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Guideline-concordant antibiotic use and survival among patients with community-acquired pneumonia admitted to the intensive care unit.

Clin Ther. 2010 Feb;32(2):293-9

Authors: Frei CR, Attridge RT, Mortensen EM, Restrepo MI, Yu Y, Oramasionwu CU, Ruiz JL, Burgess DS

OBJECTIVE: This study evaluated the survival benefit of US community-acquired pneumonia (CAP) practice guidelines in the intensive care unit (ICU) setting. METHODS: We conducted a retrospective cohort study of adult patients with CAP who were admitted to 5 community hospital ICUs between November 1, 1999, and April 30, 2000. The guidelines for antibiotic prescriptions were the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Guideline-concordant antimicrobial therapy was defined as a beta-lactam plus fluoroquinolone or macrolide, antipseudomonal beta-lactam plus fluoroquinolone, or antipseudomonal beta-lactam plus aminoglycoside plus fluoroquinolone or macrolide. Patients with a documented beta-lactam allergy were considered to have received guideline-concordant therapy if they received a fluoroquinolone with or without clindamycin, or aztreonam plus fluoroquinolone with or without aminoglycoside. All other antibiotic regimens were considered to be guideline discordant. Time to clinical stability, time to oral antibiotics, length of hospital stay, and in-hospital mortality were evaluated with regression models that included the outcome as the dependent variable, guideline-concordant antibiotic therapy as the independent variable, and the Pneumonia Severity Index (PSI) score and facility as covariates. RESULTS: The median age of the 129 patients included in the study was 71 years (interquartile range, 60-79 years). Sixty-two of 129 patients (48%) were male. Comorbidities included liver dysfunction (7 patients [5%]), heart failure (62 [48%]), renal dysfunction (39 [30%]), cerebrovascular disease (21 [16%]), and cancer (14 [11%]). The median (25th-75th percentile) PSI score was 119 (98-142), and overall mortality was 19% (25 patients). Patient demographics were similar between groups. Fifty-three patients (41%) received guideline-endorsed therapies. Guideline-discordant therapy was associated with an increase in inpatient mortality (25% vs 11%; odds ratio = 2.99 [95% CI, 1.08-9.54]). Receipt of guideline-concordant antibiotics was not associated with reductions in time to clinical stability, time to oral antibiotics, or length of hospital stay when patients who died were excluded from the analysis. CONCLUSION: Guideline-concordant empiric antibiotic therapy was associated with improved survival among these patients with CAP who were admitted to 5 ICUs.

PMID: 20206787 [PubMed - indexed for MEDLINE]

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Urine microscopy is associated with severity and worsening of acute kidney injury in hospitalized patients.

Clin J Am Soc Nephrol. 2010 Mar;5(3):402-8

Authors: Perazella MA, Coca SG, Hall IE, Iyanam U, Koraishy M, Parikh CR

BACKGROUND AND OBJECTIVES: Serum creatinine concentration at the time of nephrology consultation is not necessarily indicative of the severity of acute kidney injury (AKI). Although urine microscopy is useful to differentiate AKI, its role in predicting adverse clinical outcomes has not been well described. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The relationship between urine microscopy findings at the time of nephrology consultation for AKI and clinical outcomes was evaluated prospectively. A urinary sediment scoring system was created on the basis of the number of renal tubular epithelial cells and granular casts. The primary outcome was worsening of AKI (progressing to higher AKI Network stage, dialysis, or death) during hospitalization. RESULTS: Of 249 patients consulted for AKI, 197 had acute tubular necrosis or prerenal AKI and were included in the analysis. At consultation, 80 (40%) had stage 1, 53 (27%) had stage 2, and 66 (33%) had stage 3 AKI. The urinary sediment combined scores were lowest in those with stage 1 and highest in stage 3 AKI. Seventy-nine patients (40%) experienced worsening of AKI from the time of consultation. The urinary scoring system was significantly associated with increased risk of worsening AKI (adjusted relative risk: 7.3; 95% confidence interval: 4.5 to 9.7 for worsening with score of > or =3 versus score of 0) and was more predictive than AKI Network stage at the time of consultation. CONCLUSIONS: The urinary sediment score may be a useful tool to predict worsening of AKI due to either acute tubular necrosis or prerenal AKI during hospitalization.

PMID: 20089493 [PubMed - indexed for MEDLINE]

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The impact of a systemwide policy for emergent off-hours venous duplex ultrasound studies.

Ann Vasc Surg. 2010 Apr;24(3):388-92

Authors: Chaer RA, Myers J, Pirt D, Pacella C, Yealy DM, Makaroun MS, Leers SA

BACKGROUND: We evaluated the impact of an after-hours policy regulating venous duplex ultrasound (VDU) for deep vein thrombosis (DVT) diagnosis on resource utilization and patient care. METHODS: On July 1, 2007, we altered the approach to emergent VDU of patients with potential DVT during off-hours (defined as 5:00 p.m. to 7:00 a.m. weekdays, after 3:30 p.m. Saturdays and Sundays). Instead of 24 hr access, we permitted a venous duplex study in the noninvasive vascular laboratory (NIVL) only after meeting set criteria developed collaboratively across services. In the emergency department (ED), we based all VDU requests on a preset modified Wells score (MWS) as determined by the ED physician. Those patients with MWS 0 or 1 and those above 1 who could receive empiric single-dose low-molecular weight heparin (LMWH) received next-morning imaging unless consultation with a vascular surgeon created an emergent imaging plan. In parallel, inpatient emergent VDU was permitted only after contact with an attending vascular surgeon and where empiric short-term anticoagulation could not occur safely. We tracked NIVL utilization, patient morbidity, sonographer retention, and satisfaction. RESULTS: The number of overall off-hours emergent VDUs decreased from 59 to 19/month after implementation. Testing was deferred in 52 ED patients: 15 stayed in the ED for testing in the morning and 37 were discharged to be tested the following day. Thirty-one of 37 patients returned for testing as outpatient follow-up. Twenty-eight received ED LMWH while awaiting testing. No adverse events were noted with the delay. The mean MWS for ED after-hours studies was 2.9+/-1.6 and that for deferred ER studies was 2.4+/-1.3 (p=0.005). Incidentally, overall off-hours inpatient and ED VDU requests decreased 64% with no clinical adverse events in the first year. The rate of overall positive studies done off-hours increased from 6.7% to 20% (p<0.0001). Sonographer satisfaction was maintained with regulation of call. CONCLUSION: Our collaborative approach allowed off-hour VDU utilization to decrease without any measurable negative care impact.

PMID: 19748216 [PubMed - indexed for MEDLINE]

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Commentary: Health Care Technology and Medical Education: Putting Physical Diagnosis in Its Proper Place.

Acad Med. 2010 Jun;85(6):945-946

Authors: Goodman RL

Bemoaning the lost art of the physical exam is an ancient practice, dating back hundreds, if not thousands, of years. Since the introduction of the stethoscope in the early 19th century, the clinical skills of physicians have waned as their dependence on technology has grown. This “lost skills literature” reflects the ambivalent relationship the medical profession has had with its technology, a relationship also dating back centuries. Despite the dominant role played by technology in the life of the 21st-century physician, medical students and trainees do not receive sufficient formal training in its use and assessment. This lacuna in training likely contributes to the well-documented inappropriate use of health care technology that threatens any attempt at improved patient care and reform of the health care system. The author recommends the introduction of a formal curriculum in the use and assessment of health care technology in medical education and training.

PMID: 20505391 [PubMed - as supplied by publisher]

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2009 influenza A (H1N1): a clinical review.

Hosp Pract (Minneap). 2010 Apr;38(2):74-81

Authors: Delaney JW, Fowler RA

Since the onset of the 2009 influenza A (H1N1) pandemic, the virus has caused significant morbidity and mortality. Most cases of 2009 H1N1 have presented as mild febrile illnesses with cough, sore throat, and occasional gastrointestinal symptoms. Dyspnea has been more commonly associated with the onset of severe pulmonary disease. Unlike seasonal influenza, the prevalence of 2009 H1N1 is greatest among children and young adults, although older patients and those with comorbidities are more likely to experience worse clinical outcomes. Among the most severely affected, critical illness evolves within 4 to 6 days from symptom onset, and approximately 70% of these patients require mechanical ventilation ranging in duration from days to weeks. Compared with prior influenza seasons, the need for rescue oxygenation therapy with nitric oxide, prone ventilation, high-frequency oscillation, and extracorporeal membrane oxygenation has increased. Specific medical care with neuraminidase inhibitors and antibiotics for secondary bacterial pneumonia are the mainstays of therapy. With optimal care, mortality rates range from 5% to 7% among those hospitalized and reach approximately 20% among those admitted to the intensive care unit.

PMID: 20469616 [PubMed - indexed for MEDLINE]

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Invasive candidiasis in the intensive care unit.

Hosp Pract (Minneap). 2010 Apr;38(2):82-91

Authors: Krishnan S, Ostrosky-Zeichner L

Invasive fungal disease by Candida spp. is on the rise in the modem era of prolonged patient survival by virtue of improved critical care measures, novel chemotherapy regimens, and increasing immunosuppression following organ transplants. Invasive candidiasis (IC) in the setting of an intensive care unit results in prolonged hospital stay and increased morbidity. Clinical suspicion plays a major role in the diagnosis of IC, as current laboratory methods are not very sensitive. Various serum markers and molecular techniques are under development to improve diagnostic strategies. Treatment options involve an expanding spectrum of antifungals. Knowledge of local epidemiology and the risk factors that predispose patients to this disease are essential for effective patient care in an intensive care setting.

PMID: 20469617 [PubMed - indexed for MEDLINE]

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Prevention of acute kidney injury and protection of renal function in the intensive care unit. Expert opinion of the Working Group for Nephrology, ESICM.

Intensive Care Med. 2010 Mar;36(3):392-411

Authors: Joannidis M, Druml W, Forni LG, Groeneveld AB, Honore P, Oudemans-van Straaten HM, Ronco C, Schetz MR, Woittiez AJ,

BACKGROUND: Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. OBJECTIVES: To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. METHOD: A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system. CONCLUSIONS AND RECOMMENDATIONS: Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest using vasopressors in vasodilatory hypotension, specific vasodilators under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s00134-009-1678-y) contains supplementary material, which is available to authorized users.

PMID: 19921152 [PubMed - indexed for MEDLINE]

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Bisphosphonate use in patients with lung cancer and bone metastases: recommendations of a European expert panel.

J Thorac Oncol. 2009 Oct;4(10):1280-8

Authors: De Marinis F, Eberhardt W, Harper PG, Sureda BM, Nackaerts K, Soerensen JB, Syrigos K, Trédaniel J

INTRODUCTION: Bisphosphonates (BPs) are effective in preventing, reducing the incidence, and delaying the onset of skeletal-related events in patients with bone metastases in a variety of solid tumors, including lung cancer. The purpose of this article is to review the current evidence for the use of BPs in lung cancer and to provide specific European recommendations to support the clinical practice of using BPs to treat patients with lung cancer with bone metastases. METHODS: An expert panel of European clinical oncologists and lung cancer specialists convened for two face-to-face meetings designed to review available evidence on the efficacy of BPs in lung cancer and to develop recommendations based on published literature and clinical practice experiences. RESULTS: The panel recommends screening patients with lung cancer for bone metastases at the initial staging of disease to assess symptomatic bone metastases and screen for asymptomatic bone metastases and to allow accurate monitoring of bone disease progression and initiate bone-specific therapy. Bone assessment should be based on positron emission tomography (if available) or bone scan. BPs should be added to the treatment of patients with lung cancer (with non-small cell lung cancer or small cell lung cancer) who develop bone metastases. In such patients, BPs must be considered part of metastatic lung cancer treatment to prevent and delay the occurrence of further bone metastases and skeletal-related events and to relieve pain where present. BP treatment should continue for as long as it is practically feasible in the absence of any significant adverse effects.

PMID: 19701109 [PubMed - indexed for MEDLINE]

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Agreement between central venous and arterial blood gas measurements in the intensive care unit.

Clin J Am Soc Nephrol. 2010 Mar;5(3):390-4

Authors: Treger R, Pirouz S, Kamangar N, Corry D

BACKGROUND AND OBJECTIVES: Venous blood gas (VBG) analysis is a safer procedure than arterial blood gas (ABG) analysis and may be an alternative for determining acid-base status. The objective of this study was to examine the agreement between ABG and central VBG samples for all commonly used parameters in a medical intensive care unit (ICU) population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed a single-center, prospective trial to assess the agreement between arterial and central VBG measurements in a medical ICU. Adult patients who were admitted to the ICU and required both a central venous line and an arterial line were enrolled. When an ABG was performed, a central venous sample was obtained to examine the agreement among the pH, Pco(2), and bicarbonate. Data comparing central and peripheral VBG values were also obtained. RESULTS: The mean arterial minus venous difference for pH, Pco(2), and bicarbonate was 0.027, -3.8, and -0.80, respectively. Bland-Altman plots for agreement of pH, Pco(2), and bicarbonate showed 95% limits of agreement of -0.028 to 0.081, -12.3 to 4.8, and -4.0 to 2.4, respectively. Regression equations were derived to predict arterial values from venous values as follows: Arterial pH = -0.307 + 1.05 x venous pH, arterial Pco(2) = 0.805 + 0.936 x venous Pco(2), and arterial bicarbonate = 0.513 + 0.945 x venous bicarbonate. The mean central minus peripheral differences for pH, Pco(2), and bicarbonate were not clinically important. CONCLUSIONS: Peripheral or central venous pH, Pco(2), and bicarbonate can replace their arterial equivalents in many clinical contexts encountered in the ICU.

PMID: 20019117 [PubMed - indexed for MEDLINE]

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Idraparinux versus standard therapy in the treatment of deep venous thrombosis in cancer patients: A subgroup analysis of the Van Gogh DVT trial.

Thromb Haemost. 2010 May 27;104(1)

Authors: van Doormaal FF, Cohen AT, Davidson BL, Decousus H, Gallus AS, Gent M, Piovella F, Prins MH, Raskob GE, Büller HR

Standard treatment with heparin followed by vitamin K antagonists is frequently complicated by bleeding and recurrent venous thromboembolism (VTE) in cancer patients with VTE. To compare the efficacy, safety and overall survival of long-term idraparinux treatment to standard therapy in cancer patients we conducted a post-hoc analysis in the subgroup of non-active and active cancer patients included in the Van Gogh DVT clinical trial. The cancer patients with deep venous thrombosis (DVT) and without pulmonary embolism (PE) were randomised to standard treatment or a once-weekly subcutaneous injection of idraparinux (2.5 mg), a synthetic pentasaccharide. 421 cancer patients were included. A total of 220 patients received idraparinux and 201 were allocated to standard therapy for three months (8%) or six months (92%). A recurrent VTE was observed during the first six months in 2.5% (n=5) of the idraparinux recipients compared to 6.4% (n=12) in the standard therapy group (hazard ratio 0.39, 95% confidence interval [CI]; 0.14-1.11). The rate of bleeding was comparable (odds ratio 0.89, 95% CI; 0.50-1.59). The outcomes were similar at three months after randomisation in all patients. Of the idraparinux recipients, 22.7% (n=50) died during the study period compared to 48 patients (23.9%) in the standard treatment group (hazard ratio 0.99, 95% CI; 0.66-1.48). In conclusion, no significant safety or survival differences were observed between cancer patients with DVT treated with idraparinux for six months compared to standard therapy. Fewer recurrent VTEs were observed in the idraparinux group; however, this was not statistically significant and also because of study limitations this should be interpreted with caution.

PMID: 20508907 [PubMed - as supplied by publisher]

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Clinical Characteristics and Outcomes of Sepsis-Related vs. Non-Sepsis-Related Acute Respiratory Distress Syndrome.

Chest. 2010 May 27;

Authors: Sheu CC, Gong MN, Zhai R, Chen F, Bajwa EK, Clardy PF, Gallagher DC, Thompson BT, Christiani DC

Abstract BACKGROUND: Acute respiratory distress syndrome (ARDS) may occur after either septic or nonseptic injuries. Sepsis is the major cause of ARDS. However, little is known about the differences between sepsis-related and non-sepsis-related ARDS. METHODS: Consecutive 2786 patients with ARDS predisposing conditions were enrolled into the prospective cohort, of which 736 patients developed ARDS. We defined sepsis-related ARDS as ARDS developing in patients with sepsis, and non-sepsis-related ARDS as ARDS developing after nonseptic injuries such as trauma, aspiration, and multiple transfusions. Patients with both septic and nonseptic risks were excluded from analysis. RESULTS: Compared to non-sepsis-related ARDS patients (n=62), sepsis-related ARDS patients (n=524) were more likely to be female, diabetics, less likely to have preceding surgery, and had longer pre-ICU hospital stays and higher APACHE III scores (median, 78 vs. 65, p<0.0001). There were no differences in lung injury score, blood pH, PaO(2)/FiO(2) ratio, and PaCO(2) on ARDS diagnosis. However, sepsis-related ARDS patients had significantly lower PaO(2)/FiO(2) ratios than non-sepsis-related ARDS patients on ARDS day 3 (p=0.018), day 7 (p=0.004), and day 14 (p=0.004) (repeat measures analysis, p=0.011). Compared with non-sepsis-related ARDS patients, sepsis-related ARDS patients had a higher 60-day mortality (38.2% vs. 22.6%, p=0.016), a lower successful extubation rate (53.6% vs. 72.6%, p=0.005), and fewer ICU-free days (p=0.0001) and ventilator-free days (p=0.003). In multivariate analysis, age, APACHE III score, liver cirrhosis, metastatic cancer, admission serum bilirubin and glucose levels, and treatment with activated protein C were independently associated with 60-day ARDS mortality. After adjustment, sepsis-related ARDS was no longer associated with higher 60-day mortality, (HR, 1.26, 95% CI, 0.71-2.22). CONCLUSION: Sepsis-related ARDS has a higher overall disease severity, poorer recovery from lung injury, lower successful extubation rate, and higher mortality than non-sepsis-related ARDS. Worse clinical outcomes in sepsis-related ARDS appear to be driven by disease severity and comorbidities.

PMID: 20507948 [PubMed - as supplied by publisher]

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VALIDITY OF SEVERITY SCORES IN HOSPITALIZED PATIENTS WITH NURSING HOME ACQUIRED PNEUMONIA.

Chest. 2010 May 27;

Authors: El-Solh AA, Alhajhusain A, Abou Jaoude P, Drinka P

ABSTRACT BACKGROUND: Several severity scores have been advanced to predict patient's outcome from community acquired pneumonia (CAP). The purpose of this study is to compare the accuracy of CURB, CURB-65, CRB-65, and SOAR scoring systems in predicting 30-day mortality and ICU admission in patients with nursing home acquired pneumonia (NHAP). METHODS: A retrospective analysis of a prospectively collected database of 457 nursing home residents hospitalized with pneumonia at two university-affiliated tertiary care facilities. Clinical and laboratory features were used to compute severity scores using the British Thoracic Society severity rules and the SOAR criteria. The sensitivity, specificity, positive and negative predictive values were compared for need of ICU admission and 30-day mortality. RESULTS: The overall 30-day mortality and ICU admission rates were 23% and 25%, respectively. CURB, CURB-65, and CRB-65 performed similarly in predicting mortality with areas under the receiver operating characteristic curves (AUC) of 0.605 (95% CI 0.559-0.650), 0.593 (95% CI 0.546-0.638), and 0.592 (95% CI 0.546-0.638), respectively while SOAR showed superior accuracy with an AUC of 0.765 (95% CI 0.724-0.803) (p<0.001). The need for ICU care was also better identified with SOAR model compared to the other scoring rules. CONCLUSIONS: All three British Thoracic Society rules had lower performance accuracy in predicting 30-day mortality of hospitalized NHAP than SOAR. SOAR is also a superior alternative for better identification of severe NHAP. An improved rule for severity assessment of hospitalized NHAP is needed.

PMID: 20507947 [PubMed - as supplied by publisher]

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The interaction between prior antimicrobial drug exposure and resistance in human Salmonella infections.

J Antimicrob Chemother. 2010 May 27;

Authors: Koningstein M, Simonsen J, Helms M, Mølbak K

Objectives The use of antimicrobial drugs for food animals selects for resistant non-typhoid Salmonella strains, but human consumption of antimicrobial drugs may also increase the risk of subsequent infection. The aim of this study was to determine the risk of salmonellosis attributable to human consumption of antimicrobial drugs in a case-control study of 22 602 laboratory-confirmed Salmonella infections, diagnosed in Denmark between 1997 and 2005. Methods A population registry-based case-control study, using several Danish databases: the National Prescription Database; the National Registry for Enteric Pathogens; the Civil Registry System; and the Integrated Database on Labour Market Research. Results Exposure to trimethoprim, sulphonamides, broad-spectrum penicillins, tetracyclines and fluoroquinolones, during the year prior to diagnosis, was associated with an increased risk of non-typhoid Salmonella infection. Overall, the highest risk was associated with the prior use of fluoroquinolones. This risk increased as the time window of exposure approached the infection date. Previous use of fluoroquinolones was associated with an odds ratio (OR) of 4.55 [95% confidence interval (CI): 3.78-5.47] for Salmonella serotypes other than Salmonella Typhimurium or Salmonella Enteritidis, an OR of 2.21 (95% CI: 1.70-2.86) for Salmonella Typhimurium and an OR of 2.07 (95% CI: 1.76-2.42) for Salmonella Enteritidis. In particular for fluoroquinolones, there was an interaction between the pathogen resistance pattern and a history of antibiotic drug use. Conclusions The increasing use of antibiotics, particularly fluoroquinolones, is likely to result in increased incidence of foodborne infections with drug-resistant Salmonella.

PMID: 20507862 [PubMed - as supplied by publisher]

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Co-trimoxazole versus vancomycin for the treatment of methicillin-resistant Staphylococcus aureus bacteraemia: a retrospective cohort study.

J Antimicrob Chemother. 2010 May 27;

Authors: Goldberg E, Paul M, Talker O, Samra Z, Raskin M, Hazzan R, Leibovici L, Bishara J

Objectives To evaluate the efficacy and safety of co-trimoxazole versus that of vancomycin in adults with methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. Patients and methods Retrospective matched cohort study. Thirty-eight patients with MRSA bacteraemia, treated with co-trimoxazole as the main therapeutic agent, were matched with 76 patients treated with vancomycin as the main agent. The groups were matched for age, sex, functional status, endovascular source of infection, appropriateness of empirical antibiotic therapy, presence of a foreign body, sepsis severity and Charlson score. The outcomes collected were 30 day mortality, persistent bacteraemia [defined as positive blood culture (BC) >14 days after the first positive BC, but within 30 days], relapse (defined as recurrence of the same phenotype >30 days after the first positive BC within 12 months) and adverse events. Results The groups were well matched. Thirty day mortality was not significantly different between the groups [co-trimoxazole 13/38 (34.2%); vancomycin 31/76 (40.8%); odds ratio 0.76, 95% confidence interval 0.34-1.7]. There was only one case of relapse in the co-trimoxazole group (2.6%) compared with nine cases in the vancomycin group (11.8%). Incidence of relapse or persistent bacteraemia was lower in the co-trimoxazole group (3/38, 7.9%) than in the vancomycin group (13/76, 17.1%), although the difference was not statistically significant (P = 0.182). Development of renal failure was similar [co-trimoxazole 11/38 (28.9%); vancomycin 21/76 (27.6%)]. Conclusions Within the limitations of a small retrospective study, co-trimoxazole had a safety and efficacy profile similar to that of vancomycin and may offer an attractive additional therapeutic option for MRSA bacteraemia. A prospective, randomized controlled trial is warranted.

PMID: 20507860 [PubMed - as supplied by publisher]

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Elevation of cardiac troponin I during non-exertional heat-related illnesses in the context of a heatwave.

Crit Care. 2010 May 27;14(3):R99

Authors: Hausfater P, Doumenc B, Chopin S, Le Manach Y, Santin A, Dautheville S, Patzak A, Hericord P, Megarbane B, Andronikof M, Terbaoui N, Riou B

ABSTRACT: INTRODUCTION: The prognostic value of cardiac troponin I (cTnI) in patients having a heat-related illness during heat wave have been poorly documented. METHODS: In a post hoc analysis, we evaluated 514 patients admitted to emergency departments during the August 2003 heat wave in Paris, having a core temperature >38.5 degreesC and who had analysis of cTnI levels. cTnI was considered as normal, moderately elevated (abnormality threshold to 1.5 ng.mL-1), or severely elevated (>1.5 ng.mL-1). Patients were classified according to our previously described risk score (high, intermediate, and low-risk of death). RESULTS: Mean age was 84+/-12 years, mean body temperature 40.3 +/- 1.2 degreesC. cTnI was moderately elevated in 165 (32%) and severely elevated in 97 (19%) patients. One-year survival was significantly decreased in patients with moderate or severe increase in cTnI (24 and 46% vs 58%, all P<0.05). Using logistic regression, four independent variables were associated with an elevated cTnI: previous coronary artery disease, Glasgow coma scale <12, serum creatinine > 120 (microg)mol.L-1, and heart rate > 110 bpm. Using Cox regression, only severely elevated cTnI was an independent prognostic factor (hazard ratio 1.93, 95% confidence interval 1.35 to 2.77) when risk score was taken into account. One-year survival was decreased in patients with elevated cTnI only in high risk patients (17 vs 31%, P=0.04). CONCLUSIONS: cTnI is frequently elevated in patients with non-exertional heat-related illnesses during a heat wave and is an independent risk factor only in high risk patients where severe increase (>1.5 ng.mL-1) indicates severe myocardial damage.

PMID: 20507603 [PubMed - as supplied by publisher]

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