Jeannie D. Chan

Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit

Objective:The intensive care unit remains a setting where death is common, and a large proportion of these deaths are preceded by withdrawal of life support. We describe a quality improvement project implementing and evaluating a “withdrawal of life support order form” to improve quality of end-of-life care in the intensive care unit. Design:Before-after evaluation. Setting:County-owned, university-operated, tertiary, level I trauma center. Subjects:Subjects were 143 nurses and 61 physicians. Interventions: We conducted a before-after evaluation of the order form’s implementation. The order form has sections on preparations, sedation/analgesia, withdrawal of mechanical ventilation, and the principles of life support withdrawal. To evaluate the form, we surveyed intensive care unit clinicians regarding satisfaction with the form, measured nurse-assessed quality of dying and death with a 14-item survey (scored 0 for worst possible death to 100 for best possible), and performed chart review to assess narcotic and benzodiazepine use and time from ventilator withdrawal to death. Measurements and Main Results:We surveyed 143 nurses and 61 physicians about satisfaction with the form. Among nurses reporting that the form was used (n = 73), most (84%) reported that the order form was helpful and they were most satisfied with the sedation and mechanical ventilation sections. Almost all physicians found the form helpful (95%), and >70% of physicians found three of the four sections helpful (sedation, mechanical ventilation, and preparations). We obtained quality of dying and death scores for 41 patient deaths before and 76 deaths after the intervention. These scores did not significantly change (mean preintervention score, 78.3; mean postintervention score, 74.2; p = .54) before and after the intervention. Total doses of narcotics and benzodiazepines increased after implementation of the order form in the hour before ventilator withdrawal, the hour after ventilator withdrawal, and the hour before death (p ≤ .03). There was no change in the median time from ventilator withdrawal to death (preintervention 37 mins, postintervention 39 mins; p = .49). Conclusions:Nurses and physicians found the withdrawal of life support order form helpful. The order form did not improve nurses’ assessment of patients’ dying experience. Medications for sedation increased during the postorder form period without evidence of significantly hastening death. Although the order form was helpful to clinicians and changed medication delivery, demonstrating clear improvements in quality of dying may require larger sample sizes, more sensitive measures, or more effective interventions.

Narcotic and Benzodiazepine Use After Withdrawal of Life Support: Association With Time to Death?

OBJECTIVE To determine whether the dose of narcotics and benzodiazepines is associated with length of time from mechanical ventilation withdrawal to death in the setting of withdrawal of life-sustaining treatment in the ICU. DESIGN Retrospective chart review. SETTING University-affiliated, level I trauma center. PATIENTS Consecutive critically ill patients who had mechanical ventilation withdrawn and subsequently died in the ICU during two study time periods. RESULTS There were 75 eligible patients with a mean age of 59 years. The primary ICU admission diagnoses included intracranial hemorrhage (37%), trauma (27%), acute respiratory failure (27%), and acute renal failure (20%). Patients died during a median of 35 min (range, 1 to 890 min) after ventilator withdrawal. On average, 16.2 mg/h opiates in morphine equivalents and 7.5 mg/h benzodiazepine in lorazepam equivalents were administered during the time period starting 1 h before ventilator withdrawal and ending at death. There was no statistically significant relationship between the average hourly narcotic and benzodiazepine use during the 1-h period prior to ventilator withdrawal until death, and the time from ventilator withdrawal to death. The restriction of medication assessment in the last 2 h of life showed an inverse association between the use of benzodiazepines and time to death. For every 1 mg/h increase in benzodiazepine use, time to death was increased by 13 min (p = 0.015). There was no relationship between narcotic dose and time to death during the last 2 h of life (p = 0.11). CONCLUSIONS We found no evidence that the use of narcotics or benzodiazepines to treat discomfort after the withdrawal of life support hastens death in critically ill patients at our center. Clinicians should strive to control patient symptoms in this setting and should document the rationale for escalating drug doses.

Development of a guideline for the management of ventilator-associated pneumonia based on local microbiologic findings and impact of the guideline on antimicrobial use practices

OBJECTIVE To describe the development of a guideline for the management of ventilator-associated pneumonia (VAP) based on local microbiologic findings and to evaluate the impact of the guideline on antimicrobial use practices. DESIGN Retrospective comparison of antimicrobial use practices before and after implementation of the guideline. SETTING Intensive care units at Harborview Medical Center, Seattle, Washington, a university-affiliated urban teaching hospital. PATIENTS A total of 819 patients who received mechanical ventilation and who underwent quantitative bronchoscopy between July 1, 2003, and June 30, 2005, for suspected VAP. INTERVENTIONS Implementation of an evidence-based VAP guideline that focused on the use of quantitative bronchoscopy for diagnosis, administration of empirical antimicrobial therapy based on local microbiologic findings and resistance patterns, tailoring definitive antimicrobial therapy on the basis of culture results, and appropriate duration of therapy. RESULTS During the baseline period, 168 (46.7%) of 360 patients had quantitative cultures that met the diagnostic criteria for VAP, compared with 216 (47.1%) of 459 patients in the period after the guideline was implemented. The pathogens responsible for VAP remained similar between the 2 periods, except that the prevalence of VAP due to carbapenem-resistant Acinetobacter species increased from 1.8% to 15.3% (P<.001), particularly in late-onset VAP. Compared with the baseline period, there was an improvement in antimicrobial use practices after implementation of the guideline: antimicrobial therapy was more frequently tailored on the basis of quantitative culture results (103 [61.3%] of 168 vs 150 [69.4%] of 216 patients; P = .034), there was an increase in the use of appropriate definitive therapy (135 [80.4%] of 168 vs 193 [89.4%] of 216 patients; P = .001), and there was a decrease in the mean duration of therapy (12.0 vs 10.7 days; P = .0014). The all-cause mortality rate was similar in the periods before and after the guideline was implemented (38 [22.6%] of 168 vs 46 [21.3%] of 216 patients; P = .756). CONCLUSIONS Implementation of a guideline for the management of VAP that incorporated the use of quantitative bronchoscopy, the use of empirical therapy based on local microbiologic findings, tailoring of therapy on the basis of culture results, and use of shortened durations of therapy led to significant improvements in antimicrobial use practices without adversely affecting the all-cause mortality rate.

Antimicrobial Treatment and Clinical Outcomes of Carbapenem-Resistant Acinetobacter baumannii Ventilator-Associated Pneumonia:

Objectives: Carbapenem-resistant (CR) Acinetobacter baumannii is an important pathogen in ventilator-associated pneumonia (VAP), but therapeutic options are limited. We describe the clinical outcomes of the largest case series of CR-Acinetobacter VAP reported to date. Methods: A retrospective analysis of 55 participants with CR-Acinetobacter VAP from July 2004 to December 2007 was undertaken. The primary endpoint was clinical response or microbiological eradication. Secondary endpoint was treatment-associated nephrotoxicity defined as ≥50% increase in serum creatinine or an increase of ≥0.5 mg/dL during therapy. Results: Forty-two (76.4%) participants achieved clinical response at the completion of therapy. Clinical responses were achieved in 60.0% of sulbactam-based, 66.7% of polymyxin-based, 77.8% of aminoglycoside-based, 80.6% of minocycline-based, and 90.0% of tigecycline-based regimens. Follow-up sputum cultures were available in 6 of 10 tigecycline-treated participants with 4 of 6 isolates developing intermediate resistance to tigecycline while on therapy. Ten (18.2%) participants without preexisting renal disease developed treatment-associated nephrotoxicity. Baseline serum creatinine was 0.9 ± 0.1 mg/dL (range: 0.6-1.0 mg/dL) at the start of therapy and peaked at 1.9 ± 0.5 mg/dL (range: 1.6-3.0 mg/dL) during therapy. After excluding other potential concomitant renal toxic agents, nephrotoxicity developed in 6 of 30 (20.0%) and 4 of 7 (57.1%) participants treated with an aminoglycoside-or polymyxin-based regimen, respectively. Conclusions: Our results demonstrated that CR-Acinetobacter VAP can be effectively treated with second-line agents. However, colistin-related nephrotoxicity was much higher than recently reported and decreased susceptibility to tigecycline emerged on therapy demonstrating the limitations of alternative regimens.

Active surveillance cultures of methicillin-resistant Staphylococcus aureus as a tool to predict methicillin-resistant S. aureus ventilator-associated pneumonia.

Objective: Ventilator-associated pneumonia is one of the most common infections in the intensive care unit and methicillin-resistant Staphylococcus aureus has emerged as a common cause of ventilator-associated pneumonia. We sought to study the performance characteristics of once weekly active surveillance culture of methicillin-resistant S. aureus colonization in predicting the development of methicillin-resistant S. aureus ventilator-associated pneumonia. Design: Prospective observational study. Setting: Eighty-nine-bed surgical and medical intensive care units in a university-affiliated urban teaching hospital and level I trauma and burn center. Patients: All patients ≥16 yrs old admitted to the intensive care unit on mechanical ventilation ≥48 hrs who met diagnostic criteria for ventilator-associated pneumonia by quantitative lower respiratory tract cultures obtained through bronchoscopic alveolar lavage or brush specimen between January 2008 and October 2010 were included. Interventions: None. Measurements and Main Results: Nine hundred twenty-four episodes of suspected ventilator-associated pneumonia were evaluated, and 388 patients with bronchoalveolar lavage-confirmed ventilator-associated pneumonia were included. Surveillance cultures were taken from the nares, oropharynx or trachea, and any open wound routinely on admission to the intensive care unit, every 7 days afterward, and at intensive care unit discharge. Of the 388 patients, 37 (9.5%) had methicillin-resistant S. aureus ventilator-associated pneumonia and 54 (13.9%) had methicillin-resistant S. aureus colonization documented by active surveillance culture before the development of ventilator-associated pneumonia. The sensitivity and specificity of prior methicillin-resistant S. aureus colonization as a predictor for methicillin-resistant S. aureus ventilator-associated pneumonia are 70.3% (95% confidence interval [CI] 52.8–83.6) and 92.0% (95% CI 88.5–94.5), respectively. The positive and negative predictive values are 48.1% (95% CI 34.5– 62.0) and 96.7% (95% CI 94.0–98.3). Conclusions: In our study, prior methicillin-resistant S. aureus colonization as ascertained by once-weekly active surveillance culture yielded high specificity and negative predictive value, suggesting that negative active surveillance culture can accurately exclude methicillin-resistant S. aureus as an etiology in most patients with ventilator-associated pneumonia and may decrease the need for empirical methicillin-resistant S. aureus coverage in patients with suspected ventilator-associated pneumonia.

High incidence of discontinuations due to adverse events in patients treated with ceftaroline.

To determine clinical outcomes in patients who received ceftaroline (Teflaro) 600 mg intravenously every 8 or 12 hours after failing or developing intolerance to first‐line agents including vancomycin, daptomycin, or linezolid.

An Electronic Catheter-Associated Urinary Tract Infection Surveillance Tool

OBJECTIVE To develop and validate an electronic surveillance tool for catheter-associated urinary tract infections (CAUTIs). DESIGN Retrospective cohort study. SETTING 413-bed university-affiliated urban teaching hospital. METHODS An electronic surveillance tool was developed for CAUTI and urinary catheter utilization based on the objective components of the National Healthcare Safety Network (NHSN) definitions including fever, urinalysis, and urine culture. Results were compared to manual chart review by an infection preventionist (IP). RESULTS During January and February 2010, 204 positive urine cultures (≥10(3) colony-forming units/mL) were identified in 136 patients with indwelling urinary catheters during their hospitalization. The electronic surveillance tool detected 60 CAUTI cases and 7,098 catheter-days, yielding a CAUTI incidence rate of 8.5 per 1,000 catheter-days. Urinary catheter utilization ratios (Foley-days/patient-days) were: acute care units, 0.27 (3,637 of 13,229); intensive care units, 0.77 (3,461 of 4,469); and overall, 0.40 (7,098 of 17,698). In comparison, the IP identified 59 cases by manual review with a sensitivity of 51 of 59 (86.4%), specificity 136 of 145 (93.8%), and negative predictive value of 136 of 144 (94.4%). Fever was present in 54 of 59 (91.5%) of CAUTI cases identified manually, while subjective criteria were documented in only 6 of 59 (10.2%) infections. Agreement between the electronic surveillance and manual IP review was assessed as very good (κ, 0.80; 95% confidence interval, 0.71-0.89). CONCLUSIONS We report an attempt at automating surveillance for CAUTI. With a high negative predictive value, the electronic tool allows for more efficient CAUTI surveillance and facilitates housewide trending of rates and catheter utilization. This approach should be validated in different patient populations.

Clinical Outcomes of Linezolid vs Vancomycin in Methicillin-Resistant Staphylococcus aureus Ventilator-Associated Pneumonia: Retrospective Analysis

Background: Vancomycin has been the treatment standard for methicillin-resistant Staphylococcus aureus (MRSA) infections, but clinical efficacy is limited. We report outcomes of a cohort with MRSA ventilator-associated pneumonia (VAP) treated with vancomycin vs linezolid. Methods: Retrospective analysis of 113 participants with MRSA VAP confirmed by bronchoscopy who have been initiated on therapy with either vancomycin or linezolid within 24 hours after bronchoscopy and completed ≥7 days of therapy during their hospitalization from July 2003 to June 2007. The primary endpoints were hospital survival and clinical cure, defined as resolution of signs and symptoms of VAP or microbiological eradication after completion of therapy along with clinical pulmonary infection score (CPIS) ≤6 at day 7 of therapy. Results: At hospital discharge, 23/27 (85.2%) of linezolid and 72/86 (83.7%) of vancomycin recipients had survived (P = .672). In comparison to linezolid recipients, the adjusted odds ratio (OR) for survival was 0.72 (95% confidence interval [CI]: 0.16-3.27) with vancomycin therapy. Clinical cure was achieved in 24/27 (88.9%) of linezolid and 63/86 (73.3%) of vancomycin recipients (P = .066). Compared to linezolid recipients, the adjusted OR for clinical cure was 0.24 (95% CI: 0.05-1.10) with vancomycin therapy. Survival and clinical cure did not differ significantly between vancomycin recipients with trough level ≥15 and <15 μg/mL, respectively. Conclusions: Our results suggested no survival benefit but a trend toward higher cure rate with linezolid therapy. The optimal treatment of MRSA VAP requires further study through randomized, controlled trials.

Reduction in Clostridium difficile Infections among Neurosurgical Patients Associated with Discontinuation of Antimicrobial Prophylaxis for the Duration of External Ventricular Drain Placement

Discontinuation of Antimicrobial Prophylaxis for the Duration of External Ventricular Drain Placement Author(s): Timothy H. Dellit, MD; Jeannie D. Chan, PharmD, MPH; Charlotte Fulton, RN, MHA; Ronald F. Pergamit, MPA; Elizabeth A. McNamara, RN, MN; Louis J. Kim, MD; Richard G. Ellenbogen, MD; John B. Lynch, MD, MPH Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 5 (May 2014), pp. 589-590 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/675828 . Accessed: 28/06/2014 18:07

Relationships between vancomycin minimum inhibitory concentration, dosing strategies, and outcomes in methicillin-resistant Staphylococcus aureus bacteremia☆

Retrospective study aimed to examine outcomes of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in relationship to vancomycin minimum inhibitory concentration (VAN MIC) and serum trough concentrations among subjects who had ≥1 blood culture positive for MRSA between April 2008 and August 2009. Treatment failure occurred in 7/24 (29%) subjects with VAN MIC = 2 mg/L versus 20/94 (21%) subjects with VAN MIC ≤1.5 mg/L (adjusted OR 1.11, 95% confidence interval [CI] 0.24-5.14). Among subjects who had documented VAN serum trough concentrations, treatment failure occurred in 5/26 (19%) subjects with concentrations <15 mg/L versus 18/68 (27%) subjects with concentrations ≥15 mg/L (adjusted OR 0.91, 95% CI 0.21-3.84). In conclusion, treatment outcomes were similar regardless of VAN MIC, although there was a non-statistically significant trend towards decreased clinical efficacy among patients with VAN MIC = 2 mg/L. Optimization of VAN pharmacokinetic indices did not appear to correlate with clinical responses.