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At a minimum, conduct surveillance for HO-CDI in all inpatient healthcare facilities to detect elevated rates or outbreaks of CDI within the facility (weak recommendation, low quality of evidence ).

Express the rate of HO-CDI as the number of cases per 10000 patient-days. Express the CO-HCFA prevalence rate as the number of cases per 1000 patient admissions (good practice recommendation ).

Stratify data by patient location to target control measures when CDI incidence is above national and/or facility reduction goals or if an outbreak is noted (weak recommendation, low quality of evidence ).

Use the same standardized case definitions (HO, CO-HCFA, CA) and rate expression (cases per 10000 patient-days for HO, cases per 1000 patient admissions for CO-HCFA) in pediatric patients as for adults (good practice recommendation ).

Conduct surveillance for HO-CDI for inpatient pediatric facilities but do not include cases <2 years of age (weak recommendation, low quality of evidence ).

Consider surveillance for CA-CDI to detect trends in the community (weak recommendation, low quality of evidence ).

Patients with unexplained and new-onset ≥3 unformed stools in 24 hours are the preferred target population for testing for CDI (weak recommendation, very low quality of evidence).

Use a stool toxin test as part of a multistep algorithm (ie, glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by nucleic acid amplification test [NAAT]; or NAAT plus toxin) rather than a NAAT alone for all specimens received in the clinical laboratory when there are no preagreed institutional criteria for patient stool submission ( Figure 2 ) (weak recommendation, low quality of evidence).

Figure 2.
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infection laboratory test recommendations based on preagreed institutional criteria for patient stool submission. Abbreviations: CDI, infection; EIA, enzyme immunoassay; GDH, glutamate dehydrogenase; NAAT, nucleic acid amplification test.

Figure 2.
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infection laboratory test recommendations based on preagreed institutional criteria for patient stool submission. Abbreviations: CDI, infection; EIA, enzyme immunoassay; GDH, glutamate dehydrogenase; NAAT, nucleic acid amplification test.

Use a NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) rather than a toxin test alone when there are preagreed institutional criteria for patient stool submission ( Figure 2 ) (weak recommendation, low quality of evidence).

Do not perform repeat testing (within 7 days) during the same episode of diarrhea and do not test stool from asymptomatic patients, except for epidemiological studies (strong recommendation, moderate quality of evidence).

Two RCTs evaluating the effect of statin pre-treatment suggested effectiveness in preventing post-operative AF, possibly through anti-inflammatory effects (OR 0.57, 95% CI 0.42–0.77) [ 187 , 188 ].

Table 31 summarizes the recommendations concerning the prevention and treatment of atrial fibrillation in CABG patients.

Table 31
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Prevention and treatment of atrial fibrillation with coronary artery bypass grafting

Table 31
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Prevention and treatment of atrial fibrillation with coronary artery bypass grafting

In patients with paroxysmal AF it is worthwhile to rule out ischaemia as a potential cause. A high prevalence of obstructive CAD was observed among patients with AF undergoing systematic multislice CT, confirming the hypothesis that AF could be a marker of advanced coronary atherosclerosis. Issues related to antiplatelet therapy in patients under anticoagulants are discussed in Section 12.4.

The relationship between supraventricular arrhythmia other than AF and/or atrial flutter and CAD is unclear. During supraventricular tachycardia episodes, ECG changes and clinical symptoms suggestive of cardiac ischaemia may be present. Screening for CAD should be restricted to patients with typical symptoms outside arrhythmia episodes, who have a high-risk profile or increasing frequency of arrhythmia episodes [ 191 ].

Because of the effectiveness of percutaneous catheter ablation techniques for the treatment of accessory pathways, such as in Wolff-Parkinson-White syndrome, surgery should be restricted to patients after failed catheter ablation, with complex congenital heart disease or scheduled for valve surgery. Anti-arrhythmic surgical procedures should be performed in experienced centres.

In the setting of transient cardiac ischaemia, within 24–48 h of ACS, during primary PCI for STEMI or late after MI, ventricular arrhythmias are a major cause of death. Large RCTs have shown a beneficial effect of ICD therapy in survivors of life-threatening arrhythmias and in patients at risk of sudden death (primary prevention).

Patients with LVEF ≤ 35% are at risk of sudden cardiac death and may benefit from ICD therapy. However, screening for and treating cardiac ischaemia is required prior to ICD implantation because LV function may recover after revascularization of viable myocardium [ 16 ]. ICD therapy should be postponed for at least 3 months after PCI or CABG to allow time for LV recovery. In patients with large scar areas, recovery of LVEF is less likely and ICD implantation may be considered appropriate shortly after revascularization.

Patients surviving out-of-hospital cardiac arrest are at high risk of recurrence. Prevention of potentially lethal recurrence starts with a systematic evaluation of the underlying pathology and the subsequent risk for recurrence, to allow the implementation of an individualized treatment plan.

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