 70 years. Data collection takes place during a 5-month baseline period and a 7-month follow-up period. Finally, we perform a process evaluation. The study has been delayed for 6 months due to COVID-19 and is expected to end in July 2021. Ethics and dissemination Ethical approvals and/or waivers were obtained from the ethical committees in Poland, the Netherlands, Norway and Sweden. The results will be disseminated through publication in peer-reviewed journals and conference presentations.
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| 68. |
- Holmström, M., et al.
(författare)
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Long-term liver-related morbidity and mortality related to chronic hepatitis C virus infection in Swedish patients with inherited bleeding disorders
- 2016
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Ingår i: Haemophilia. - : Wiley-Blackwell Publishing Inc.. - 1351-8216 .- 1365-2516. ; 22:6, s. e494-e501
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: Hepatitis C virus (HCV) infection is common in patients with inherited bleeding disorders treated with clotting factor concentrates prior to the introduction of viral inactivation of these products. The long-term consequences of hepatitis C infection in Swedish patients are not fully understood.Aim: To examine the impact of HCV infection on liver-related morbidity and mortality in Swedish patients with inherited bleeding disorders.Methods: We retrospectively collected data on 183 patients with inherited bleeding disorders infected with HCV who attended the Coagulation Unit at Karolinska University Hospital, Sweden. Data regarding end-stage liver disease (ESLD), defined as presence of ascites, encephalopathy, variceal bleeding, hepatocellular carcinoma or liver-related death, were collected from the patient records and the national registers.Results: The median follow-up time was 35.9 years (IQR 29.0-41.2). A total of 41% had achieved sustained virological response (SVR) after treatment. In total, 14.2% developed ESLD at the median age of 52.6 years (IQR 46.5-64.7). Nineteen (35.8%) of all deaths were due to liver-related causes. Co-infection with human immunodeficiency virus (HIV), older age at time of infection and severe form of bleeding disorder was associated with higher risk of developing ESLD, while SVR was a strong protective factor.Conclusions: This study demonstrated that liver-related morbidity and mortality was significant in patients with bleeding disorders and HCV infection in Sweden. Patients with HCV-infection should be candidates for treatment with the new highly effective antiviral drugs, since SVR proved to be a strong protective factor.
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| 69. |
- Mayne, S., et al.
(författare)
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Confusion Strongly Associated with Antibiotic Prescribing Due to Suspected Urinary Tract Infections in Nursing Homes
- 2018
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Ingår i: Journal of the American Geriatrics Society. - : Wiley. - 0002-8614. ; 66:2, s. 274-281
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Tidskriftsartikel (refereegranskat)abstract
- ObjectivesTo quantify the prevalence of documented urinary tract infection (UTI), nonspecific symptoms, and antibiotic treatment of suspected UTI in nursing homes (NHs) in the tropics and to describe the typical resident likely to receive antibiotic treatment for suspected UTI and factors associated with the development of confusion, fatigue, and restlessness. MeasurementsChartreviews of NH residents between August 28, 2015, and June 21, 2016, to determine the prevalence of documented UTI, new or worsening nonspecific and specific symptoms that are specific or nonspecific to the urinary tract, antibiotic use, medical conditions, and medication factors. ResultsUTI accounted for 33% of all current infections treated with antibiotics and 40% of all infections treated with antibiotics within the last 30days. One in 5 NH residents had received antibiotics within the last 30days, of which 45% were for UTI. The most significant factors independently associated with antibiotics for UTI were urinary catheter (OR=13, 95% CI=2.4-67, P=.003), urinary frequency (OR=10, 95% CI=2.2-47, P=.003), fever (OR=10, 95% CI=1.3-85, P=.028), new-onset hypotension (OR=10, 95% CI=1.4-73, P=.024), and confusion (OR=8.9, 95% CI=3.1-26, P<.001). Of these, confusion was the most prevalent factor in the population. ConclusionUTI is commonly documented in NH residents, with new or worsening confusion being one of the strongest factors associated with antibiotic treatment for suspected UTI.
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| 70. |
- Mayne, Sean., et al.
(författare)
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The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - A systematic literature review
- 2019
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Ingår i: BMC Geriatrics. - : Springer Science and Business Media LLC. - 1471-2318. ; 19, s. 1-15
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Forskningsöversikt (refereegranskat)abstract
- Context: Non-specific symptoms in elderly patients such as confusion is often suspected to be caused by a urinary tract infection (UTI) and it continues to be the most common reason for suspecting a UTI despite many other plausible causes. This leads to significant over diagnosis of UTI, increased inappropriate antibiotic use and potentially harmful outcomes through misdiagnosis. This problem is particularly prevalent in nursing homes settings. Objective: Clarify the correlation between lower UTI or bacteriuria and concurrent confusion. Setting: Any care setting for elderly (hospital, community and long term care facility). Design: A systematic literature review Main And Secondary Outcome Measures: A review of the literature was conducted assessing the association between confusion and UTI in the elderly. PubMed, Scopus and PsychInfo were searched with the following terms: confusion, delirium, altered mental status, acute confusional state, urinary tract infection, urine infection, urinary infection and bacteriuria. Inclusion criteria and methods were specified in advance and documented in the protocol, which was published with PROSPERO (registration ID CRD42015025804). Quality assessment was conducted independently by two authors. Data was extracted using a standardised extraction tool and a qualitative synthesis of evidence was made. Results: 1702 original records were identified of which 22 were included in the final analysis. Following this review, it appears that insufficient evidence is available to accurately determine if UTI and confusion are associated. Conclusion: The potential link between UTI and non-specific symptoms in elderly patients remain confusing. More epidemiological studies are unlikely to resolve this problem. The next logical step to clarify this issue should be a randomized controlled trial comparing the effect of antibiotics versus placebo using validated criteria for both UTI and confusion.
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