VanA rectal swab screening as a predictor of subsequent vancomycin-resistant enterococcal bloodstream infection in critically ill adults

Abstract Objective: To evaluate whether vanA rectal screening for vancomycin-resistant Enterococcus (VRE) predicts vancomycin resistance for patients with enterococcal bloodstream infection (BSI). Design: A retrospective cohort study. Setting: Large academic medical center. Methods: The predictive performance of a vanA rectal swab was evaluated in 161 critically ill adults with an enterococcal BSI from January 1, 2007, to September 1, 2014, and who had a vanA rectal swab screening obtained within 14 days prior to blood culture. Results: Of the patients meeting inclusion criteria, 83 (51.6%) were vanA swab positive. Rectal-swab–positive patients were more likely to be younger, to be immunocompromised, to have an indwelling central vascular catheter, and to have a history of MDR bacteria. The vanA rectal swab had sensitivity and negative predictive values of 83.6% and 85.9%, respectively, and specificity and positive predictive values of 71.3% and 67.5%, respectively, for predicting a vancomycin-resistant enterococcal BSI in critically ill adults. Conclusions: VanA rectal swabs may be useful for antimicrobial stewardship at institutions with VRE screening already in place for infection control purposes. A higher PPV would be warranted to implement a universal vanA screen on all ICU patients.

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Medication Histories in Critically Ill Patients Completed by Pharmacy Personnel

Annals of Pharmacotherapy ◽

10.1177/1060028018825483 ◽

2019 ◽

Vol 53 (6) ◽

pp. 596-602

Author(s):

Bridgette L. Kram ◽

Morgan A. Trammel ◽

Shawn J. Kram ◽

Sandy E. Wheeley ◽

Ben G. Mancheril ◽

...

Keyword(s):

Critically Ill ◽

Medical Center ◽

Phase 1 ◽

Academic Medical Center ◽

Median Number ◽

Phase 2 ◽

Medication History ◽

Medication Discrepancies ◽

Critically Ill Adults ◽

Ill Adults

Background: Although critically ill adults often have extended hospital lengths of stay and are at high risk of having medication-related adverse events, the value of medication histories in these patients remains underreported. Objective: To assess the feasibility of performing medication histories in critically ill adults and to establish the frequency of and characterize identified discrepancies. Methods: This prospective study included patients admitted to 4 intensive care units (ICUs) in a large academic medical center and was conducted in 2 phases. In phase 1, medication histories were conducted over a 5-week period by clinical pharmacists to assess feasibility. In phase 2, medication histories were conducted over a 3-week period by a pharmacy technician. Medication discrepancies, defined as any difference between the documented and pharmacy personnel–identified home medication list, were aggregated in both phases and adjudicated for severity. Results: In phase 1, 127 medication histories were completed (42.3% of admitted patients). Impaired cognition was the most common barrier encountered; however, 76% of patients were able to have a history completed if an attempt was made. In phase 2, a medication history was completed for 176 patients (58.9% of admitted patients). In aggregate, 1155 discrepancies were identified, with 78.2% of patients having a discrepancy. The median number of discrepancies per patient was 3 (interquartile range = 1-5); 11 life-threatening, 101 serious, and 326 significant discrepancies were identified. Conclusion and Relevance: A pharmacy personnel–based medication history program in the ICU is feasible and assists in the discovery of medication discrepancies with the potential for patient harm.

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Performance of a new national nutrition screening tool (spent nutrition screening tool) in hospitalized non-critically ill adults at an academic medical center

Clinical Nutrition ◽

10.1016/j.clnu.2018.06.1841 ◽

2018 ◽

Vol 37 ◽

pp. S236-S237

Author(s):

P. Pramyothin ◽

S. Keawtanom ◽

S. Dawilai ◽

R. Sarasak ◽

C. Sukaruttanawong ◽

...

Keyword(s):

Critically Ill ◽

Screening Tool ◽

Medical Center ◽

Academic Medical Center ◽

Nutrition Screening ◽

Academic Medical ◽

Critically Ill Adults ◽

Nutrition Screening Tool ◽

Ill Adults

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Hemodynamic Effects of Ketamine Compared With Propofol or Dexmedetomidine as Continuous ICU Sedation

Annals of Pharmacotherapy ◽

10.1177/10600280211051028 ◽

2021 ◽

pp. 106002802110510

Author(s):

Evan Atchley ◽

Eljim Tesoro ◽

Robert Meyer ◽

Alexia Bauer ◽

Mark Pulver ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Medical Center ◽

Academic Medical Center ◽

Academic Medical ◽

Clinically Significant ◽

Critically Ill Adults ◽

Icu Sedation ◽

Ill Adults ◽

Positive Effect

Background Ketamine has seen increased use for sedation in the intensive care unit. In contrast to propofol or dexmedetomidine, ketamine may provide a positive effect on hemodynamics. Objective The objective of this study was to compare the development of clinically significant hypotension or bradycardia (ie, negative hemodynamic event) between critically ill adults receiving sedation with ketamine and either propofol or dexmedetomidine. Methods This was a retrospective cohort study of adults admitted to an intensive care unit at an academic medical center between January 2016 and January 2021. Results Patients in the ketamine group (n = 78) had significantly less clinically significant hypotension or bradycardia compared with those receiving propofol or dexmedetomidine (n = 156) (34.6% vs 63.5%; P < 0.001). Patients receiving ketamine also experienced smaller degree of hypotension observed by percent decrease in mean arterial pressure (25.3% [17.4] vs 33.8% [14.5]; P < 0.001) and absolute reduction in systolic blood pressure (26.5 [23.8] vs 42.0 [37.8] mm Hg; P < 0.001) and bradycardia (15.5 [24.3] vs 32.0 [23.0] reduction in beats per minute; P < 0.001). In multivariate logistic regression modeling, receipt of propofol or dexmedetomidine was the only independent predictor of a negative hemodynamic event (odds ratio [OR]: 3.3, 95% confidence interval [CI], 1.7 to 6.1; P < 0.001). Conclusion and Relevance Ketamine was associated with less clinically relevant hypotension or bradycardia when compared with propofol or dexmedetomidine, in addition to a smaller absolute decrease in hemodynamic parameters. The clinical significance of these findings requires further investigation.

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A Brief Informant Screening Instrument for Dementia in the ICU: The Diagnostic Accuracy of the AD8 in Critically Ill Adults Suspected of Having Pre-Existing Dementia

Dementia and Geriatric Cognitive Disorders ◽

10.1159/000490379 ◽

2019 ◽

Vol 48 (5-6) ◽

pp. 241-249

Author(s):

Maria C. Duggan ◽

Madeline E. Morrell ◽

Rameela Chandrasekhar ◽

Annachiara Marra ◽

Kwame Frimpong ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Critically Ill ◽

Rating Scale ◽

The Elderly ◽

Clinical Dementia Rating ◽

Specific Patient ◽

Predictive Values ◽

Mild Dementia ◽

Critically Ill Adults ◽

Ill Adults

Background/Aim: The diagnostic accuracy of brief informant screening instruments to detect dementia in critically ill adults is unknown. We sought to determine the diagnostic accuracy of the 2- to 3-min Ascertain Dementia 8 (AD8) completed by surrogates in detecting dementia among critically ill adults suspected of having pre-existing dementia by comparing it to the Clinical Dementia Rating Scale (CDR). Methods: This substudy of BRAIN-ICU included a subgroup of 75 critically ill medical/surgical patients determined to be at medium risk of having pre-existing dementia (Informant Questionnaire on Cognitive Decline in the Elderly [IQCODE] score ≥3.3). We calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and AUC for the standard AD8 cutoff of ≥2 versus the reference standard CDR score of ≥1 for mild dementia. Results: By the CDR, 38 patients had very mild or no dementia and 37 had mild dementia or greater. For diagnosing mild dementia, the AD8 had a sensitivity of 97% (95% CI 86–100), a specificity of 16% (6–31), a PPV of 53% (40–65), an NPV of 86% (42–100), and an AUC of 0.738 (0.626–0.850). Conclusions: Among critically ill patients judged at risk for pre-existing dementia, the 2- to 3-min AD8 is highly sensitive and has a high NPV. These data indicate that the brief tool can serve to rule out dementia in a specific patient population.

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112. Physiological Signature of Bloodstream Infection in Critically Ill Patients

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.187 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S87-S88

Author(s):

Alex Zimmet ◽

Matthew Clark ◽

Shrirang M Gadrey ◽

Taison Bell ◽

J Randall Moorman ◽

...

Keyword(s):

Blood Culture ◽

Bloodstream Infection ◽

Critically Ill ◽

Positive Blood Culture ◽

Critically Ill Patients ◽

Vital Sign ◽

Physiological Data ◽

Surgical Trauma ◽

Critically Ill Adults ◽

Ill Adults

Abstract Background Bloodstream infection (BSI) is associated with high mortality rates in critically ill patients but is difficult to identify clinically. This uncertainty results in frequent blood culture testing, which exposes patients to additional costs and the potential harms of unnecessary antibiotics. Accordingly, we aimed to identify signatures in physiological data from critically ill adults that characterize BSI. Methods We reviewed all blood culture, vital sign, laboratory, and cardiorespiratory monitoring (CRM) data from patients admitted to the medical and surgical/trauma ICUs at the University of Virginia Medical Center from February 2011 to June 2015. Blood culture results were categorized as positive, negative, or contaminant. For the BSI population, we included data obtained within 12 hours before or 24 hours after the acquisition of a positive blood culture. The control population included data greater than 12 hours before or 24 hours after the acquisition of a positive blood culture, and all data from patients without BSI. We used multivariable logistic regression to identify the physiological characteristics of BSI. Results We analyzed 9,955 ICU admissions with 144 patient-years of vital sign and CRM data (1.3M hourly measurements). The average age was 59 years; the population was mostly Caucasian (81%) and male (56%). There were 5,671 (57%) admissions with ≥1 blood culture, and 744 (7%) had a BSI. The in-hospital mortality rate for patients with BSI was 28% vs. 12% for all others. The physiological signature of BSI was characterized by abnormalities in 12 parameters (Figure 1)—e.g., BSI was more likely in patients with a higher pulse and lower platelets. Several associations were nonlinear—e.g., temperature and WBC had U-shaped relationships with BSI. The internally validated C-statistic was 0.77. Conclusion Statistical modeling revealed a clinically sensible physiological signature of BSI that could assist with bedside decisions regarding the utility of blood culture testing in critically ill adults. Disclosures All authors: No reported disclosures.

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