Lewis Rubinson

Low caloric intake is associated with nosocomial bloodstream infections in patients in the medical intensive care unit

ObjectiveTo determine whether caloric intake is associated with risk of nosocomial bloodstream infection in critically ill medical patients. DesignProspective cohort study. SettingUrban, academic medical intensive care unit. PatientsPatients were 138 adult patients who did not take food by mouth for ≥96 hrs after medical intensive care unit admission. MeasurementsDaily caloric intake was recorded for each patient. Participants subsequently were grouped into one of four categories of caloric intake: <25%, 25–49%, 50–74%, and ≥75% of average daily recommended calories based on the American College of Chest Physicians guidelines. Simplified Acute Physiology Score II and serum albumin were measured on medical intensive care unit admission. Serum glucose (average value and maximum value each day) and route of feeding (enteral, parenteral, or both) were collected daily. Nosocomial bloodstream infections were identified by infection control surveillance methods. Main ResultsThe overall mean (±sd) daily caloric intake for all study participants was 49.4 ± 29.3% of American College of Chest Physicians guidelines. Nosocomial bloodstream infection occurred in 31 (22.4%) participants. Bivariate Cox analysis revealed that receiving ≥25% of recommended calories compared with <25% was associated with significantly lower risk of bloodstream infection (relative hazard, 0.24; 95% confidence interval, 0.10–0.60). Simplified Acute Physiology Score II also was associated with risk of nosocomial bloodstream infection (relative hazard, 1.27; 95% confidence interval, 1.01–1.60). Average daily serum glucose, admission serum albumin, time to initiating nutritional support, and route of nutrition did not affect risk of bloodstream infection. After adjustment for Simplified Acute Physiology Score II in a multivariable analysis, receiving ≥25% of recommended calories was associated with a significantly lower risk of bloodstream infection (relative hazard, 0.27; 95% confidence interval, 0.11–0.68). ConclusionsIn the context of reducing risk of nosocomial bloodstream infections, failing to provide ≥25% of the recommended calories may be harmful. Higher caloric goals may be necessary to achieve other clinically important outcomes.

Critically ill children during the 2009-2010 influenza pandemic in the United States.

BACKGROUND: The 2009 pandemic influenza A (H1N1) (pH1N1) virus continues to circulate worldwide. Determining the roles of chronic conditions and bacterial coinfection in mortality is difficult because of the limited data for children with pH1N1-related critical illness. METHODS: We identified children (<21 years old) with confirmed or probable pH1N1 admitted to 35 US PICUs from April 15, 2009, through April 15, 2010. We collected data on demographics, baseline health, laboratory results, treatments, and outcomes. RESULTS: Of 838 children with pH1N1 admitted to a PICU, the median age was 6 years, 58% were male, 70% had ≥1 chronic health condition, and 88.2% received oseltamivir (5.8% started before PICU admission). Most patients had respiratory failure with 564 (67.3%) receiving mechanical ventilation; 162 (19.3%) received vasopressors, and 75 (8.9%) died. Overall, 71 (8.5%) of the patients had a presumed diagnosis of early (within 72 hours after PICU admission) Staphylococcus aureus coinfection of the lung with 48% methicillin-resistant S aureus (MRSA). In multivariable analyses, preexisting neurologic conditions or immunosuppression, encephalitis (1.7% of cases), myocarditis (1.4% of cases), early presumed MRSA lung coinfection, and female gender were mortality risk factors. Among 251 previously healthy children, only early presumed MRSA coinfection of the lung (relative risk: 8 [95% confidence interval: 3.1–20.6]; P < .0001) remained a mortality risk factor. CONCLUSIONS: Children with preexisting neurologic conditions and immune compromise were at increased risk of pH1N1-associated death after PICU admission. Secondary complications of pH1N1, including myocarditis, encephalitis, and clinical diagnosis of early presumed MRSA coinfection of the lung, were mortality risk factors.

Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of the Working Group on Emergency Mass Critical Care‡

The Working Group on Emergency Mass Critical Care was convened by the Center for Biosecurity of the University of Pittsburgh Medical Center and the Society of Critical Care Medicine to provide recommendations to hospital and clinical leaders regarding the delivery of critical care services in the wake of a bioterrorist attack resulting in hundreds or thousands of critically ill patients. In these conditions, traditional hospital and clinical care standards in general, and critical care standards in particular, likely could no longer be maintained, and clinical guidelines for U.S. hospitals facing these situations have not been developed. The Working Group offers recommendations for this situation.

A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness.

BACKGROUND Various organizations and universities have developed competencies for health professionals and other emergency responders. Little effort has been devoted to the integration of these competencies across health specialties and professions. The American Medical Association Center for Public Health Preparedness and Disaster Response convened an expert working group (EWG) to review extant competencies and achieve consensus on an educational framework and competency set from which educators could devise learning objectives and curricula tailored to fit the needs of all health professionals in a disaster. METHODS The EWG conducted a systematic review of peer-reviewed and non-peer reviewed published literature. In addition, after-action reports from Hurricane Katrina and relevant publications recommended by EWG members and other subject matter experts were reviewed for congruencies and gaps. Consensus was ensured through a 3-stage Delphi process. RESULTS The EWG process developed a new educational framework for disaster medicine and public health preparedness based on consensus identification of 7 core learning domains, 19 core competencies, and 73 specific competencies targeted at 3 broad health personnel categories. CONCLUSIONS The competencies can be applied to a wide range of health professionals who are expected to perform at different levels (informed worker/student, practitioner, leader) according to experience, professional role, level of education, or job function. Although these competencies strongly reflect lessons learned following the health system response to Hurricane Katrina, it must be understood that preparedness is a process, and that these competencies must be reviewed continually and refined over time.

Critical illness from 2009 pandemic influenza A virus and bacterial coinfection in the United States.

Objectives: The contribution of bacterial coinfection to critical illness associated with 2009 influenza A virus infection remains uncertain. The objective of this study was to determine whether bacterial coinfection increased the morbidity and mortality of 2009 influenza A. Design: Retrospective and prospective cohort study. Setting: Thirty-five adult U.S. intensive care units over the course of 1 yr. Patients: Six hundred eighty-three critically ill adults with confirmed or probable 2009 influenza A. Interventions: None. Measurements and Main Results: A confirmed or probable case was defined as a positive 2009 influenza A test result or positive test for influenza A that was otherwise not subtyped. Bacterial coinfection was defined as documented bacteremia or any presumed bacterial pneumonia with or without positive respiratory tract culture within 72 hrs of intensive care unit admission. The mean age was 45 ± 16 yrs, mean body mass index was 32.5 ± 11.1 kg/m2, and mean Acute Physiology and Chronic Health Examination II score was 21 ± 9, with 76% having at least one comorbidity. Of 207 (30.3%) patients with bacterial coinfection on intensive care unit admission, 154 had positive cultures with Staphylococcus aureus (n = 57) and Streptococcus pneumoniae (n = 19), the most commonly identified pathogens. Bacterial coinfected patients were more likely to present with shock (21% vs. 10%; p = .0001), require mechanical ventilation at the time of intensive care unit admission (63% vs. 52%; p = .005), and have longer duration of intensive care unit care (median, 7 vs. 6 days; p = .05). Hospital mortality was 23%; 31% in bacterial coinfected patients and 21% in patients without coinfection (p = .002). Immunosuppression (relative risk 1.57; 95% confidence interval 1.20 –2.06; p = .0009) and Staphylococcus aureus at admission (relative risk 2.82; 95% confidence interval 1.76–4.51; p < .0001) were independently associated with increased mortality. Conclusions: Among intensive care unit patients with 2009 influenza A, bacterial coinfection diagnosed within 72 hrs of admission, especially with Staphylococcus aureus, was associated with significantly higher morbidity and mortality.

Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26–27, 2007

2008;133;1S-7S Chest Geiling and Lewis Rubinson Asha Devereaux, Michael D. Christian, Jeffrey R. Dichter, James A. * 27, 2007 − January 26 Force for Mass Critical Care Summit, Summary of Suggestions From the Task http://chestjournal.chestpubs.org/content/133/5_suppl/1S.full.html services can be found online on the World Wide Web at: The online version of this article, along with updated information and ISSN:0012-3692 ) http://chestjournal.chestpubs.org/site/misc/reprints.xhtml ( written permission of the copyright holder. this article or PDF may be reproduced or distributed without the prior Dundee Road, Northbrook, IL 60062. All rights reserved. No part of Copyright2008by the American College of Chest Physicians, 3300 Physicians. It has been published monthly since 1935. is the official journal of the American College of Chest Chest

The use of personal protective equipment for control of influenza among critical care clinicians: A survey study

Background: Intensive care units (ICUs) are potential high-risk areas for transmission of viruses causing febrile respiratory illness, such as influenza. Healthcare-associated influenza is prevented through healthcare worker (HCW) vaccination and effective use of U.S. Centers for Disease Control and Prevention recommended infection control practices, including use of personal protective equipment (PPE). Although effective PPE use may significantly reduce healthcare-associated influenza transmission, PPE adherence among ICU HCWs for preventing nosocomial influenza infection has not been evaluated. Objective: To characterize ICU HCW behavior, knowledge, and attitudes about recommended precautions for the prevention of healthcare-associated influenza infections. Design, Setting, and Participants: A survey of 292 internal medicine housestaff, pulmonary/critical care fellows and faculty, nurses, and respiratory care professionals working in four ICUs in two hospitals in Baltimore, MD. Measurements and Main Results: Of those surveyed, 88% (n = 256) completed the survey. Only 63% of respondents were able to correctly identify adequate influenza PPE, and 62% reported high adherence (>80%) with PPE use for prevention of nosocomial influenza. In multivariable modeling, odds of high adherence varied by clinician type. Respondents who believed adherence was inconvenient had lower odds of high adherence (odds ratio 0.42, 95% confidence interval 0.22–0.82), and those reporting likelihood of being reprimanded for nonadherence were more likely to adhere (odds ratio 2.40, 95% confidence interval 1.25–4.62). Conclusions: ICU HCWs report suboptimal levels of influenza PPE adherence. This finding in a high-risk setting is particularly concerning, given that it likely overestimates actual behavior. Both suboptimal adherence levels and significant PPE knowledge gaps indicate that ICU HCWs may be at a substantial risk of developing and/or transmitting nosocomial respiratory viral infection. Improving respiratory virus infection control will likely require closing knowledge gaps and changing organizational factors that influence behavior.

Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care: From a Task Force for Mass Critical Care Summit Meeting, January 26–27, 2007, Chicago, IL

BACKGROUND Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources. TASK FORCE SUGGESTIONS In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.

Emergency Postexposure Vaccination With Vesicular Stomatitis Virus–Vectored Ebola Vaccine After Needlestick

IMPORTANCE Safe and effective vaccines and drugs are needed for the prevention and treatment of Ebola virus disease, including following a potentially high-risk exposure such as a needlestick. OBJECTIVE To assess response to postexposure vaccination in a health care worker who was exposed to the Ebola virus. DESIGN AND SETTING Case report of a physician who experienced a needlestick while working in an Ebola treatment unit in Sierra Leone on September 26, 2014. Medical evacuation to the United States was rapidly initiated. Given the concern about potentially lethal Ebola virus disease, the patient was offered, and provided his consent for, postexposure vaccination with an experimental vaccine available through an emergency Investigational New Drug application. He was vaccinated on September 28, 2014. INTERVENTIONS The vaccine used was VSVΔG-ZEBOV, a replicating, attenuated, recombinant vesicular stomatitis virus (serotype Indiana) whose surface glycoprotein gene was replaced by the Zaire Ebola virus glycoprotein gene. This vaccine has entered a clinical trial for the prevention of Ebola in West Africa. RESULTS The vaccine was administered 43 hours after the needlestick occurred. Fever and moderate to severe symptoms developed 12 hours after vaccination and diminished over 3 to 4 days. The real-time reverse transcription polymerase chain reaction results were transiently positive for vesicular stomatitis virus nucleoprotein gene and Ebola virus glycoprotein gene (both included in the vaccine) but consistently negative for Ebola virus nucleoprotein gene (not in the vaccine). Early postvaccination cytokine secretion and T lymphocyte and plasmablast activation were detected. Subsequently, Ebola virus glycoprotein-specific antibodies and T cells became detectable, but antibodies against Ebola viral matrix protein 40 (not in the vaccine) were not detected. CONCLUSIONS AND RELEVANCE It is unknown if VSVΔG-ZEBOV is safe or effective for postexposure vaccination in humans who have experienced a high-risk occupational exposure to the Ebola virus, such as a needlestick. In this patient, postexposure vaccination with VSVΔG-ZEBOV induced a self-limited febrile syndrome that was associated with transient detection of the recombinant vesicular stomatitis vaccine virus in blood. Strong innate and Ebola-specific adaptive immune responses were detected after vaccination. The clinical syndrome and laboratory evidence were consistent with vaccination response, and no evidence of Ebola virus infection was detected.

Definitive care for the critically ill during a disaster: current capabilities and limitations: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL.

In the twentieth century, rarely have mass casualty events yielded hundreds or thousands of critically ill patients requiring definitive critical care. However, future catastrophic natural disasters, epidemics or pandemics, nuclear device detonations, or large chemical exposures may change usual disaster epidemiology and require a large critical care response. This article reviews the existing state of emergency preparedness for mass critical illness and presents an analysis of limitations to support the suggestions of the Task Force on Mass Casualty Critical Care, which are presented in subsequent articles. Baseline shortages of specialized resources such as critical care staff, medical supplies, and treatment spaces are likely to limit the number of critically ill victims who can receive life-sustaining interventions. The deficiency in critical care surge capacity is exacerbated by lack of a sufficient framework to integrate critical care within the overall institutional response and coordination of critical care across local institutions and broader geographic areas.