Abelardo Capdevila

Is a Strategy Based on Routine Endotracheal Cultures the Best Way to Prescribe Antibiotics in Ventilator-Associated Pneumonia?

OBJECTIVES The objectives of this study were to evaluate if a strategy based on routine endotracheal aspirate (ETA) cultures is better than using the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines to prescribe antimicrobials in ventilator-associated pneumonia (VAP). METHODS This was a prospective, observational, cohort study conducted in a 15-bed ICU and comprising 283 patients who were mechanically ventilated for ≥48 h. Interventions included twice-weekly ETA; BAL culture was done if VAP was suspected. BAL (collected at the time of VAP) plus ETA cultures (collected≤7 days before VAP) (n=146 different pairs) were defined. We compared two models of 10 days of empirical antimicrobials (ETA-based vs ATS/IDSA guidelines-based strategies), analyzing their impact on appropriateness of therapy and total antimicrobial-days, using the BAL result as the standard for comparison. RESULTS Complete ETA and BAL culture concordance (identical pathogens or negative result) occurred in 52 pairs; discordance (false positive or false negative) in 67, and partial concordance in two. ETA predicted the etiology in 62.4% of all pairs, in 74.0% of pairs if ETA was performed≤2 days before BAL, and in 46.2% of pairs if ETA was performed 3 to 7 days before BAL (P=.016). Strategies based on the ATS/IDSA guidelines and on ETA results led to appropriate therapy in 97.9% and 77.4% of pairs, respectively (P<.001). The numbers of antimicrobial-days were 1,942 and 1,557 for therapies based on ATS/IDSA guidelines and ETA results, respectively (P<.001). CONCLUSIONS The ATS/IDSA guidelines-based approach was more accurate than the ETA-based strategy for prescribing appropriate, initial, empirical antibiotics in VAP, unless a sample was available≤2 days of the onset of VAP. The ETA-based strategy led to fewer days on prescribed antimicrobials.

Outcome of Patients With Systemic Rheumatic Diseases Admitted to a Medical Intensive Care Unit

Systemic rheumatic diseases, including connective tissue diseases (CTDs) and necrotizing vasculitis, are a heterogeneous group of pathologies with a variety of clinical manifestations, disease courses, and prognoses. Patient admission to intensive care unit (ICU) may be due to acute manifestations of primary disease or secondary to complications from immunosuppressive agents, complications unrelated to primary disease, or a combination of these. The objective of the following study was to describe the causes, clinical course, and outcome in patients with systemic rheumatic diseases who required admission to the ICU.

Interrelationship between oxygen‐related variables in patients with acute myocardial infarction: an interpretative review

The high mortality rate of cardiogenic shock in acute myocardial infarction (AMI) implies that debate over the correct haemodynamic management is still unresolved. The purpose of this review is to re‐evaluate the reciprocal relationships between oxygen‐related variables and response to treatment in a large number of patients with AMI. A MEDLINE search of reports published between 1970 and 2008 was performed. Twelve clinical reports including 453 patients with AMI and 989 sets of oxygen delivery and oxygen consumption expressed in ml min−1 m−2 and oxygen extraction ratio were selected. While processing this data, we found an early down‐regulation in oxygen demand linked to a decrease in oxygen supply. This mechanism is also supported in some studies by a critically low oxygen uptake that was not associated with lactic acidosis.