<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_407"
                     title="ICU Catheter Infections Can Be Virtually Eliminated (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/CriticalCare/InfectionControl/tb/18308?impressionId=1265802754361"
                     
      Catheter-related infections aren&apos;t inevitable in the ICU, according to a quality initiative that maintained rates at nearly zero for three years in Michigan hospitals.&lt;br&gt;
&lt;br&gt;The maintenance phase, after initial implementation of low-tech measures such as handwashing and removal of unneeded catheters, saw no rebound in catheter-related infections, Peter J. Pronovost, MD, PhD, of Johns Hopkins, and colleagues reported online in &lt;em&gt;BMJ&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;The first 18 months of their &lt;a href=&quot;http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/4771&quot; mce_href=&quot;http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/4771&quot; target=&quot;_blank&quot;&gt;Keystone ICU initiative&lt;/a&gt; dropped catheter-related interventions from a mean of 7.7 and median of 2.2 per 1,000 catheter days down to 1.3 and 0, respectively.&lt;br&gt;
&lt;br&gt;At the 36 month mark, infection rates remained almost nil, at a mean of 1.1 and median of 0 per 1,000 catheter days.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;For the most part, hospitals view these infections as inevitable, as the cost of doing business, that patients are too sick, that these can&apos;t be prevented,&quot; Pronovost told &lt;em&gt;MedPage Today&lt;/em&gt;. &quot;That&apos;s just not true.&quot;&lt;/p&gt;
&lt;p&gt;Catheter-related infections are the number one cause of preventable death in hospitals and ICUs, ahead of even ventilator-related pneumonia, he noted.&lt;/p&gt;
&lt;p&gt;The changes seen at the 90 Michigan ICUs that stayed with the catheter-related infection initiative were impressive, representing one of the largest and longest improvements the field has seen.&lt;/p&gt;
&lt;p&gt;Often, quality initiatives fail on durability after the study funding and resources disappear, and hospitals are left on their own, Pronovost noted.&lt;/p&gt;
&lt;p&gt;&quot;If you push you might get some effect, but then you stop pushing  --  in other words the external control goes away  --  and the performance goes right back down,&quot; he said in an interview. &quot;It can&apos;t just be the stick that drives it.&quot;&lt;/p&gt;
&lt;p&gt;The intervention started with 103 ICUs that implemented strategies to reduce rates of catheter-related bloodstream infections rates over 18 months, with measurement and feedback of infection rates.&lt;/p&gt;
&lt;p&gt;The strategies aimed at improving execution of five evidence-based recommendations, as follows: &lt;ul&gt; &lt;li&gt;Hand washing before insertion of the catheter&lt;/li&gt; &lt;li&gt;Using gowns and full barrier precautions at catheter insertion&lt;/li&gt; &lt;li&gt;Cleaning the skin with chlorhexidine before catheter insertion&lt;/li&gt; &lt;li&gt;Avoiding the femoral site when possible&lt;/li&gt; &lt;li&gt;Removing unnecessary catheters&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Then, over the subsequent 18-month maintenance period, ICU teams were instructed to integrate this intervention into staff orientation, to collect monthly data from hospital infection control staff, and to report infection rates to physicians and others.&lt;/p&gt;
&lt;p&gt;Along with the sustained reduction in overall catheter-related infections, the researchers found a prolonged reduction in bloodstream infections that was significant during all study periods, compared to baseline.&lt;/p&gt;
&lt;p&gt;Rates decreased from a mean of 7.7 and median 2.7 of per 1,000 catheter days at baseline to 1.3 and 0, respectively, at 16 to 18 months after implementation. They remained at 1.1 and 0 at months 34 to 36 (-1% versus 18 months, 95% CI -9% to +7%).&lt;/p&gt;
&lt;p&gt;ICU teams interviewed attributed the continuously low rates to five factors: &lt;ul&gt; &lt;li&gt;Continued feedback on infection data&lt;/li&gt; &lt;li&gt;Improvements in safety culture as part of the project&lt;/li&gt; &lt;li&gt;An &quot;unremitting belief in the preventability of bloodstream infections&quot;&lt;/li&gt; &lt;li&gt;Involvement of senior leaders&lt;/li&gt; &lt;li&gt;A noncompetitive, shared goal to reduce infection rates throughout the state&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Of these, Pronovost called culture change in the ICUs the key factor to sustainability, although the researchers cautioned that which aspects contributed were not formally evaluated.&lt;/p&gt;
&lt;p&gt;They said they could not determine the impact incentive payments from Blue Cross Blue Shield of Michigan to hospitals that continued their participation  --  payments that were based on performance thresholds in subsequent years.&lt;/p&gt;
&lt;p&gt;Pronovost&apos;s team is now working to implement the quality initiative state-by-state nationwide, supported by the Agency for Healthcare Research and Technology.&lt;/p&gt;
&lt;p&gt;&quot;It seems absurd that this wouldn&apos;t be in every hospital in the country,&quot; he said in an interview. &quot;It&apos;s worked on a large scale, it&apos;s exceedingly cheap, there&apos;s no fancy technology.&quot;&lt;/p&gt;
&lt;p&gt;Success isn&apos;t only for community hospitals, Pronovost emphasized.&lt;/p&gt;
&lt;p&gt;Large, often academic, medical centers frequently express the conviction that their sicker, more complex ICU population wouldn&apos;t produce the same results, that their infections truly are inevitable, he said.&lt;/p&gt;
&lt;p&gt;&quot;To them I say, Not so,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;. &quot;We have shown at Johns Hopkins, at the University of Michigan, at Pittsburgh, using a similar but different approach, at Tufts  --  many large academic medical centers have had dramatic reductions of these infections.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The project was supported, for the period from October 2003 to September 2005, by the Agency for Healthcare Research and Quality and the Michigan Health &amp;amp; Hospital Association.&lt;/p&gt;&lt;p&gt;Pronovost and a co-author reported receiving received lecture fees from various healthcare organizations and grant support from the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the National Patient Safety Agency, and the World Health Organization to study and improve quality of care, including catheter-related bloodstream infections.&lt;/p&gt;&lt;p&gt;Co-authors reported conflicts of interest with government agencies, Cubist, Astellas, Merck, Forrest, Cadence, the Robert Wood Johnson Foundation, Lilly, Edward Life Sciences, and Sage.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_301"
                     title="Tight Glucose Control Fails in Septic Shock (CME/CE)"
                     score="0.002"
                     href="http://www.medpagetoday.com/CriticalCare/Sepsis/tb/18160?impressionId=1265802754361"
                     
      Septic shock patients treated with a corticosteroid get no survival advantage from tight glucose control or addition of a second corticosteroid to provide more mineralocorticoid activity, according to results of a randomized trial.&lt;br&gt;
&lt;br&gt;Aiming for normoglycemia at 80 to 110 mg/dL rather than the standard 150 mg/dL had no impact on inhospital mortality rates (45.9% versus 42.9%, &lt;em&gt;P&lt;/em&gt;=0.50), Djillali Annane, MD, of H&amp;#244;pital Raymond Poincar&amp;#233; in Garches, France, and colleagues found.&lt;br&gt;
&lt;br&gt;Inhospital mortality was likewise similar whether patients got hydrocortisone (Solu-Cortef) alone or with the addition of fludrocortisone ([Florinef] 42.9% versus 45.8%, &lt;em&gt;P&lt;/em&gt;=0.50), they reported in the Jan. 27 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;This aggressive treatment strategy should not be routine, the researchers recommended.&lt;/p&gt;
&lt;p&gt;These findings largely match the general lack of benefit seen with tight glycemic control in recent studies with ICU patients overall.&lt;/p&gt;
&lt;p&gt;The prematurely terminated &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/SCCM/5096&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/SCCM/5096&quot; target=&quot;_blank&quot;&gt;European Glucontrol Trial&lt;/a&gt; found no mortality benefit but a seven-fold higher risk of hypoglycemia with an 80 to 110 mg/dL target in the ICU.&lt;/p&gt;
&lt;p&gt;In the &lt;a href=&quot;http://www.medpagetoday.com/CriticalCare/Intensivists/13397&quot; mce_href=&quot;http://www.medpagetoday.com/CriticalCare/Intensivists/13397&quot; target=&quot;_blank&quot;&gt;NICE-SUGAR&lt;/a&gt; study, 90-day mortality was actually higher in the tight glucose control group (27.9% versus 24.9%, &lt;em&gt;P&lt;/em&gt;=0.02), although there was a trend for benefit in patients who got corticosteroids (&lt;em&gt;P&lt;/em&gt;=0.06).&lt;/p&gt;
&lt;p&gt;Glucose targets are being re-evaluated across medicine as the &quot;lower is better&quot; paradigm has had a safety asterisk added everywhere from diabetes care to the ICU, noted Richard Bergenstal, MD, American Diabetes Association president for medicine and science.&lt;/p&gt;
&lt;p&gt;&quot;All of a sudden it&apos;s becoming more than a single number,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;. &quot;Now be it inpatient or outpatient, we&apos;re realizing that ... you have to do it while you&apos;re minimizing hypoglycemia.&quot;&lt;/p&gt;
&lt;p&gt;A more nuanced and &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/Diabetes/13818&quot; target=&quot;_blank&quot;&gt;individualized&lt;/a&gt; strategy is prudent, Bergenstal agreed.&lt;/p&gt;
&lt;p&gt;The current clinical uncertainty underscores the need for large-scale international cooperation to get adequately powered trials, according to an accompanying editorial.&lt;/p&gt;
&lt;p&gt;In it, Greet Van den Berghe, MD, PhD, of the Catholic University of Leuven, Belgium, cautioned that Annane&apos;s Corticosteroids and Intensive Insulin Therapy for Septic Shock (COIITSS) study was grossly underpowered.&lt;/p&gt;
&lt;p&gt;The initial studies that led to rapid adoption of intensive insulin therapy in ICUs around the world had suggested an absolute reduction in mortality of only 3%, whereas the COIITSS study projected a 12.5% absolute benefit.&lt;/p&gt;
&lt;p&gt;More importantly, the study achieved mean glucose levels of only between 120 and 130 mg/dL in the intervention group for whom the aim was 80 to 110 mg/dL, which resulted in considerable overlap with the standard care group for whom mean levels were about 145 mg/dL.&lt;/p&gt;
&lt;p&gt;This could account for the lack of difference in outcome, Van den Berghe said.&lt;/p&gt;
&lt;p&gt;But the intensive insulin group did have &quot;markedly&quot; lower blood glucose levels for the duration of their ICU stay and spent more time in the 80 to 110 mg/dL range compared with the standard care group (both &lt;em&gt;P&lt;/em&gt;&amp;lt;0.00001), the researchers noted.&lt;/p&gt;
&lt;p&gt;Because corticosteroids further aggravate the &quot;diabetes of injury&quot; seen with septic shock, Annane&apos;s group undertook a multicenter trial of 509 adults treated for septic shock with multiple organ dysfunction over a three year period at 11 ICUs in France.&lt;/p&gt;
&lt;p&gt;Patients were randomly assigned to tight glucose control using continuous intravenous insulin infusion to target a glucose level of 80 to 110 mg/dL or conventional insulin therapy targeted to guidelines-recommended 150 mg/dL or under. They were additionally randomized to receive hydrocortisone alone (50-mg bolus every six hours) or in combination with fludrocortisone (50-&amp;#956;g tablets once daily) for seven days.&lt;/p&gt;
&lt;p&gt;Aside from the lack of inhospital mortality advantage, tight glucose control also failed to produce a benefit for the following secondary endpoints: &lt;ul&gt; &lt;li&gt;Overall survival (hazard ratio 1.04, &lt;em&gt;P&lt;/em&gt;=0.78) &lt;/li&gt; &lt;li&gt; ICU length of stay for survivors (median 10 versus nine days, &lt;em&gt;P&lt;/em&gt;=0.68)&lt;/li&gt; &lt;li&gt;Duration of hospital stay overall (24 versus 22 days, &lt;em&gt;P&lt;/em&gt;=0.87)&lt;/li&gt; &lt;li&gt;Median vasopressor-free days (four for both, P=0.58)&lt;/li&gt; &lt;li&gt;Median mechanical ventilation-free days (10 versus 13, &lt;em&gt;P&lt;/em&gt;=0.51)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Nor was there evidence for interaction with fludrocortisone in the primary endpoint (relative risk 0.89 versus 0.91 hydrocortisone alone, &lt;em&gt;P&lt;/em&gt;=0.31) or benefit in any other endpoint.&lt;/p&gt;
&lt;p&gt;The one effect of intensive insulin appeared to be an increase in episodes of severe hypoglycemia, defined by glucose falling below 40 mg/dL (mean 0.29 versus 0.14 episodes per patient, &lt;em&gt;P&lt;/em&gt;=0.003).&lt;/p&gt;
&lt;p&gt;However, having hypoglycemia did not increase the risk of death in intervention group patients compared with controls (45.2% versus 50%).&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the study did not rule out a benefit from some degree of glucose control compared with none.&lt;/p&gt;
&lt;p&gt;They also noted that healthcare providers were not blinded to administration of fludrocortisone, for which no placebo was available.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Assistance Publique&amp;#8211;H&amp;#244;pitaux de Paris. The researchers reported no conflicts of interest.&lt;/p&gt;&lt;p&gt;Van den Berghe, through the Catholic University of Leuven, reported receiving structural research financing from the Methusalem program, funded by the Flemish government.&lt;/p&gt;&lt;p&gt;Bergenstal reported receiving research funding and serving on advisory boards for various pharmaceutical companies related to novel diabetes drugs but without any personal financial compensation.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_255"
                     title="Biomarker Guideline Reduced Antibiotic Use (CME/CE)"
                     score="-0.001"
                     href="http://www.medpagetoday.com/HospitalBasedMedicine/InfectionControl/tb/18114?impressionId=1265802754361"
                     
      &lt;p&gt;A biomarker-guided strategy for antibiotics in intensive care units reduced drug use without increasing mortality, French researchers said.&lt;/p&gt;
&lt;p&gt;In a randomized, open-label study, the biomarker procalcitonin allowed physicians to reduce the quantity of antibiotics they prescribed, according to Michel Wolff, MD, of H&amp;#244;pital Bichat-Claude-Bernard in Paris, and colleagues.&lt;/p&gt;
&lt;p&gt;In principle, the approach could slow the emergence of antibiotic resistance, Wolff and colleagues concluded online in &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Procalcitonin is thought to be a &quot;fairly specific marker for severe bacterial infection in patients with suspected sepsis,&quot; the researchers noted in the journal.&lt;/p&gt;
&lt;p&gt;As well, serum procalcitonin concentrations have been shown to be a useful guide to reducing antibiotic use in patients with lower-respiratory-tract infections, they said.&lt;/p&gt;
&lt;p&gt;But the value of the biomarker in reducing inappropriate antibiotic use has not been shown in all intensive care patients, they said. To fill the gap, they conducted a prospective study of 630 patients in eight French ICUs.&lt;/p&gt;
&lt;p&gt;Patients were randomly assigned to be treated according to usual antibiotic protocols or to have their therapy guided by procalcitonin levels.&lt;/p&gt;
&lt;p&gt;For patients in the procalcitonin group, doctors were encouraged to start antibiotics at inclusion if the levels were 0.5 micrograms per liter or greater. Otherwise, they were discouraged from doing so.&lt;/p&gt;
&lt;p&gt;They were also encouraged to stop antibiotics, once started, if the procalcitonin concentration fell by 80% or more from its peak, or if the concentration was below 0.5 micrograms per liter.&lt;/p&gt;
&lt;p&gt;The primary endpoints were death from any cause at 28 and 60 days and differences in antibiotic use.&lt;/p&gt;
&lt;p&gt;The researchers reported: &lt;ul&gt; &lt;li&gt;At 30 days, mortality in the procalcitonin group was 21.2%, compared with 20.4% in the control group, for an absolute difference of 0.8%. That was well below the pre-set 10% difference for non-inferiority.&lt;/li&gt; &lt;li&gt;At 60 days, the comparable figures were 30% and 26.1%, for an absolute difference of 3.8%, which also established non-inferiority.&lt;/li&gt; &lt;li&gt;Patients in the procalcitonin group had 14.3 days without antibiotics, on average, compared with 11.6 days in the control group. The absolute difference of 2.7 days was significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The researchers cited a number of limitations, including the open design, which might have permitted bias, and a low number of surgical patients, which may limit how widely the findings can be applied.&lt;/p&gt;
&lt;p&gt;As well, they noted, 53% of patients in the procalcitonin group did not get therapy guided by the study protocol. Despite that, Wolff and colleagues said, the results remained statistically significant if those patients were excluded.&lt;/p&gt;
&lt;p&gt;Various studies have shown that it&apos;s possible to curtail unnecessary antibiotic use in hospitals, according to Marin Kollef, MD, of Washington University School of Medicine in St Louis.&lt;/p&gt;
&lt;p&gt;But because of the limitations of the French study, it remains unclear whether using procalcitonin is the best approach, he wrote in an accompanying editorial.&lt;/p&gt;
&lt;p&gt;&quot;Whether the ideal strategy involves the use of a serum marker such as procalcitonin or a locally applied practice protocol remains to be established,&quot; Kollef concluded.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the Assistance Publique-H&amp;#244;pitaux de Paris, France, and Brahms, Germany. Wolff reported financial links with Merck Sharp &amp;amp; Dohme-Chibret, Janssen-Cilag, Gilead, and AstraZeneca.&lt;/p&gt;&lt;p&gt;Kollef reported no conflicts.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3110"
                     title="Study Shows Surgical Masks Equal Respirators for Healthcare Workers (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/HospitalBasedMedicine/InfectionControl/tb/16248?impressionId=1265802754361"
                     
      Surgical masks may be just as good as N95 respirators for protecting healthcare workers against the flu, according to a randomized clinical trial whose findings conflict with the only previous study.&lt;br&gt;
&lt;br&gt;Nurses who wore surgical masks while caring for patients with flu-like symptoms were no more likely to catch seasonal flu than those who wore the higher filtration devices (23.6% versus 22.9%, &lt;em&gt;P&lt;/em&gt;=0.86), Mark Loeb, MD, MSc, of McMaster University in Hamilton, Ontario, and colleagues reported online in the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;These findings do not apply to settings where there is a high risk that the virus will become aerosolized, such as intubation or bronchoscopy, the researchers cautioned.&lt;br&gt;
&lt;br&gt;But for &quot;routine healthcare settings, particularly where the availability of N95 respirators is limited,&quot; the results are reassuring, they wrote.&lt;br&gt;
&lt;br&gt;However, the new findings contradict those of another randomized, controlled trial comparing efficacy of the N95 respirators and standard surgical masks, a trial reported just two weeks ago at the &lt;a href=&quot;http://www.medpagetoday.com/MeetingCoverage/ICAAC/16006&quot; mce_href=&quot;http://www.medpagetoday.com/MeetingCoverage/ICAAC/16006&quot; target=&quot;_blank&quot;&gt;Interscience Conference on Antimicrobial Agents and Chemotherapy&lt;/a&gt;.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;That study indicated that when used consistently, N95 respirator masks prevented 75% of respiratory infections for high-risk healthcare workers in China. But consistent surgical mask use was no better than low use for prevention of clinical respiratory illness (6.7% versus 9.2%, &lt;em&gt;P&lt;/em&gt;=0.159) or of influenza-like illness (0.6% versus 1.3%, &lt;em&gt;P&lt;/em&gt;=0.336).&lt;/p&gt;
&lt;p&gt;Given the discrepancies, &quot;a single study will not end the debate over influenza respiratory protection for healthcare professionals,&quot; noted CDC&apos;s Arjun Srinivasan, MD, and Trish M. Perl, MD, MSc, of Johns Hopkins, in an editorial accompanying today&apos;s online &lt;em&gt;JAMA&lt;/em&gt; article.&lt;/p&gt;
&lt;p&gt;With the current H1N1 pandemic (swine) flu, the issue has gained urgency, but there is little consensus, they wrote.&lt;/p&gt;
&lt;p&gt;Some groups, including the World Health Organization and Society for Healthcare Epidemiology of America (SHEA), say surgical masks are sufficient for most patient care activities. SHEA cited &quot;serious cost, compliance, and supply concerns&quot; in a statement opposing mandatory N95 respirator use.&lt;/p&gt;
&lt;p&gt;While the CDC recommends surgical masks as part of the arsenal deployed against seasonal flu, it recommended only N95 respirators for protection against H1N1  --  in part, because of animal studies indicating airborne transmission via small particles.&lt;/p&gt;
&lt;p&gt;Surgical masks were designed to prevent transmission via relatively large particles, such as sputum droplets, whereas N95 respirators are made of material certified to block 95% of particles 0.3 &amp;#956;m or larger in diameter. Unlike surgical masks, they also seal tight to block inflow around the nose and mouth.&lt;/p&gt;
&lt;p&gt;Last month, after hearing interim results of the Chinese trial, the Institute of Medicine sided with the CDC in &lt;a href=&quot;http://www.medpagetoday.com/HospitalBasedMedicine/WorkForce/15518&quot; mce_href=&quot;http://www.medpagetoday.com/HospitalBasedMedicine/WorkForce/15518&quot; target=&quot;_blank&quot;&gt;recommending N95 respirators&lt;/a&gt; to protect healthcare workers from the pandemic flu.&lt;/p&gt;
&lt;p&gt;That study included nearly 2,000 emergency and respiratory ward nurses and physicians. They were cluster-randomized to wear surgical masks, fit-tested N95 respirators, or non-fit tested N95 respirators during all work hours for four consecutive weeks during the cold and flu season.&lt;/p&gt;
&lt;p&gt;Loeb&apos;s study included 478 nurses who worked in emergency departments, medical units, and pediatric units in eight Ontario tertiary care hospitals. They were randomized to open-label use of a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season.&lt;/p&gt;
&lt;p&gt;Participants were to maintain randomization even during aerosol-generating procedures such as intubation. The groups had similar rates of flu vaccination and exposure to a sick spouse, roommate, or child.&lt;/p&gt;
&lt;p&gt;Unlike the findings of the Chinese study, though, laboratory-confirmed influenza on nasal swabs met noninferiority criteria for surgical masks compared with N95 respirators (absolute risk difference -0.73%, 95% confidence interval -8.8% to 7.3%).&lt;/p&gt;
&lt;p&gt;The results, if anything, tended to be better for surgical masks in confirmed H1N1 rates (8.0% versus 11.9%, &lt;em&gt;P&lt;/em&gt;=0.18), though again meeting noninferiority criteria.&lt;/p&gt;
&lt;p&gt;Clinical influenza-like illness, though, tended to be less likely with use of the N95 respirators (1.0% versus 4.2%, &lt;em&gt;P&lt;/em&gt;=0.06), which the researchers called an unexpected finding based on similarity of the serology results.&lt;/p&gt;
&lt;p&gt;Srinivasan speculated that the difference could have been accounted for by bias if nurses felt more protected with the N95 respirators and were less likely to report symptoms.&lt;/p&gt;
&lt;p&gt;Adherence to randomization was 100% in the surgical mask group and 85.7% with the respirators, high rates likely driven by &quot;the fact that all hospitals in the study were in Ontario, which was affected by the SARS outbreak and where use of personal protective equipment is mandated and audited by the Ontario Ministry of Labour,&quot; Loeb&apos;s group said.&lt;/p&gt;
&lt;p&gt;The CDC will consider these results as an important part, but only one piece, of the evidence in ongoing revision of its guidelines for healthcare worker respiratory protection to replace the interim recommendations made in the spring, Srinivasan said.&lt;/p&gt;
&lt;p&gt;&quot;We&apos;ve learned a lot since then,&quot; he declared.&lt;/p&gt;
&lt;p&gt;The revised guidelines are expected to be released by the end of next week , according to a CDC spokesperson.&lt;/p&gt;
&lt;p&gt;The JAMA editorialists also stressed the need for multiple measures to prevent spread of influenza and other respiratory diseases.&lt;/p&gt;
&lt;p&gt;&quot;Unfortunately, this intense discussion over respiratory protection has distracted attention from the critical importance of implementing other strategies known to prevent the transmission of influenza in healthcare settings,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;Indeed, the use of personal protective equipment such as masks and respirators should be considered the &apos;last line of defense&apos; in a hierarchy of infection control measures.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the Public Health Agency of Canada.The researchers reported no conflicts of interest.&lt;/p&gt;&lt;p&gt;The editorialists reported no conflicts of interest, though Perl reported being a member of the IOM committee that set recommendations for respiratory protection of healthcare workers against H1N1 influenza.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_943"
                     title="Study Supports Mass Antibiotics for Trachoma"
                     score="-0.005"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/tb/13465?impressionId=1265802754361"
                     
      SAN FRANCISCO, March 27 -- Quarterly mass administrations of prophylactic antibiotics to children significantly decreased the incidence of trachoma in all community residents in an Ethiopian trial, investigators here reported. 
              &lt;p&gt;
              &lt;p&gt;The mass distribution reduced the incidence of trachoma from 48.4% to 3.6% in treated individuals, Thomas M. Lietman, M.D., of the University of California San Francisco, and colleagues said in the March 28 issue of &lt;em&gt;The Lancet&lt;/em&gt;.
              &lt;p&gt; 
              &lt;p&gt;In addition, untreated children and adults in these same communities had significantly lower rates of the ocular infection than residents of communities that did not receive antibiotic prophylaxis. 
              &lt;p&gt;
              &lt;p&gt;The results provide evidence of &quot;herd protection&quot; via mass antibiotic prophylaxis, benefiting both treated and untreated individuals, the researchers argued. 
              &lt;p&gt;
              &lt;p&gt;&quot;Frequent treatment of children, who are a core group for transmission of trachoma, could eventually eliminate infection from the entire community,&quot; the authors concluded. 
              &lt;p&gt;
              &lt;p&gt;&quot;Herd protection is offered by repeated mass antibiotic treatments, providing a strategy for elimination of a bacterial disease when an effective vaccine is unavailable,&quot; they added. 
              &lt;p&gt;
              &lt;p&gt;Mathematical models have shown antimicrobials can eliminate an infectious disease, even when treatments are suboptimal or not universally available, the authors noted. 
              &lt;p&gt;
              &lt;p&gt;Trachoma-specific models suggest the infection can be eliminated with repeated community-wide distribution of antibiotics, regardless of the extent to which a community is affected. 
              &lt;p&gt;
              &lt;p&gt;But treatment of an entire community is costly and inefficient, the authors noted. So they tested a theory that targeting a core group could eliminate the infection throughout the community. 
              &lt;p&gt;
              &lt;p&gt;Drawing from models suggesting that children are a core group for trachoma transmission, investigators performed a cluster randomized trial in the Amhara Region of northern Ethiopia. 
              &lt;p&gt;
              &lt;p&gt;Single oral doses of azithromycin were distributed quarterly to children ages one to 10 in 12 communities, while in 12 other communities, children of the same age did not receive the antibiotic until after the study ended, serving as the control group. 
              &lt;p&gt;
              &lt;p&gt;The primary outcomes were the rate of ocular chlamydial infection at 12 months in untreated individuals 11 and older in treated communities and the difference in the rate of infection at 12 months between treated and control communities. 
              &lt;p&gt;
              &lt;p&gt;At the end of the study, investigators analyzed data on 637 children ages 1 to 10 and 561 older individuals in treated communities. Infection rates were compared with those of 618 children and 550 older individuals in the control communities. 
              &lt;p&gt;
              &lt;p&gt;In addition to the large reduction in the rate of infection in treated individuals, the infection rate in the older untreated individuals in the same communities declined by 47% compared with baseline (&lt;em&gt;P&lt;/em&gt;=0.002) and by 35% compared with the untreated communities (&lt;em&gt;P&lt;/em&gt;=0.04). 
              &lt;p&gt;
              &lt;p&gt;In an accompanying commentary, Hugh Taylor, M.D., of the University of Melbourne in Australia, pointed out that mass distribution of antibiotics is only one of four strategies recommended by the World Health Organization to eliminate trachoma. 
              &lt;p&gt;
              &lt;p&gt;The other three are trichiasis surgery, facial cleanliness, and environmental changes in the community. 
              &lt;p&gt;
              &lt;p&gt;Even so, the study &quot;reinforces the importance of children as the main reservoir of infection in trachoma, and the need to investigate further the best frequency of antibiotic treatment.&quot; 
              &lt;p&gt;
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;The study was supported by NIH, the International Trachoma Initiative, the Bernard Osher Foundation, That Man May See, the Harper Inglis Trust, the Bodri Foundation, the South Asia Research Fund, and Research to Prevent Blindness. 
              &lt;p&gt;The authors and Dr. Taylor reported no potential conflicts of interest.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
         
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