YANKAUER CATHETERS CAN HARBOR MANY PATHOGENS
A study finds MRSA and VRE on a commonly used suction device.
A suction device that removes excess oral and nasal secretions is a standard piece of equipment used in the ICU, and the Yankauer catheter, familiar to most ICU nurses, routinely serves that purpose. Because it is effective in rapidly clearing the upper airway, the nonsterile unit often is left at the patient's bedside for convenience and ready accessibility. Researchers at a Southern California hospital investigated the rate of contamination of Yankauer catheters to determine whether they can serve as a source of nosocomial infection.
The researchers collected data in three ICUs---medical, coronary, and surgical. On each unit there was a guideline on changing the catheters but no formal infection-control practice for their placement by the bedside.
Over a three-month period, specimens were collected from 20 catheters used each by a different patient. The researchers noted the location of the catheter in the patient's room, then the tip of the device was immersed into a culture broth and agitated for 10 to 15 seconds. The solution then was centrifuged in the laboratory, and the resultant sediments planted on agar plates for incubation. Further culturing was performed for the detection of possible vancomycin-resistant enterococci (VRE) and on suspect colonies identified after that incubation.
The results indicate that, prior to culturing, 55% (11) of the catheters had been kept in a designated receptacle, 30% (6) had been lying atop a piece of medical equipment, 10% (2) had been retrieved from the patient's bed, and 5% (1) had been found on the floor.
Only 20% of the catheters did not yield a specimen that cultured positive for a pathogen and, of the 16 (80%) that did, seven (35% of the total number) were found to have been colonized by more than one type. Species of Candida were identified in 30% of the catheter specimen cultures and Staphylococcus aureus in 25% of them; more than half (60%) of the latter were identified as methicillin resistant S. aureus (MRSA). One culture (5%) was positive also for VRE, and the laboratory analysis also revealed "moderate" or "abundant" levels of growth of the organisms on 75% of the catheters.
The Yankauer catheter often is necessary in ICU care, and the high rate of contamination of it found in the study should encourage bedside practitioners to take stringent infection-control measures, such as handwashing and wearing gloves, when using the device. Further, the researchers recommend placing a receptacle near the bedside designated for placing the catheter when it's not in use.-AK
Brown M, Wilms D. Am J Infect Control 2005;33(8):483-5.
INDUCING HYPOTHERMIA IN NEWBORNS WITH ENCEPHALOPATHY
Within six hours of birth, it may decrease the risk of death and disability.
A recently published study showed that in moderately-to-severely encephalopathic neonates treated with total-body cooling within six hours of birth, outcomes upon follow-up were better than they were among the infants who did not receive the treatment. This finding contributes significantly to a growing body of knowledge on inducing hypothermia in newborns in an effort to minimize brain injury.
Fifteen institutions holding membership in a national neonatal research organization participated in the study, in which researchers enlisted 208 newborns over a 34-month interval according to eligibility criteria indicating acute hypoxicischemic encephalopathy: a gestational age of at least 36 weeks and ICU admission within six hours of birth because of either respiratory problems and acidosis necessitating resuscitation or a diagnosis of encephalopathy. Only neonates with moderate-to-severe encephalopathy were included.
Once enrolled, each infant was randomized into either a treatment (hypothermia) group or a control group. Those in the control group (n = 106) received the standard care for the diagnosis and body temperature was maintained between 36.5[degrees]C and 37[degrees]C. In the treatment group (n = 102) systemic hypothermia was initiated through the use of two cooling blankets, the end goal being a body temperature of 33.5[degrees]C. In both groups, the temperature was monitored continually with an internal esophageal probe and an external skin probe. After 72 hours, the hypothermic infant was gradually rewarmed to a temperature of 36.5[degrees]C.
In the ICU there was no significant difference in the numbers of adverse events in either group. The researchers subsequently followed up 205 of the 208 infants at 18 to 22 months of age and discovered that outcomes were better among the infants in the treatment group than they were in the control group. In the hypothermia and control groups, respectively, the outcome rates were death or significant (moderate-to-severe) disability, 44% and 62% (death alone, 24% and 37%); cerebral palsy, 19% and 30%; blindness, 7% and 14%; and hearing impairment necessitating the use of aids, 4% and 6%. Also, the more favorable results in the treatment group were unchanged after adjustment for both the extent of encephalopathy and the institution. The researchers concluded that the induction of hypothermia produced neuroprotective effects that lessened the rates of death and disability in the neonates.
The treatment is largely considered experimental in the absence of long-term data on infants' development. Additional randomized trials are necessary to corroborate these results before the treatment can be adopted into standard clinical practice.-AK
Shankaran S, et al. N Engl J Med 2005; 353(15):1574-84.
SHOULD GESTATIONAL DIABETES BE TREATED?
Study shows treatment may improve outcomes for baby and mother.
Whether the risk of serious perinatal outcomes can be reduced by screening for and treating gestational diabetes mellitus has been unclear; organizational bodies have offered disparate recommendations (or offered none, citing a lack of evidence). Researchers in Australia, however, recently completed a randomized clinical trial of 1,000 women, the Australian Carbohydrate Intolerance Study in Pregnant Women, to determine whether treating gestational diabetes affected the incidence of serious perinatal complications (death, shoulder dystocia, bone fracture, and nerve palsy). Women included in the study had one or more risk factors for gestational diabetes or a positive result on oral glucose challenge. Researchers also examined the rates of cesarean section, labor induction, neonatal nursery admissions, and jaundice necessitating phototherapy, as well as maternal anxiety, depression, and health status. The control group (n = 510) received routine obstetric care, and the intervention group (n = 490) received dietary advice, blood glucose monitoring, and insulin therapy as needed.
The rate of serious perinatal complications was lower in the intervention group, as compared with the control group (1% versus 4%), although the rates of neonatal nursery admissions (71% versus 61%) and labor induction (39% versus 29%) were higher; the rate of cesarean section was not significantly different. The rate of nerve palsy was higher in the routine-care group. The rates of postpartum anxiety in the two groups were comparable, but women in the intervention group were less likely to have postpartum depression.
The biggest difference between the intervention and routine care groups was in the number of perinatal deaths (0 and 5, respectively). The researchers attributed this difference to the treatment administered. Other studies have shown no clear correlation between gestational diabetes and perinatal mortality.
An accompanying editorial raised the question of whether it was ethical not to offer treatment for elevated serum glucose levels, one of the criteria for inclusion in the study, but concluded that because no evidence existed to show that treatment improves outcomes, the rational was "reasonable."-LE
Crowther CA, et al. N Engl J Med 2005;352(24):2477-86; Greene MF, Solomon CG. N Engl J Med 2005;352(24):2544.