P. Muthiah

Potential role of leukotriene modifiers in the treatment of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is characterized by progressive, irreversible airflow limitation coupled with an abnormal inflammatory process. It is associated with high morbidity and mortality. Leukotriene modifiers, approved by the United States Food and Drug Administration as treatment for asthma and allergic rhinitis, may also alleviate the abnormal inflammatory response seen in patients with COPD. To explore the outcomes of research in this area, we conducted a literature search from 1950–2007, using the PubMed database. We found no published studies that provided conclusive evidence that the available leukotriene modifiers benefit patients with COPD. However, data do suggest that leukotriene modifiers may offer benefits to patients with COPD, including effects that pertain to airflow limitation, neutrophil and lymphocyte chemotaxis, and neutrophil longevity. Added to conventional treatment, these agents appear to reduce symptoms, improve objective measures of disease, and control inflammation. Further studies are needed to determine the precise role of leukotriene modifiers in the treatment of COPD.

The Utility of the Candida Score in Patients With Sepsis.

Background:Candida is a leading cause of infection in the intensive care unit. Colonization versus infection remains a challenge. A Candida Score (CS) of 3 or greater has been used to target antifungal therapy in surgical patients at risk of candidemia but has not been well evaluated in medical patients with sepsis. Objectives:The aim of this study was to assess utility of the CS in detecting candidemia early in patients with sepsis. Methods:This was a secondary analysis of patients with sepsis (n = 77) who were followed up for development of new infections. Patients with known fungal infection at admission were excluded. Candida colonization was defined as Candida cultured from any baseline culture, except blood, as a part of routine clinical care. Results:Candidemia was detected in 8 of 77 participants (10.4%; 4 [15.4%] with a CS ≥3 and 4 [7.8%] with a CS <3). Demographic variables (age, race, sex) were similar among those who did and did not develop candidemia. Using the recommended CS of 3 or greater, sensitivity was (4/8) 50%, specificity was (47/69) 68.1%, positive predictive value was (4/26) 15.4%, and negative predictive value was (47/51) 92.2%. Baseline colonization was significantly higher among those who developed candidemia (50% vs 11.6%; P = .02), but no significant differences were observed among CS components or total scores. Conclusions:Despite a relatively poor sensitivity, a reasonable specificity with a strong negative predictive value makes this tool a viable option for screening medically ill patients who may require antifungal agents. The CS should be evaluated in a larger, more inclusive, medical population.

A 74-Year-Old Man Presenting With Cough, Malaise, and Mediastinal Lymphadenopathy

CASE PRESENTATIONnA 74-year-old white male farmer was admitted from his primary care physicians office after he presented with symptoms of cough productive of clear sputum, malaise, weakness, fatigue, and shortness of breath on exertion for 3xa0weeks. He was an ex-smoker with a history of hypertension, hyperlipidemia, and coronary artery bypass graft surgery. He did not report any chills, night sweats, or fevers during this presentation.

658: PREDICTION OF INVASIVE CANDIDIASIS IN A VETERAN POPULATION

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) assay in critically ill patients with nosocomial pneumonia. Methods: This retrospective, single-center study included adults admitted to an intensive care unit (ICU) from January 2012 to December 2014 with nosocomial pneumonia who received a MRSA nasal PCR and respiratory culture within fixed time intervals. The primary outcome included the diagnostic performance characteristics of the assay. Secondary outcomes included the change in negative predictive value (NPV) over time, rate of acute kidney injury (AKI), and cost avoidance related to vancomycin and monitoring. Results: Of 400 included patients, 9.3% had MRSA pneumonia. Compared to initial cultures, the assay demonstrated 91.89% sensitivity, 84.3% specificity, with a positive predictive value and NPV of 37.36% and 99.03% at a median time of 1.4 days. The assay maintained similar performance over time with a NPV of 87.5% for the fourth culture at a median time of 21.9 days. The assay was used to de-escalate vancomycin in 45.3% of patients with negative PCR. Patients continued on vancomycin had a longer ICU length of stay than those de-escalated (13 vs 10 days, p=0.001). The overall incidence of AKI was 10.8% and no difference was found in rate of AKI in those continued on vancomycin vs. de-escalated (9.2% vs 12.3%, p=0.34). Early vancomycin de-escalation resulted in an estimated 621 doses and 207 levels avoided with total cost avoidance of

Unusual presentations of disseminated histoplasmosis.

21,031 or

Surgical biopsy prevented with PET/CT scan in a young female with intrathoracic lymphadenopathy.

108 per patient. Conclusions: In critically ill patients, a MRSA nasal PCR assay has a high NPV for nosocomial pneumonia and can be used to guide vancomycin de-escalation.