Sergio Sarquis

Is a Strategy Based on Routine Endotracheal Cultures the Best Way to Prescribe Antibiotics in Ventilator-Associated Pneumonia?

OBJECTIVES The objectives of this study were to evaluate if a strategy based on routine endotracheal aspirate (ETA) cultures is better than using the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines to prescribe antimicrobials in ventilator-associated pneumonia (VAP). METHODS This was a prospective, observational, cohort study conducted in a 15-bed ICU and comprising 283 patients who were mechanically ventilated for ≥48 h. Interventions included twice-weekly ETA; BAL culture was done if VAP was suspected. BAL (collected at the time of VAP) plus ETA cultures (collected≤7 days before VAP) (n=146 different pairs) were defined. We compared two models of 10 days of empirical antimicrobials (ETA-based vs ATS/IDSA guidelines-based strategies), analyzing their impact on appropriateness of therapy and total antimicrobial-days, using the BAL result as the standard for comparison. RESULTS Complete ETA and BAL culture concordance (identical pathogens or negative result) occurred in 52 pairs; discordance (false positive or false negative) in 67, and partial concordance in two. ETA predicted the etiology in 62.4% of all pairs, in 74.0% of pairs if ETA was performed≤2 days before BAL, and in 46.2% of pairs if ETA was performed 3 to 7 days before BAL (P=.016). Strategies based on the ATS/IDSA guidelines and on ETA results led to appropriate therapy in 97.9% and 77.4% of pairs, respectively (P<.001). The numbers of antimicrobial-days were 1,942 and 1,557 for therapies based on ATS/IDSA guidelines and ETA results, respectively (P<.001). CONCLUSIONS The ATS/IDSA guidelines-based approach was more accurate than the ETA-based strategy for prescribing appropriate, initial, empirical antibiotics in VAP, unless a sample was available≤2 days of the onset of VAP. The ETA-based strategy led to fewer days on prescribed antimicrobials.

Neutropenia and the development of the systemic inflammatory response syndrome

Abstract Objective. To determine outcome and natural course of systemic inflammatory response syndrome (SIRS) stages in adult febrile neutropenic patients. Design and setting. Retrospective cohort study in the medicine department and intensive care unit of a university hospital. Patients. Adults with cancer-related neutropenia and community-acquired fever. Measurements and results. Patients were classified on admission according to SIRS parameters, tumor type, and degree of neutropenia. Records of clinical and laboratory data during hospitalization were reviewed. Univariate and logistic regression analyses were performed. Seventy-nine events in 62 patients were analyzed. Overall mortality rate was 20.2% (16/79). Mortality increased as SIRS stage worsened on admission. No patients with stage 2 SIRS died (neutropenia and fever alone) but 11.1% of patients with SIRS 3, 43.4% with SIRS 4, 66.6% with sepsis induced hypotension, and 90% with septic shock. SIRS stage on admission was an independent predictor of death and was related directly to rate of progression to shock, i.e., none of the patients with SIRS 2, 2.7%(1/36) of those with SIRS 3, and 30.4% (7/23) of those admitted with SIRS 4. Conclusions. Mortality and progression to septic shock increased as more SIRS criteria were met on admission. SIRS stages could serve as a risk-assessing model in febrile neutropenic patients.

Outcome of Patients With Systemic Rheumatic Diseases Admitted to a Medical Intensive Care Unit

Systemic rheumatic diseases, including connective tissue diseases (CTDs) and necrotizing vasculitis, are a heterogeneous group of pathologies with a variety of clinical manifestations, disease courses, and prognoses. Patient admission to intensive care unit (ICU) may be due to acute manifestations of primary disease or secondary to complications from immunosuppressive agents, complications unrelated to primary disease, or a combination of these. The objective of the following study was to describe the causes, clinical course, and outcome in patients with systemic rheumatic diseases who required admission to the ICU.

Why do nice people get bad pneumonia? "Be quick or be dead" (Iron Maiden).

Community-acquired pneumonia (CAP) is a common human disease; in average, it could affect everybody at least once in his/her life and what’s more, it is a common cause of death. Globally, pneumonia remains the number one cause of death among respiratory and infectious diseases, surpassing chronic obstructive pulmonary disease and human immunodeficiency virus/acquired immunodeficiency virus (1). The need of intensive care unit (ICU) admission in patients with CAP is characteristic of deadly pneumonia. Low-acuity ICU admissions occurs; however, the major concern is initial admission to the general medical unit with subsequent transfer to the ICU, when the real concern should be premature admission. A late transfer to the ICU suggests the presence of rapidly progressive pneumonia which was not obvious at admission; as many as 45% of the patients with CAP who ultimately required ICU admission were initially admitted to a non-ICU setting (2). Sometimes there may be some subtle findings including those designed as “minor criteria” in the 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ ATS) guidelines for CAP (3) that might warrant direct admission to the ICU. CAP-requiring admission to the ICU is the leading cause of severe sepsis and, in this subset of patients, mortality can be as high as 50%. Early and appropriate empirical antimicrobial therapy has been associated with improved outcome of severe sepsis in multiple studies (4, 5). As in other causes of severe infection, the early recognition of such severity in CAP leads to an earlier initiation of appropriate empirical antimicrobials. Clinical judgment is probably the best tool for early severity recognition. This quality is a gift acquired by talented physicians after extensive clinical experience, yet skill makes it more difficult to define and even more difficult to measure. In this issue of Critical Care Medicine, Renaud et al (6) reported on a retrospective secondary analysis of the association between the timing of ICU admission and outcomes on 453 ICU patients extracted from four large multicentered, cohort studies of adults with CAP (138 delayedtransfer and 315 direct-transfer). The analysis was restricted to patients without overt cardiovascular or respiratory failure at the time of emergency department presentation. The authors performed rigorous adjustment for differences in baseline characteristics between study groups, using multivariable and propensity score analyses to match each delayed-transfer patient to a single directtransfer patient. The propensity score adjusted odds ratios for 28-day mortality and the length of stay for direct-transfer group survivors was significantly lower in comparison with the delayed-transfer group. They concluded that some patients without typical severe CAP might still benefit from direct transfer to the ICU. This study describes a reality that leads us to consider several questions: Does this outcome difference really exist? Why does this happen? What can we do to solve it? The answer to the first question that came up is yes—this study and previous studies that demonstrated that CAP transfer to the ICU for delayed respiratory failure or delayed onset of septic shock is associated with increased mortality (7) are sufficient evidence. This editorial will provide some insights on why to answer the other questions. The retrospective analysis used in the study presents certain drawbacks. On one hand, it might be unclear regarding the distinction of both groups and their possible outcomes; and on the other hand, it might disable the presence of other severity criteria, such as septic shock and the need of mechanical ventilation. However, the authors succeeded in demonstrating a clear distinction between the two main groups: those who were admitted immediately, and those who were transferred up to 3 days later. Earlier identification of patients with severe CAP proposed by this study is consistent with the so-called “early goal-directed therapy strategy” for sepsis (8), consisting of earlier diagnosis and application of therapy at the initial stage of hospital presentation with the intention of reverting the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression, and increased metabolic demands which in the case of being achieved should greatly improve the outcome. Several questions could not be answered in this study and will remain to be addressed in the future, including how many patients were not admitted to the ICU due to bed shortage, or what the influence of an inappropriate initial antimicrobial therapy does to the outcome. Additionally, the authors could not evaluate the validity of the “minor criteria” for severe CAP proposed in the IDSA/ATS guidelines, as some of those criteria need to be collected prospectively. Some future actions should be undertaken, inferring the validity of the conclusions of this study, including validating the minor criteria defined by the IDSA/ATS guidelines (respiratory rate 30/min, PaO2/FIO2 ratio 250, multilobar infiltrates, confusion, blood urea nitrogen level 20 mg/dL, leukopenia, thrombocytopenia, hypothermia and hypotension requiring aggressive fluid resuscitation) and evaluating the potential role of other criteria (hypoglycemia, acute alcoholism/alcoholic withdrawal, hyponatremia, metabolic acidosis, elevated lactate level, cirrhosis, asplenia, and need for noninvasive ventilation). It also should be necessary to evaluate the *See also p. 2867.