Association Between a Silver-Coated Endotracheal Tube and Reduced Mortality in Patients With Ventilator-Associated Pneumonia.

Chest. 2009 Dec 28;

Authors: Afessa B, Shorr AF, Anzueto AR, Craven DE, Schinner R, Kollef MH

BACKGROUND: A silver-coated endotracheal tube (ETT) reduced the incidence of ventilator-associated pneumonia (VAP), compared with an uncoated ETT in the North American Silver-Coated Endotracheal Tube (NASCENT) study. METHODS: To evaluate effect of ETT and risk factors on mortality, we performed a retrospective cohort analysis in patients who developed VAP in the NASCENT study. We determined causes of death and VAP due to potentially multidrug-resistant bacteria (eg, Pseudomonas, Acinetobacter), and performed stepwise multivariate logistic regression with the following predefined variables: treatment group, APACHE II, continuous sedation, coma, COPD, emergency surgery/trauma, immunodeficiency, potentially multidrug-resistant bacteria, and inappropriate initial antibiotics. RESULTS: The silver-coated ETT was associated with reduced mortality in patients with VAP (silver vs control, 5/37 [14%] vs 20/56 [36%]; p=0.03), but not in those without VAP (228/729 [31%] vs 178/687 [26%]; p=0.03). The only between-group difference in leading causes of death was respiratory failure (silver vs control, 45/233 [19%] vs 22/198 [11%]; p=0.02). Of the VAP-related deaths, 1 in the silver group was caused by Acinetobacter sepsis. In the control group, 6 deaths were caused by sepsis and 3 by pneumonia; 6 of 9 pathogens were potentially multidrug-resistant. In multivariate analysis, treatment group was a predictor of mortality (odds ratio, silver vs control, 0.28; 95% confidence interval, 0.09-0.89; p=0.03). APACHE II >/=20 and inappropriate antibiotics also remained in the model (p<0.1). CONCLUSIONS: These findings suggest that silver-coated ETT was associated with reduced mortality in patients who developed VAP in the NASCENT study. Studies are needed to confirm these exploratory findings.

PMID: 20038737 [PubMed - as supplied by publisher]

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Coagulopathy Does Not Protect Against Venous Thromboembolism in Hospitalized Patients with Chronic Liver Disease.

Chest. 2009 Dec 29;

Authors: Dabbagh O, Oza A, Prakash S, Sunna R, Saettele TM

BACKGROUND: It is uncertain whether pathologically prolonged International Normalized Ratio INR seen in Chronic Liver Disease CLD protects against venous thromboembolism VTE. Previous studies reported VTE incidence of 0.5-1.9% in CLD patients .We sought to evaluate VTE incidence among hospitalized CLD patients according to INR levels. METHODS: This is a retrospective cohort study performed at a tertiary university hospital. We included all adult patients admitted with a primary diagnosis of CLD over a seven year period. The primary outcome was the development of VTE during hospital stay. Patients were divided into quartiles according to their highest admission INR.VTE events and prophylaxis rates were compared among INR quartiles. RESULTS: Over the allotted 7 year period, we included 190 patients. Of these 12 developed VTE events yielding a VTE incidence of 6.3% .There was no significant difference in the incidence of VTE between INR quartiles. Hospital mortality rates were higher in the higher INR quartiles than in the lower ones (p<0.001), but hospital length of stay was not significantly different. Of the patients with documented VTE, one (4.2%) was Child-Pugh stage A, three (4.6%) were stage B, and eight (8.0%) were stage C (p=0.602).VTE prophylaxis was not utilized in 75% of patients. CONCLUSIONS: An elevated INR in the setting of CLD does not appear to protect against the development of hospital-acquired VTE. The notion that "auto-anticoagulation" protects against VTE is unfounded. Utilization of DVT prophylaxis was extremely low in this population.

PMID: 20040609 [PubMed - as supplied by publisher]

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Combination Flucytosine and High-Dose Fluconazole Compared with Fluconazole Monotherapy for the Treatment of Cryptococcal Meningitis: A Randomized Trial in Malawi.

Clin Infect Dis. 2009 Dec 28;

Authors: Nussbaum JC, Jackson A, Namarika D, Phulusa J, Kenala J, Kanyemba C, Jarvis JN, Jaffar S, Hosseinipour MC, Kamwendo D, van der Horst CM, Harrison TS

Background. Cryptococcal meningitis is a major cause of human immunodeficiency virus (HIV)-associated morbidity and mortality in Africa. Improved oral treatment regimens are needed because amphotericin B is neither available nor feasible in many centers. Fluconazole at a dosage of 1200 mg per day is more fungicidal than at a dosage of 800 mg per day, but mortality rates remain unacceptably high. Therefore, we examined the effect of adding oral flucytosine to fluconazole. Methods. From 13 February through 2 December 2008, HIV-seropositive, antiretroviral-naive patients experiencing their first episode of cryptococcal meningitis were randomized to receive (1) 14 days of fluconazole (1200 mg per day) alone or (2) in combination with flucytosine (100 mg/kg per day) followed by fluconazole (800 mg per day), with both groups undergoing 10 weeks of follow-up. The primary end point was early fungicidal activity, derived from quantitative cerebrospinal fluid cultures on days 1, 3, 7, and 14. Secondary end points were safety and 2- and 10-week mortality. Results. Forty-one patients were analyzed. Baseline mental status, cryptococcal burden, opening pressure, CD4(+) cell count, and HIV load were similar between groups. Combination therapy was more fungicidal than fluconazole alone (mean early fungicidal activity +/- standard deviation, -[Formula: see text] log colony-forming units [CFU]/mL per day vs -[Formula: see text] log CFU/mL per day; [Formula: see text]). The combination arm had fewer deaths by 2 weeks (10% vs 37%) and 10 weeks (43% vs 58%). More patients had grade III or IV neutropenia with combination therapy (5 vs 1, within the first 2 weeks; [Formula: see text]), but there was no increase in infection-related adverse events. Conclusions. The results suggest that optimal oral treatment for cryptococcal meningitis is high-dose fluconazole with flucytosine. Efforts are needed to increase availability of flucytosine in Africa. Clinical trials registration. isrctn.org Identifier: ISRCTN02725351.

PMID: 20038244 [PubMed - as supplied by publisher]

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Natural History of Very Severe Aortic Stenosis.

Circulation. 2009 Dec 21;

Authors: Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G

BACKGROUND: -We sought to assess the outcome of asymptomatic patients with very severe aortic stenosis. Methods and Results-We prospectively followed 116 consecutive asymptomatic patients (57 women; age, 67+/-16 years) with very severe isolated aortic stenosis defined by a peak aortic jet velocity (AV-Vel) >/=5.0 m/s (average AV-Vel, 5.37+/-0.35 m/s; valve area, 0.63+/-0.12 cm(2)). During a median follow-up of 41 months (interquartile range, 26 to 63 months), 96 events occurred (indication for aortic valve replacement, 90; cardiac deaths, 6). Event-free survival was 64%, 36%, 25%, 12%, and 3% at 1, 2, 3, 4, and 6 years, respectively. AV-Vel but not aortic valve area was shown to independently affect event-free survival. Patients with an AV-Vel >/=5.5 m/s had an event-free survival of 44%, 25%, 11%, and 4% at 1, 2, 3, and 4 years, respectively, compared with 76%, 43%, 33%, and 17% for patients with an AV-Vel between 5.0 and 5.5 m/s (P<0.0001). Six cardiac deaths occurred in previously asymptomatic patients (sudden death, 1; congestive heart failure, 4; myocardial infarction, 1). Patients with an initial AV-Vel >/=5.5 m/s had a higher likelihood (52%) of severe symptom onset (New York Heart Association or Canadian Cardiovascular Society class >II) than those with an AV-Vel between 5.0 and 5.5 m/s (27%; P=0.03). Conclusions-Despite being asymptomatic, patients with very severe aortic stenosis have a poor prognosis with a high event rate and a risk of rapid functional deterioration. Early elective valve replacement surgery should therefore be considered in these patients.

PMID: 20026771 [PubMed - as supplied by publisher]

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Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.

Clin Infect Dis. 2010 Jan 15;50(2):133-164

Authors: Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O’Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

PMID: 20034345 [PubMed - as supplied by publisher]

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Nonventilatory strategies for patients with life-threatening 2009 H1N1 influenza and severe respiratory failure.

Crit Care Med. 2009 Dec 23;

Authors: Napolitano LM, Park PK, Raghavendran K, Bartlett RH

Severe respiratory failure (including acute lung injury and acute respiratory distress syndrome) caused by 2009 H1N1 influenza infection has been reported worldwide. Refractory hypoxemia is a common finding in these patients and can be challenging to manage. This review focuses on nonventilatory strategies in the advanced treatment of severe respiratory failure and refractory hypoxemia such as that seen in patients with severe acute respiratory distress syndrome attributable to 2009 H1N1 influenza. Specific modalities covered include conservative fluid management, prone positioning, inhaled nitric oxide, and extracorporeal membrane oxygenation and life support. Pharmacologic strategies (including steroids) investigated for the treatment of severe respiratory failure are also reviewed.

PMID: 20035216 [PubMed - as supplied by publisher]

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Variable daptomycin susceptibility in patients receiving intravenous vancomycin for meticillin-resistant Staphylococcus aureus infections.

Int J Antimicrob Agents. 2009 Dec 23;

Authors: Golden M, Shaib W, Havill N

PMID: 20036108 [PubMed - as supplied by publisher]

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Risk factors and outcome of transfusion-related acute lung injury in the critically ill: A nested case-control study.

Crit Care Med. 2009 Dec 23;

Authors: Vlaar AP, Binnekade JM, Prins D, van Stein D, Hofstra JJ, Schultz MJ, Juffermans NP

OBJECTIVES:: To determine the incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of critically ill patients. DESIGN:: In a retrospective cohort study, patients with transfusion-related acute lung injury were identified using the consensus criteria of acute lung injury within 6 hrs after transfusion. Inclusion criterion was a length of intensive care unit admission >48 hrs. Patients developing transfusion-related acute lung injury were matched (on age, sex, and admission diagnosis) to transfused control subjects and patients developing acute lung injury from another origin. SETTING:: Tertiary referral hospital. PATIENTS:: All first-admitted patients from November 1, 2004, until October 1, 2007, to the intensive care unit. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: Of 5208 admitted patients, 2024 patients had a length of stay >48 hrs, of whom 109 were suspected transfusion-related acute lung injury cases. Compared with transfused control subjects, risk factors for transfusion-related acute lung injury were emergency cardiac surgery (odds ratio, 17.6 [1.8-168.5]), hematologic malignancy (odds ratio, 13.1 [2.7-63.8]), massive transfusion (odds ratio, 4.5 [2.1-9.8]), sepsis (odds ratio, 2.5 [1.2-5.2]), mechanical ventilation (odds ratio, 3.0 [1.3-7.1], and high Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.1 [1.0-1.1]; p < .03 for all). The volume of platelets and plasma transfused was associated with transfusion-related acute lung injury in the univariate analysis. However, this association disappeared in the multivariate analysis. Compared with acute lung injury control subjects, risk factors for transfusion-related acute lung injury were sepsis (odds ratio, 2.4 [1.1-5.3]) and high Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.1 [1.0-1.1]), whereas pneumonia (odds ratio, 0.4 [0.2-0.7]) was a negative predictive factor. Patients with transfusion-related acute lung injury had a longer duration of mechanical ventilation compared with transfused control subjects and acute lung injury control subjects (231 [138-472] vs. 71 [46-163] and 70 [42-121] hrs, p < .001). Also, 90-day survival of patients with transfusion-related acute lung injury was lower compared with transfused control subjects and acute lung injury control subjects (53% vs. 75% and 83%, p < .02). CONCLUSIONS:: Transfusion-related acute lung injury is common in critically ill patients. Transfusion-related acute lung injury may contribute to an adverse outcome associated with transfusion. This study identifies transfusion-related acute lung injury risk factors, which may aid in assessing the risks and benefits of transfusion in critically ill patients.

PMID: 20035217 [PubMed - as supplied by publisher]

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Safety of triazole antifungal drugs in patients with cancer.

J Antimicrob Chemother. 2009 Dec 24;

Authors: Cronin S, Chandrasekar PH

Triazole drugs are widely used in cancer patients for prophylaxis and treatment of life-threatening invasive fungal infections. Fluconazole, available for over two decades, is safe and effective in patients with cancer; however, the excellent safety profile of fluconazole may not be applicable to the newer triazoles. Itraconazole, voriconazole and posaconazole are associated with adverse events, and drug interactions frequently occur, particularly in cancer patients, since the triazoles and many drugs used in cancer chemotherapy are metabolized via a common metabolic pathway, the hepatic cytochrome P450 system. Close monitoring for drug interactions is needed when triazoles are used with anti-neoplastic drugs and dosage modification of the triazole or its discontinuation may be required. Monitoring of triazole serum concentrations is becoming an important aspect of management to minimize toxicity and ensure efficacy.

PMID: 20035021 [PubMed - as supplied by publisher]

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The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis.

Crit Care Med. 2009 Dec 23;

Authors: Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, Schorr C, Artigas A, Ramsay G, Beale R, Parker MM, Gerlach H, Reinhart K, Silva E, Harvey M, Regan S, Angus DC,

OBJECTIVE:: The Surviving Sepsis Campaign (SSC or "the Campaign") developed guidelines for management of severe sepsis and septic shock. A performance improvement initiative targeted changing clinical behavior (process improvement) via bundles based on key SSC guideline recommendations. DESIGN AND SETTING:: A multifaceted intervention to facilitate compliance with selected guideline recommendations in the intensive care unit, emergency department, and wards of individual hospitals and regional hospital networks was implemented voluntarily in the United States, Europe, and South America. Elements of the guidelines were "bundled" into two sets of targets to be completed within 6 hrs and within 24 hrs. An analysis was conducted on data submitted from January 2005 through March 2008. SUBJECTS:: A total of 15,022 subjects. MEASUREMENTS AND MAIN RESULTS:: Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mortality. Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 yrs (p < .0001). Compliance with the entire management bundle started at 18.4% in the first quarter and increased to 36.1% by the end of 2 yrs (p = .008). Compliance with all bundle elements increased significantly, except for inspiratory plateau pressure, which was high at baseline. Unadjusted hospital mortality decreased from 37% to 30.8% over 2 yrs (p = .001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, resulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 yrs (95% confidence interval, 2.5-8.4). CONCLUSIONS:: The Campaign was associated with sustained, continuous quality improvement in sepsis care. Although not necessarily cause and effect, a reduction in reported hospital mortality rates was associated with participation. The implications of this study may serve as an impetus for similar improvement efforts.

PMID: 20035219 [PubMed - as supplied by publisher]

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Increasing Resistance of Acinetobacter Species to Imipenem in United States Hospitals, 1999-2006.

Infect Control Hosp Epidemiol. 2009 Dec 23;

Authors: Hoffmann MS, Eber MR, Laxminarayan R

PMID: 20030564 [PubMed - as supplied by publisher]

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Nasogastric Aspiration: A Useful Tool in Some Patients With Gastrointestinal Bleeding.

Ann Emerg Med. 2009 Dec 21;

Authors: Anderson RS, Witting MD

PMID: 20031264 [PubMed - as supplied by publisher]

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Patient Identification Errors Are Common in a Simulated Setting.

Ann Emerg Med. 2009 Dec 21;

Authors: Henneman PL, Fisher DL, Henneman EA, Pham TA, Campbell MM, Nathanson BH

STUDY OBJECTIVE: We evaluate the frequency and accuracy of health care workers verifying patient identity before performing common tasks. METHODS: The study included prospective, simulated patient scenarios with an eye-tracking device that showed where the health care workers looked. Simulations involved nurses administering an intravenous medication, technicians labeling a blood specimen, and clerks applying an identity band. Participants were asked to perform their assigned task on 3 simulated patients, and the third patient had a different date of birth and medical record number than the identity information on the artifact label specific to the health care workers’ task. Health care workers were unaware that the focus of the study was patient identity. RESULTS: Sixty-one emergency health care workers participated-28 nurses, 16 technicians, and 17 emergency service associates-in 183 patient scenarios. Sixty-one percent of health care workers (37/61) caught the identity error (61% nurses, 94% technicians, 29% emergency service associates). Thirty-nine percent of health care workers (24/61) performed their assigned task on the wrong patient (39% nurses, 6% technicians, 71% emergency service associates). Eye-tracking data were available for 73% of the patient scenarios (133/183). Seventy-four percent of health care workers (74/100) failed to match the patient to the identity band (87% nurses, 49% technicians). Twenty-seven percent of health care workers (36/133) failed to match the artifact to the patient or the identity band before performing their task (33% nurses, 9% technicians, 33% emergency service associates). Fifteen percent (5/33) of health care workers who completed the steps to verify patient identity on the patient with the identification error still failed to recognize the error. CONCLUSION: Wide variation exists among health care workers verifying patient identity before performing everyday tasks. Education, process changes, and technology are needed to improve the frequency and accuracy of patient identification.

PMID: 20031263 [PubMed - as supplied by publisher]

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Just Say No: Gastric Aspiration and Lavage Rarely Provide Benefit.

Ann Emerg Med. 2009 Dec 21;

Authors: Pitera A, Sarko J

PMID: 20031262 [PubMed - as supplied by publisher]

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Combined oral prolonged-release oxycodone and naloxone in opioid-induced bowel dysfunction: review of efficacy and safety data in the treatment of patients experiencing chronic pain.

Expert Opin Pharmacother. 2009 Dec 23;

Authors: Clemens KE, Mikus G

Importance of the field: Despite proven analgesic efficacy, opioid use is associated with frequently dose-limiting bowel dysfunction that seriously impacts patients’ quality of life (QoL). Agents used at present to manage opioid-induced constipation do not address the underlying opioid receptor-mediated cause of bowel dysfunction and are often ineffective. There is, therefore, a significant need for more effective treatment options. The combination of the strong opioid oxycodone and the opioid antagonist naloxone has the potential to prevent opioid-induced bowel dysfunction (OIBD) while maintaining analgesic efficacy. Objective: To review the safety and efficacy of oral prolonged-release (PR) oxycodone/naloxone in the treatment of patients experiencing chronic pain. Areas covered in this review: A MEDLINE search was done (January 2002 – July 2009) for available literature for prolonged release oxycodone and naloxone in different patient groups. Results were limited to English-language and clinical trials. Data were also obtained from congress materials. What knowledge the reader will gain: Unmet needs of opioid pain treatment in terms of OIBD, reduced QoL and low treatment compliance, leading to reduced efficacy. A data overview demonstrates the efficacy and tolerability of PR oxycodone/naloxone in the management of severe chronic pain without the burden of severe gastrointestinal adverse events. The combined formulation of a highly effective opioid and an antagonist that acts locally to reduce gastrointestinal side effects is expected to simplify pain management. Take home message: The combination of PR oxycodone/naloxone offers the potential of maintaining normal bowel function in patients requiring opioid therapy – it is a strong analgesic that is well tolerated.

PMID: 20030568 [PubMed - as supplied by publisher]

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