Craig Whiteley

Efficacy and Limitation of a Chlorhexidine-Based Decolonization Strategy in Preventing Transmission of Methicillin-Resistant Staphylococcus aureus in an Intensive Care Unit

BACKGROUND Surface-active antiseptics, such as chlorhexidine, are increasingly being used as part of intervention programs to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission, despite limited evidence and potential for resistance. We report on the effect of an antiseptic protocol on acquisition of both endemic MRSA and an outbreak strain of MRSA sequence type 239 (designated TW). METHODS Interrupted time-series data on MRSA acquisitions in two 15-bed intensive care units were analyzed using segmented regression models to estimate the effects of sequential introduction of an educational campaign, cohorting, and a chlorhexidine-based antiseptic protocol on transmission of TW and non-TW MRSA strains. Representative TW and non-TW MRSA strains were assessed for carriage of qacA/B genes and antiseptic susceptibility. RESULTS The antiseptic protocol was associated with a highly significant, immediate 70% reduction in acquisition of non-TW MRSA strains (estimated model-averaged incidence rate ratio, 0.3; 95% confidence interval, 0.19-0.47) and an increase in acquisition of TW MRSA strains (estimated model-averaged incidence rate ratio, 3.85; 95% confidence interval, 0.80-18.59). There was only weak evidence of an effect of other interventions on MRSA transmission. All TW MRSA strains (21 of 21 isolates) and <5% (1 of 21 isolates) of non-TW MRSA strains tested carried the chlorhexidine resistance loci qacA/B. In vitro chlorhexidine minimum bactericidal concentrations of TW strains were 3-fold higher than those of non-TW MRSA strains, and in vivo, only patients with non-TW MRSA demonstrated a reduction in the number of colonization sites in response to chlorhexidine treatment. CONCLUSION A chlorhexidine-based surface antiseptic protocol can interrupt transmission of MRSA in the intensive care unit, but strains carrying qacA/B genes may be unaffected or potentially spread more rapidly.

Therapeutic hypothermia after cardiac arrest: a retrospective comparison of surface and endovascular cooling techniques.

OBJECTIVES Therapeutic hypothermia (32-34 degrees C) is recommended for comatose survivors of cardiac arrest; however, the optimal technique for cooling is unknown. We aimed to compare therapeutic hypothermia using either surface or endovascular techniques in terms of efficacy, complications and outcome. DESIGN Retrospective cohort study. SETTING Thirty-bed teaching hospital intensive care unit (ICU). PATIENTS All patients (n=83) undergoing therapeutic hypothermia following cardiac arrest over a 2.5-year period. The mean age was 61+/-16 years; 88% of arrests occurred out of hospital, and 64% were ventricular fibrillation/tachycardia. INTERVENTIONS Therapeutic hypothermia was initiated in the ICU using iced Hartmanns solution, followed by either surface (n=41) or endovascular (n=42) cooling; choice of technique was based upon endovascular device availability. The target temperature was 32-34 degrees C for 12-24 h, followed by rewarming at a rate of 0.25 degrees Ch(-1). MEASUREMENTS AND MAIN RESULTS Endovascular cooling provided a longer time within the target temperature range (p=0.02), less temperature fluctuation (p=0.003), better control during rewarming (0.04), and a lower 48-h temperature load (p=0.008). Endovascular cooling also produced less cooling-associated complications in terms of both overcooling (p=0.05) and failure to reach the target temperature (p=0.04). After adjustment for known confounders, there were no differences in outcome between the groups in terms of ICU or hospital mortality, ventilator free days and neurological outcome. CONCLUSION Endovascular cooling provides better temperature management than surface cooling, as well as a more favorable complication profile. The equivalence in outcome suggested by this small study requires confirmation in a randomized trial.

ICU and 6-month outcome of oncology patients in the intensive care unit

BACKGROUND Advances in oncological care have led to improved short- and long-term prognosis of cancer patients but admission to the intensive care unit (ICU) remains controversial. AIM The objective was to assess the outcome of patients with haematological malignancies and solid tumours admitted to the ICU as emergencies, and to identify risk factors for mortality. DESIGN AND METHODS Retrospective and prospective analysis of 185 cancer patients admitted to the ICU at Guys Hospital (259 admissions), a large tertiary referral oncology centre between February 2004 and July 2008. RESULTS One hundred and fifteen patients had haematological malignancies of whom 30.4% died in ICU. Seventy patients had solid tumours. ICU mortality was 27.1%. Fifty-four patients had >1 admission to ICU. ICU survivors had significantly lower acute physiology and chronic health evaluation II scores and less failed organ systems on admission to ICU and less organ failure during stay in the ICU. Neutropenia, sepsis and re-admission were not associated with an increased mortality. Six-month mortality rates for patients with haematological malignancies and solid tumours were 73 and 78.6%, respectively. CONCLUSION Short-term outcome of critically ill cancer patients in ICU is better than previously reported. The decision to admit cancer patients to ICU should depend on the severity of the acute illness rather than factors related to the malignancy. In appropriate patients, invasive organ support and re-admission should not be withheld.

Statins do not prevent acute organ failure in ventilated ICU patients: single-centre retrospective cohort study

IntroductionObservational studies suggest statin therapy reduces incident sepsis, but few studies have examined the impact on new organ failure. We tested the hypothesis that statin therapy, administered for standard clinical indications to ventilated intensive care unit patients, prevents acute organ failure without harming the liver.MethodsWe performed a retrospective, single-centre cohort study in a tertiary mixed medical/surgical intensive care unit. Mechanically ventilated patients without nonrespiratory organ failure within 24 hours after admission were assessed (during the first 15 days) for new acute organ failure (defined as Sequential Organ Failure Assessment (SOFA) score 3 or 4), liver failure (defined as new hepatic SOFA ≥3, or a 1.5 times increase of bilirubin from baseline to a value ≥20 mmol/l), and alanine transferase (ALT) > 165 IU/l. The effect of statin administration was explored in generalised linear mixed models.ResultsA total of 1,397 patients were included. Two hundred and nineteen patients received a median (interquartile range) of three (two, eight) statin doses. Patients receiving statins were older (67.4 vs. 55.5 years, P < 0.0001), less likely female (25.1% vs. 37.9%, P = 0.0003) and sicker (Acute Physiology and Chronic Health Evaluation (APACHE) II score 20.3 vs. 17.8, P < 0.0001). Considering outcome events at least 1 day after statin administration, statin patients were equally likely to develop acute organ failure (28.4% vs. 22.3%, P = 0.29) and hepatic failure (9.5% vs. 7.6%, P = 0.34), but were more likely to experience an ALT increase to > 165 IU/l ((11.2% vs. 4.8%, P = 0.0005). Multivariable analysis showed that APACHE II score (odds ratio (OR) = 1.05 per point; 95% confidence interval (CI) = 1.03 to 1.07) and APACHE II admission category (P < 0.0001), but not statin administration (OR = 1.21; 95% CI = 0.92 to 1.62), were significantly associated with acute organ failure occurring on or after the day of first statin administration. Statin administration was not associated with liver impairment (OR = 1.08; 95% CI = 0.66 to 1.77) but was associated with a rise in ALT > 165 IU/l (OR = 2.25; 95% CI = 1.32 to 3.84), along with APACHE II score (P = 0.016) and admission ALT (P = 0.0001).ConclusionsConcurrent statin therapy does not appear to protect against the development of new acute organ failure in critically ill, ventilated patients. The lack of effect may be due to residual confounding, a relatively low number of doses received, or an absence of true effect. Randomised controlled trials are needed to confirm a protective effect.

Short-term and medium-term survival of critically ill patients with solid tumours admitted to the intensive care unit: a retrospective analysis

Objectives Patients with cancer frequently require unplanned admission to the intensive care unit (ICU). Our objectives were to assess hospital and 180-day mortality in patients with a non-haematological malignancy and unplanned ICU admission and to identify which factors present on admission were the best predictors of mortality. Design Retrospective review of all patients with a diagnosis of solid tumours following unplanned admission to the ICU between 1 August 2008 and 31 July 2012. Setting Single centre tertiary care hospital in London (UK). Participants 300 adult patients with non-haematological solid tumours requiring unplanned admission to the ICU. Interventions None. Primary and secondary outcomes Hospital and 180-day survival. Results 300 patients were admitted to the ICU (median age 66.5 years; 61.7% men). Survival to hospital discharge and 180 days were 69% and 47.8%, respectively. Greater number of failed organ systems on admission was associated with significantly worse hospital survival (p<0.001) but not with 180-day survival (p=0.24). In multivariate analysis, predictors of hospital mortality were the presence of metastases (OR 1.97, 95% CI 1.08 to 3.59), Acute Physiology and Chronic Health Evaluation II (APACHE II) Score (OR 1.07, 95% CI 1.01 to 1.13) and a Glasgow Coma Scale Score <7 on admission to ICU (OR 5.21, 95% CI 1.65 to 16.43). Predictors of worse 180-day survival were the presence of metastases (OR 2.82, 95% CI 1.57 to 5.06), APACHE II Score (OR 1.07, 95% CI 1.01 to 1.13) and sepsis (OR 1.92, 95% CI 1.09 to 3.38). Conclusions Short-term and medium-term survival in patients with solid tumours admitted to ICU is better than previously reported, suggesting that the presence of cancer alone should not be a barrier to ICU admission.

Management of long‐term hypothyroidism: a potential marker of quality of medicines reconciliation in the intensive care unit

Objective  Significant errors can be made during medication prescribing, dispensing and administration. One source of error and potential for harm is unintentional omission. Medicines reconciliation seeks to reduce the impact of this between transfer of care. In long‐term hypothyroidism, patients are dependent upon levothyroxine and there are few contraindications to its prescription. We considered levothyroxine prescription in long‐term hypothyroidism as a marker of medicines reconciliation on admission and during stay in the intensive care unit (ICU).

Retrospective analysis of outcome of women with breast or gynaecological cancer in the intensive care unit.

Objectives Advances in oncological care have led to improved short and long-term outcomes of female patients with breast and gynecological cancer but little is known about their prognosis when admitted to the intensive care unit (ICU). Our aim was to describe the epidemiology of patients with womens cancer in ICU. Design Retrospective analysis of data of patients with breast and gynecological cancer in ICU between February 2004 and July 2008. Setting ICU in a tertiary referral centre in London. Participants Nineteen critically ill women with breast or gynaecological cancer. Main outcome measures ICU and six-month outcome. Results Eleven women had breast cancer and eight patients had gynaecological cancer. Twelve patients were known to have metastatic disease. The main reasons for admission to ICU were sepsis (94.7%), respiratory failure (36.8%) and need for vasoactive support (26.3%). ICU mortality was 31.6%. There was no difference in age and Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) score on admission to ICU between ICU survivors and non-survivors. During their stay in ICU, non-survivors had significantly more organ failure. Six-month mortality was 68.4%. Four patients had >1 admission to ICU. Conclusions ICU outcome of critically ill women with breast or gynaecological cancer was similar to that of other non-cancer patient cohorts but six-month mortality was significantly higher. The decision to admit patients with womens cancer to the ICU should depend on the severity of the acute illness rather than factors related to the underlying malignancy. More research is needed to explore the outcome of patients with womens cancer after discharge from ICU.

Healthcare-associated bloodstream infections in critically ill patients: descriptive cross-sectional database study evaluating concordance with clinical site isolates.

BackgroundHealthcare-associated bloodstream infections are related to both increased antibiotic use and risk of adverse outcomes. An in-depth understanding of their epidemiology is essential to reduce occurrence and to improve outcomes by targeted prevention strategies. The objectives of the study were to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates.MethodsWe conducted a descriptive cross-sectional study in critically ill adults admitted to a tertiary semi-closed intensive care unit in England to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates. All nosocomial positive blood cultures over a 4-year study period were identified. Pathogens detected and concordances with clinical site are reported as proportions.ResultsContaminant pathogens accounted for half of the isolates. The most common non-contaminant pathogens cultured were Pseudomonas spp. (8.0%), Enterococcus spp. (7.3%) and Escherichia coli (5.6%). Central venous catheter-linked bloodstream infections represent only 6.0% of the positive blood cultures. Excluding contaminants and central venous line infections, in only 39.5% of the bloodstream infections could a concordant clinical site source be identified, the respiratory and urinary tracts being the most common.ConclusionsClinical practice should focus on a) improving blood culture techniques to reduce detection of contaminant pathogens and b) ensuring paired clinical site cultures are performed alongside all blood cultures to better understand the epidemiology and potential implications of primary and secondary discordant health-care associated bloodstream infections.

IMPACT OF TRIALS ON CLINICAL PRACTICE: INTERVENTIONS IN SEPTIC SHOCK PATIENTS BETWEEN 2005 AND 2013

Evidence based medicine [EBM] at bedside, a key healthcare quality measure, refers to the compendium for delivering optimum clinical care by balancing benefit-harm-costs. EBM involves appraisal, interpretation and implementation with adoption of beneficial interventions and de-adoption of interventions with potential harm. Our hypothesis from Niven et al [1] where the reversal of intervention effect was not associated with timely de-adoption, is that for a rapid change in clinical practice perceived cost [monetary or clinical harm] attributable to the intervention must be high. Tight glucose control [TGC] and corticosteroids are examples of nonproprietary and recombinant Activated protein C [rt-APC] an example of proprietary intervention with reversal of effect between publications, from benefit to harm. All three interventions were part of the Surviving Sepsis Campaign [SSC] EBM [2].

Management of long-term hypothyroidism: a potential marker of quality of medicines reconciliation in the intensive care unit: Management of long-term hypothyroidism

Objective  Significant errors can be made during medication prescribing, dispensing and administration. One source of error and potential for harm is unintentional omission. Medicines reconciliation seeks to reduce the impact of this between transfer of care. In long‐term hypothyroidism, patients are dependent upon levothyroxine and there are few contraindications to its prescription. We considered levothyroxine prescription in long‐term hypothyroidism as a marker of medicines reconciliation on admission and during stay in the intensive care unit (ICU).