David Oxman

Candidaemia associated with decreased in vitro fluconazole susceptibility: is Candida speciation predictive of the susceptibility pattern?

BACKGROUND Candidaemia is often treated with fluconazole in the absence of susceptibility testing. We examined factors associated with candidaemia caused by Candida isolates with reduced susceptibility to fluconazole. METHODS We identified consecutive episodes of candidaemia at two hospitals from 2001 to 2007. Species identification followed CLSI methodology and fluconazole susceptibility was determined by Etest or broth microdilution. Susceptibility to fluconazole was defined as: full susceptibility (MIC < or = 8 mg/L); and reduced susceptibility (MIC > or = 32 mg/L). Complete resistance was defined as an MIC > 32 mg/L. RESULTS Of 243 episodes of candidaemia, 190 (78%) were fully susceptible to fluconazole and 45 (19%) had reduced susceptibility (of which 27 were fully resistant). Of Candida krusei and Candida glabrata isolates, 100% and 51%, respectively, had reduced susceptibility. Despite the small proportion of Candida albicans (8%), Candida tropicalis (4%) and Candida parapsilosis (4%) with reduced fluconazole susceptibility, these species composed 36% of the reduced-susceptibility group and 48% of the fully resistant group. In multivariate analysis, independent factors associated with reduced fluconazole susceptibility included male sex [odds ratio (OR) 3.2, P < 0.01], chronic lung disease (OR 2.7, P = 0.01), the presence of a central vascular catheter (OR 4.0, P < 0.01) and prior exposure to antifungal agents (OR 2.2, P = 0.04). CONCLUSIONS A significant proportion of candidaemia with reduced fluconazole susceptibility may be caused by C. albicans, C. tropicalis and C. parapsilosis, species usually considered fully susceptible to fluconazole. Thus, identification of these species may not be predictive of fluconazole susceptibility. Other factors that are associated with reduced fluconazole susceptibility may help clinicians choose adequate empirical anti-Candida therapy.

Measuring Communication in the Surgical ICU: Better Communication Equals Better Care

BACKGROUND The Joint Commission on the Accreditation of Healthcare Organizations reports that communication breakdowns are responsible for 85% of sentinel events in hospitals. Patients in surgical ICUs are the most vulnerable to communication errors. Fellows and residents are an integral part of the surgical ICU team, but little is known about resident-fellow communication and its impact on surgical ICU patient outcomes. The objective of this study is to describe resident-fellow patient care communication patterns in the surgical ICU and correlate established communication patterns with short-term outcomes. STUDY DESIGN A prospective observational trial was conducted for 136 consecutive surgical ICU days. We evaluated resident-fellow communication of four cardiorespiratory events: hypotension, new arrhythmias, tachypnea, and desaturation. We prospectively defined three short-term outcomes: improved, not improved, and worse. An intervention was attempted to improve communication. RESULTS Three hundred twelve events were collected (166 observational and 146 interventional). PGY3 residents covered approximately 60% of days in both phases. PGY3 residents were responsible for 73% of communication errors in the observational phase and 59% of communication errors in the interventional phase. Communication errors were more likely in the late shift (p < 0.0001). The late shift was responsible for 77% of all communication errors. Communication errors resulted in worse short-term outcomes for cardiorespiratory events (p < 0.0002). Effective communication was a significant predictor of improved short-term outcomes (p < 0.0003). The intervention decreased communication errors in the late shift by 10% (p < 0.052). CONCLUSIONS Communication errors occurred more frequently during the late shift. These communication errors were associated with worsened short-term outcomes. Improved communication in the surgical ICU is a fruitful target to improve clinical outcomes.

Postoperative Antibacterial Prophylaxis for the Prevention of Infectious Complications Associated With Tube Thoracostomy in Patients Undergoing Elective General Thoracic Surgery: A Double-blind, Placebo-Controlled, Randomized Trial

OBJECTIVE To determine whether extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery with tube thoracostomy reduces the risk of infectious complications compared with preoperative prophylaxis only. DESIGN Prospective, randomized, double-blind, placebo-controlled trial. SETTING Brigham and Womens Hospital, an 800-bed tertiary care teaching hospital in Boston, Massachusetts. PARTICIPANTS A total of 251 adult patients undergoing elective thoracic surgery requiring tube thoracostomy between April 2008 and April 2011. INTERVENTIONS Patients received preoperative antibacterial prophylaxis with cefazolin sodium (or other drug if the patient was allergic to cefazolin). Postoperatively, patients were randomly assigned (at a 1:1 ratio) using a computer-generated randomization sequence to receive extended antibacterial prophylaxis (n = 125) or placebo (n = 126) for 48 hours or until all thoracostomy tubes were removed, whichever came first. MAIN OUTCOME MEASURES The combined occurrence of surgical site infection, empyema, pneumonia, and Clostridium difficile colitis by postoperative day 28. RESULTS A total of 245 patients were included in the modified intention-to-treat analysis (121 in the intervention group and 124 in the placebo group). Thirteen patients (10.7%) in the intervention group and 8 patients (6.5%) in the placebo group had a primary end point (risk difference, -4.3% [95% CI, -11.3% to 2.7%]; P = .26). Six patients (5.0%) in the intervention group and 5 patients (4.0%) in the placebo group developed surgical site infections (risk difference, -0.93% [95% CI, -6.1% to 4.3%]; P = .77). Seven patients (5.8%) in the intervention group and 3 patients (2.4%) in the placebo group developed pneumonia (risk difference, -3.4% [95% CI, -8.3% to 1.6%]; P = .21). One patient in the intervention group developed empyema. No patients experienced C difficile colitis. CONCLUSIONS Extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery requiring tube thoracostomy did not reduce the number of infectious complications compared with preoperative prophylaxis only. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00818766.

Abdominal Compartment Syndrome and Acute Kidney Injury Due to Excessive Auto–Positive End-Expiratory Pressure

Abdominal compartment syndrome is an under-recognized cause of acute kidney injury in critically ill patients. We report a case of a patient with severe obstructive lung disease who, while intubated for respiratory failure, developed abdominal compartment syndrome and oliguric acute kidney injury due to air-trapping and excessive auto-positive end-expiratory pressure (auto-PEEP; also known as intrinsic PEEP). When chemical paralysis was initiated and the auto-PEEP resolved, the patients intra-abdominal hypertension rapidly improved and kidney function recovered immediately. Abdominal compartment syndrome secondary to excessive auto-PEEP appears to be unreported in the literature; however, any process that significantly increases intrathoracic pressure conceivably could cause increased pressure to be transmitted to the abdominal compartment, resulting in organ failure. Patients undergoing mechanical ventilation, which puts them at risk of airflow obstruction and the development of intra-abdominal hypertension, should be evaluated for air-trapping and excessive auto-PEEP.

A Comparison of Usage and Outcomes Between Nurse Practitioner and Resident-Staffed Medical ICUs.

Objective: To compare usage patterns and outcomes of a nurse practitioner–staffed medical ICU and a resident-staffed physician medical ICU. Design: Retrospective chart review of 1,157 medical ICU admissions from March 2012 to February 2013. Setting: Large urban academic university hospital. Subjects: One thousand one hundred fifty-seven consecutive medical ICU admissions including 221 nurse practitioner-staffed medical ICU admissions (19.1%) and 936 resident-staffed medical ICU admissions (80.9%). Interventions: None. Measurements and Main Results: Data obtained included age, gender, race, medical ICU admitting diagnosis, location at time of ICU transfer, code status at ICU admission, and severity of illness using both Acute Physiology and Chronic Health Evaluation II scores and a model for relative expected mortality. Primary outcomes compared included ICU mortality, in-hospital mortality, medical ICU length of stay, and post-ICU discharge hospital length of stay. Patients admitted to the nurse practitioner–staffed medical ICU were older (63 ± 16.5 vs 59.2 ± 16.9 yr for resident-staffed medical ICU; p = 0.019), more likely to be transferred from an inpatient unit (52.0% vs 40.0% for the resident-staffed medical ICU; p = 0.002), and had a higher severity of illness by relative expected mortality (21.3 % vs 17.2 % for the resident-staffed medical ICU; p = 0.001). There were no differences among primary outcomes except for medical ICU length of stay (nurse practitioner-resident-staffed 7.9 ± 7.5 d vs resident-staffed medical ICU 5.6 ± 6.5 d; p = 0.0001). Post-hospital discharge to nonhome location was also significantly higher in the nurse practitioner–ICU (31.7% in nurse practitioner–staffed medical ICU vs 23.9% in resident-staffed medical ICU; p = 0.24). Conclusions: We found no difference in mortality between an nurse practitioner–staffed medical ICU and a resident-staffed physician medical ICU. Our study adds further evidence that advanced practice providers can render safe and effective ICU care.

Differences in Utilization of Life Support and End-of-life Care for Medical Icu Patients With Versus Without Cancer.

Objectives: To explore differences in the utilization of life support and end-of-life care between patients dying in the medical ICU with cancer compared with those without cancer. Design: Retrospective review of 403 deaths or hospice transfers in the medical ICU from January 1, 2012, to June 30, 2013. Setting: Urban tertiary care university hospital. Patients: Consecutive medical ICU deaths or hospice transfers over an 18-month period. Interventions: None. Measurements and Main Results: One hundred eighty-two patients (45%) had a diagnosis of active cancer and 221 (55%) did not. Despite similar severity of illness, there were significant differences in the use of life support and end-of-life care. Patients without cancer had longer medical ICU length of stay (median, 5 vs 4 d; p = 0.0495), used mechanical ventilation more often and for longer (83.7% vs 70.9%, p = 0.002; 4 vs 3 d, p = 0.017), and initiated dialysis more frequently (26.7% vs 14.8%; p = 0.0038). Patients without active cancer had family meetings later (median, 3 vs 2 d; p = 0.001), less frequent palliative care consultation (17.6% vs 32.4%; p = 0.0006), and took longer to transition to do not resuscitate or comfort care (median, 4 vs 3 d; p = 0.048). Conclusions: Among patients dying in the medical ICU, the diagnosis of active cancer influences the intensity of life support utilization and the quality of end-of-life care. Patients with active cancer use less life support and may receive better end-of-life care than similar patients without cancer. These differences are likely due to biases or misunderstandings about the trajectory of advanced nonmalignant disease among patients, families, and perhaps providers.

Monthly “Grief Rounds” to Improve Residents’ Experience and Decrease Burnout in a Medical Intensive Care Unit Rotation:

Medical residents rotating through the medical intensive care unit (MICU) are regularly exposed to dying patients. Yet residents consistently report that they are not trained in palliative care or end-of-life issues. Nor are many medical residents adequately prepared for the emotional toll the day-to-day care of dying patients may exact on them. Trainees often incorrectly perceive patients’ death to be a personal failure, or experience burnout—a state of emotional exhaustion that leads to depersonalization and a sense of low personal accomplishment. Forums for discussion of issues related to death in the ICU have been shown in prior studies to improve the experience for medical residents. We hypothesized that monthly “Grief Rounds” also might reduce levels of resident burnout. We developed and implemented “Grief Rounds,” a monthly forum for residents rotating through the MICU to discuss issues surrounding the deaths of patients they cared for on their rotation. The monthly sessions were designed as an open forum for residents to discuss emotionally complex patients, difficult team dynamics, and other stressors they encountered related to deaths during their rotation. These rounds also were created as a means to help residents process death and dying and avoid burnout. Grief Rounds were facilitated by one palliative care and one MICU attending physician. The rounds were also open to MICU fellows and other MICU attending physicians in addition to the rotating interns and residents. Using a tool derived from the Maslach Burnout Scale, respondents were asked to rate various statements to assess their baseline level of burnout and their comfort with caring for critically ill dying patients. Statements included “I leave work at the end of the day feeling emotionally drained,” “I wish that I had chosen another career path,” and “I feel disconnected when one of my patients dies.” Residents were asked to rate their response to these statements on a scale of Never, Seldom, Sometimes, or Often. Results revealed high levels of baseline burnout. We also used an online survey to ask residents about their perception of Grief Rounds and its impact on feelings associated with burnout. When asked to rate the utility of Grief Rounds, 77% of respondents agreed or strongly agreed that Grief Rounds improved their ICU experience and felt that Grief Rounds should be incorporated into all ICU rotations. We plan to continue administering the survey to assess if Grief Rounds can have an impact on levels of resident burnout. Grief Rounds may be a way to address issues medical residents face surrounding the care of dying patients in the MICU. Levels of burnout among medical residents in our MICU are high and Grief Rounds may be an effective intervention to reduce burnout and improve the resident MICU experience.

Improving Antibiotic De-Escalation in Suspected Ventilator-Associated Pneumonia: An Observational Study With a Pharmacist-Driven Intervention

Background: Recommendations for treatment of ventilator-associated pneumonia (VAP) emphasize early empiric broad-spectrum antibiotics. However, appropriate antibiotic de-escalation is also critical for optimal patient care. Materials and Methods: We examined how often intensivists in our institution appropriately de-escalated antibiotics in cases of suspected VAP, and whether decision support by intensive care unit pharmacists could improve rates of antibiotic targeting and early antibiotic discontinuation in low-risk patients. Main Results: A total of 92 (observation phase = 50; intervention phase = 42) patients with suspected VAP were identified. During the observation phase, 39 cases yielded positive sputum cultures, but in only 23 (59%) were antibiotics targeted to culture results. This rate improved during the intervention phase when 29 (91%) of 32 cases with positive cultures were targeted (P value .003). There were 48 cases in which the risk of pneumonia was considered low. Of the 26 low-risk cases in the observation phase, 5 (19%) had antibiotics discontinued early versus 5 (23%) of the 22 cases in the intervention phase. Conclusions: Decision support by clinical pharmacists significantly improved rates of appropriate antibiotic targeting in cases of culture-positive suspected VAP but did not have a significant effect on early antibiotic discontinuation in patients at low risk of true pneumonia.

In-hospital fellow coverage reduces communication errors in the surgical intensive care unit☆

BACKGROUND Staff coverage strategies of intensive care units (ICUs) impact clinical outcomes. High-intensity staff coverage strategies are associated with lower morbidity and mortality. Accessible clinical expertise, team work, and effective communication have all been attributed to the success of this coverage strategy. We evaluate the impact of in-hospital fellow coverage (IHFC) on improving communication of cardiorespiratory events. METHODS A prospective observational study performed in an academic tertiary care center with high-intensity staff coverage. The main outcome measure was resident to fellow communication of cardiorespiratory events during IHFC vs home coverage (HC) periods. RESULTS Three hundred twelve cardiorespiratory events were collected in 114 surgical ICU patients in 134 study days. Complete data were available for 306 events. One hundred three communication errors occurred. IHFC was associated with significantly better communication of events compared to HC (P<.0001). Residents communicated 89% of events during IHFC vs 51% of events during HC (P<.001). Communication patterns of junior and midlevel residents were similar. Midlevel residents communicated 68% of all on-call events (87% IHFC vs 50% HC, P<.001). Junior residents communicated 66% of events (94% IHFC vs 52% HC, P<.001). Communication errors were lower in all ICUs during IHFC (P<.001). CONCLUSIONS IHFC reduced communication errors.