Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-3 (of 3 Records) |
Query Trace: Murphy MV[original query] |
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Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster-randomised trial
Huang SS , Septimus E , Kleinman K , Moody J , Hickok J , Heim L , Gombosev A , Avery TR , Haffenreffer K , Shimelman L , Hayden MK , Weinstein RA , Spencer-Smith C , Kaganov RE , Murphy MV , Forehand T , Lankiewicz J , Coady MH , Portillo L , Sarup-Patel J , Jernigan JA , Perlin JB , Platt R . Lancet 2019 393 (10177) 1205-1215 BACKGROUND: Universal skin and nasal decolonisation reduces multidrug-resistant pathogens and bloodstream infections in intensive care units. The effect of universal decolonisation on pathogens and infections in non-critical-care units is unknown. The aim of the ABATE Infection trial was to evaluate the use of chlorhexidine bathing in non-critical-care units, with an intervention similar to one that was found to reduce multidrug-resistant organisms and bacteraemia in intensive care units. METHODS: The ABATE Infection (active bathing to eliminate infection) trial was a cluster-randomised trial of 53 hospitals comparing routine bathing to decolonisation with universal chlorhexidine and targeted nasal mupirocin in non-critical-care units. The trial was done in hospitals affiliated with HCA Healthcare and consisted of a 12-month baseline period from March 1, 2013, to Feb 28, 2014, a 2-month phase-in period from April 1, 2014, to May 31, 2014, and a 21-month intervention period from June 1, 2014, to Feb 29, 2016. Hospitals were randomised and their participating non-critical-care units assigned to either routine care or daily chlorhexidine bathing for all patients plus mupirocin for known methicillin-resistant Staphylococcus aureus (MRSA) carriers. The primary outcome was MRSA or vancomycin-resistant enterococcus clinical cultures attributed to participating units, measured in the unadjusted, intention-to-treat population as the HR for the intervention period versus the baseline period in the decolonisation group versus the HR in the routine care group. Proportional hazards models assessed differences in outcome reductions across groups, accounting for clustering within hospitals. This trial is registered with ClinicalTrials.gov, number NCT02063867. FINDINGS: There were 189 081 patients in the baseline period and 339 902 patients (156 889 patients in the routine care group and 183 013 patients in the decolonisation group) in the intervention period across 194 non-critical-care units in 53 hospitals. For the primary outcome of unit-attributable MRSA-positive or VRE-positive clinical cultures (figure 2), the HR for the intervention period versus the baseline period was 0.79 (0.73-0.87) in the decolonisation group versus 0.87 (95% CI 0.79-0.95) in the routine care group. No difference was seen in the relative HRs (p=0.17). There were 25 (<1%) adverse events, all involving chlorhexidine, among 183 013 patients in units assigned to chlorhexidine, and none were reported for mupirocin. INTERPRETATION: Decolonisation with universal chlorhexidine bathing and targeted mupirocin for MRSA carriers did not significantly reduce multidrug-resistant organisms in non-critical-care patients. FUNDING: National Institutes of Health. |
Associations between different sedatives and ventilator-associated events, length-of-stay, and mortality in mechanically ventilated patients
Klompas M , Li L , Szumita P , Kleinman K , Murphy MV . Chest 2015 149 (6) 1373-9 BACKGROUND: Current sedation guidelines recommend avoiding benzodiazepines but express no preference for propofol versus dexmedetomidine. In addition, there are limited data on how well randomized controlled trials on sedatives generalize to routine practice where conditions tend to be more varied and complex. METHODS: We gathered daily sedative exposure data from all patients on mechanical ventilation for ≥3 days over a 7-year period in a large academic medical center. We compared hazard ratios for ventilator-associated events (VAEs), extubation, hospital discharge, and hospital death amongst benzodiazepines, propofol, and dexmedetomidine using proportional subdistribution hazard models with competing risks. We adjusted all analyses for ICU type, demographics, comorbidities, procedures, severity of illness, hypotension, oxygenation, renal function, opioids, neuroleptics, neuromuscular blockers, awakening and breathing trials, and calendar year. RESULTS: We evaluated 9,603 consecutive episodes of mechanical ventilation. Benzodiazepines and propofol were associated with increased VAE risk whereas dexmedetomidine was not. Propofol was associated with less time to extubation compared to benzodiazepines (HR for extubation 1.4, 95% CI 1.3-1.5). Dexmedetomidine was associated with less time to extubation compared to both benzodiazepines (HR 2.3, 95% CI 2.0-2.7) and propofol (HR 1.7, 95% CI 1.4-2.0) but there were relatively few dexmedetomidine exposures available for analysis. There were no differences between any two agents in hazards for hospital discharge or mortality. CONCLUSIONS: In this large, real-world cohort, propofol and dexmedetomidine were associated with less time to extubation compared to benzodiazepines but dexmedetomidine was also associated with less time to extubation compared to propofol. These possible differences merit further study. |
The preventability of ventilator-associated events: the CDC Prevention Epicenters' Wake Up and Breathe Collaborative
Klompas M , Anderson D , Trick W , Babcock H , Kerlin MP , Li L , Sinkowitz-Cochran R , Ely EW , Jernigan J , Magill S , Lyles R , O'Neil C , Kitch BT , Arrington E , Balas MC , Kleinman K , Bruce C , Lankiewicz J , Murphy MV , ECox C , Lautenbach E , Sexton D , Fraser V , Weinstein RA , Platt R . Am J Respir Crit Care Med 2014 191 (3) 292-301 RATIONALE: The Centers for Disease Control and Prevention (CDC) introduced ventilator-associated event (VAE) definitions in January 2013. Little is known about VAE prevention. We hypothesized that daily, coordinated spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) might prevent VAEs. OBJECTIVES: To assess the preventability of VAEs. METHODS: We nested a multicenter quality improvement collaborative within a prospective study of VAE surveillance amongst 20 intensive care units between November 2011 and May 2013. Twelve units joined the collaborative and implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs. The remaining 8 units conducted surveillance alone. We measured temporal trends in VAEs using generalized mixed effects regression models adjusted for patient-level unit, age, sex, reason for intubation, SOFA score, and comorbidity index. MEASUREMENTS AND MAIN RESULTS: We tracked 5,164 consecutive episodes of mechanical ventilation: 3,425 in collaborative units and 1,739 in surveillance-only units. Within collaborative units, significant increases in SATs, SBTs, and percentage of SBTs performed without sedation were mirrored by significant decreases in duration of mechanical ventilation and hospital length-of-stay. There was no change in VAE risk per ventilator-day but significant decreases in VAE risk per episode of mechanical ventilation (OR 0.63, 95% CI 0.42-0.97) and infection-related ventilator-associated complications (OR 0.35, 95% CI 0.17-0.71) but not pneumonias (OR 0.51, 95% CI 0.19-1.3). Within surveillance-only units, there were no significant changes in SAT, SBT, or VAE rates. CONCLUSIONS: Enhanced performance of paired, daily SATs and SBTs is associated with lower VAE rates. Clinical trial registration available at www.clinicaltrials.gov, ID NCT01583413. |
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