scholarly journals 112. Physiological Signature of Bloodstream Infection in Critically Ill Patients

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.

scholarly journals 303. Physiological Changes Due to Bloodstream Infection in Intensive Care Unit Patients Differ According to Transplant Status

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S149-S150
Author(s):  
Alex Zimmet ◽  
Douglas Lake ◽  
Amanda M Zimmet ◽  
Shrirang M Gadrey ◽  
Taison Bell ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Intensive Care ◽  
Blood Culture ◽  
Bloodstream Infection ◽  
Critically Ill ◽  
Positive Blood Culture ◽  
Critically Ill Patients ◽  
Regression Modeling ◽  
Transplant Recipients ◽  
Logistic Regression Modeling

Abstract Background Transplant recipients are at increased risk of bloodstream infection (BSI), which often leads to critical illness. Due to immunosuppression, BSI in these patients may manifest with different pathophysiology compared to non-transplant recipients. We aimed to identify different trends in the pathophysiology of critically ill patients with BSI based on transplant status. Methods We reviewed data from patients admitted to the medical and surgical/trauma intensive care units (ICUs) at the University of Virginia Medical Center from 2011 to 2015. We included both solid organ and hematopoietic stem cell transplant recipients. We performed univariate logistic regression modeling to evaluate trends in different physiological features in both transplant and non-transplant recipients in the 96 hours surrounding a positive blood culture. We then performed multivariate logistic regression modeling to identify features independently associated with a positive blood culture in the next 24 hours in transplant recipients. Results We analyzed 9,954 ICU patient-admissions (including 505 transplant recipients), with a total of 144 patient-years of physiological data, 1.3 million hourly measurements, and 15,577 blood culture instances. Of the 1,068 blood culture instances in transplant recipients, 125 (12%) were positive, compared to 1,051 of 14,509 (7%) blood culture instances in non-transplant recipients. Critically ill transplant recipients with BSI had greater abnormalities in vital signs, oxygen requirement, markers of organ damage, APACHE score, and Charlson Comorbidity Index (CCI) compared to non-transplant recipients (Figure 1). Trends in many of these features also differed based on transplant status. The multivariable logistic regression model of BSI in transplant recipients included, in decreasing strength of association: total bilirubin, systolic blood pressure, fraction of inspired oxygen, number of intravenous lines, and CCI. This model had an AUC of 0.75. Figure 1. Trends in pathophysiological abnormalities in 9,954 critically ill patients with BSI based on transplant status, 2011–2015. Each graph demonstrates the average value of the physiological variable over time relative to the acquisition of a positive blood culture. Blue curves depict trends in transplant recipients, while red curves depict trends in non-transplant recipients. We assessed 108 physiological features and show the 24 features with the greatest change around the time of blood culture. Conclusion Critically ill transplant recipients have a higher prevalence of BSI and different pathophysiological manifestations of BSI compared to non-transplant recipients. This may have implications regarding early detection and treatment of BSI in these patients. Disclosures Randall Moorman, MD, Advanced Medical Predictive Devices, Diagnostics, and Displays (Board Member, Shareholder)

scholarly journals Analysis of the impact of secondary prophylaxis on Clostridioides difficile recurrence in critically ill adults

2020 ◽  
Vol 8 ◽  
pp. 205031212093089
Author(s):  
Kathryn A Connor ◽  
Kelly M Conn
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Low Dose ◽  
Secondary Prophylaxis ◽  
Infection Prophylaxis ◽  
Clostridioides Difficile ◽  
Clostridioides Difficile Infection ◽  
Critically Ill Adults ◽  
Ill Adults ◽  
Infection Recurrence

Introduction: Clostridioides (formerly Clostridium) difficile infection recurrence in patients re-exposed to antibiotics for treatment of a non- Clostridioides difficile infection is high at approximately 33%. Low-dose per os vancomycin (e.g. 125 mg q12 h) or metronidazole (e.g. 500 mg intravenous/per osq8 h) may help prevent recurrences, but study of secondary prophylaxis in critically ill patients is needed. Objectives: To determine whether critically ill adults receiving low-dose per os vancomycin for secondary Clostridioides difficile infection prophylaxis have fewer recurrences of Clostridioides difficile infection in 90 days compared with patients receiving metronidazole for secondary Clostridioides difficile infection prophylaxis or control (no secondary prophylaxis). Methods: This was a retrospective, two-center, observational study in a large academic medical center and affiliated community hospital. Included patients had a history of Clostridioides difficile infection within 1 year of receiving antibiotics for clinical care. We compared patients receiving secondary prophylaxis with vancomycin or metronidazole and control patients; in addition, an unplanned fourth group (vancomycin/metronidazole combination) was identified and analyzed. The primary outcome was Clostridioides difficile infection recurrence within 90 days of a course of broad-spectrum antibiotic therapy. Fisher’s exact, analysis of variance, and Kruskal–Wallis tests were used to compare Clostridioides difficile infection recurrence with prophylaxis group and additional contributing factors. Results: Eighty-two patients were included: 38 control (46.3%), 20 metronidazole (24.4%), 17 vancomycin (20.7%), and 7 combination (8.5%). Ten of 82 patients (12.2%) had at least one Clostridioides difficile infection recurrence; 8/38 patients in the control group (21.1%), 1/7 patients in the combination group (14.3%), 1/17 patients in the per os vancomycin group (5.9%), and 0/20 in the metronidazole group (0%; p = 0.073). As a post hoc secondary analysis, the three prophylaxis groups were coalesced into one group and compared with control (4.5% vs 21%; p = 0.039). Additional factors (e.g. age, obesity, immunosuppression, acid suppression) were not significantly associated with Clostridioides difficile infection recurrence or with prophylaxis group. Conclusion: There was no difference in Clostridioides difficile infection recurrence between prophylaxis groups, however, given the low recurrence rate, prospective evaluation with a larger sample of critically ill patients is necessary.

scholarly journals Stress ulcer prophylaxis with proton pump inhibitors or histamine 2 receptor antagonists in critically ill adults - a meta-analysis of randomized controlled trials with trial sequential analysis

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Xiaoyang Zhou ◽  
Hanyuan Fang ◽  
Jianfei Xu ◽  
Peifu Chen ◽  
Xujun Hu ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Sequential Analysis ◽  
Stress Ulcer ◽  
Meta Analysis ◽  
Trial Sequential Analysis ◽  
Gi Bleeding ◽  
Ulcer Prophylaxis ◽  
Critically Ill Adults ◽  
Ill Adults

Abstract Background Proton pump inhibitors (PPI) and histamine 2 receptor antagonists (H2RA) have been widely used as stress ulcer prophylaxis (SUP) in critically ill patients, however, its efficacy and safety remain unclear. This study aimed to assess the effect of SUP on clinical outcomes in critically ill adults. Methods Literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane database of clinical trials for randomized controlled trials (RCTs) that investigated SUP, with PPI or H2RA, versus placebo or no prophylaxis in critically ill patients from database inception through 1 June 2019. Study selection, data extraction and quality assessment were performed in duplicate. The primary outcomes were clinically important gastrointestinal (GI) bleeding and overt GI bleeding. Conventional meta-analysis with random-effects model and trial sequential analysis (TSA) were performed. Results Twenty-nine RCTs were identified, of which four RCTs were judged as low risk of bias. Overall, SUP could reduce the incident of clinically important GI bleeding [relative risk (RR) = 0.58; 95% confidence intervals (CI): 0.42–0.81] and overt GI bleeding (RR = 0.48; 95% CI: 0.36–0.63), these results were confirmed by the sub-analysis of trials with low risk of bias, TSA indicated a firm evidence on its beneficial effects on the overt GI bleeding (TSA-adjusted CI: 0.31–0.75), but lack of sufficient evidence on the clinically important GI bleeding (TSA-adjusted CI: 0.23–1.51). Among patients who received enteral nutrition (EN), SUP was associated with a decreased risk of clinically important GI bleeding (RR = 0.61; 95% CI: 0.44–0.85; TSA-adjusted CI: 0.16–2.38) and overt GI bleeding (RR = 0.64; 95% CI: 0.42–0.96; TSA-adjusted CI: 0.12–3.35), but these benefits disappeared after adjustment with TSA. Among patients who did not receive EN, SUP had only benefits in reducing the risk of overt GI bleeding (RR = 0.37; 95% CI: 0.25–0.55; TSA-adjusted CI: 0.22–0.63), but not the clinically important GI bleeding (RR = 0.27; 95% CI: 0.04–2.09). Conclusions SUP has benefits on the overt GI bleeding in critically ill patients who did not receive EN, however, its benefits on clinically important GI bleeding still needs more evidence to confirm.

Delirium Assessment Tools for Use in Critically Ill Adults: A Psychometric Analysis and Systematic Review

2018 ◽  
Vol 38 (1) ◽  
pp. 38-49 ◽  
Author(s):  
Céline Gélinas ◽  
Mélanie Bérubé ◽  
Annie Chevrier ◽  
Brenda T. Pun ◽  
E. Wesley Ely ◽  
...  
Keyword(s):  
Psychometric Properties ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Assessment Tools ◽  
Cognitive Test ◽  
Delirium Assessment ◽  
Nursing Delirium Screening Scale ◽  
Detection Score ◽  
Critically Ill Adults ◽  
Ill Adults

BACKGROUNDDelirium is highly prevalent in critically ill patients. Its detection with valid tools is crucial.OBJECTIVETo analyze the development and psychometric properties of delirium assessment tools for critically ill adults.METHODSDatabases were searched to identify relevant studies. Inclusion criteria were English language, publication before January 2015, 30 or more patients, and patient population of critically ill adults (>18 years old). Search terms were delirium, scales, critically ill patients, adult, validity, and reliability. Thirty-six manuscripts were identified, encompassing 5 delirium assessment tools (Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), Cognitive Test for Delirium, Delirium Detection Score, Intensive Care Delirium Screening Checklist (ICDSC), and Nursing Delirium Screening Scale). Two independent reviewers analyzed the psychometric properties of these tools by using a standardized scoring system (range, 0–20) to assess the tool development process, reliability, validity, feasibility, and implementation of each tool.RESULTSPsychometric properties were very good for the CAM-ICU (19.6) and the ICDSC (19.2), moderate for the Nursing Delirium Screening Scale (13.6), low for the Delirium Detection Score (11.2), and very low for the Cognitive Test for Delirium (8.2).CONCLUSIONSThe results indicate that the CAM-ICU and the ICDSC are the most valid and reliable delirium assessment tools for critically ill adults. Additional studies are needed to further validate these tools in critically ill patients with neurological disorders and those at various levels of sedation or consciousness.

scholarly journals Association of multiple glycemic parameters at intensive care unit admission with mortality and clinical outcomes in critically ill patients

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Priscila Bellaver ◽  
Ariell F. Schaeffer ◽  
Diego P. Dullius ◽  
Marina V. Viana ◽  
Cristiane B. Leitão ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Glycemic Variability ◽  
Stress Hyperglycemia ◽  
Critically Ill Adults ◽  
Ill Adults

AbstractThe aim of the present study was to investigate the association of multiple glycemic parameters at intensive care unit (ICU) admission with outcomes in critically ill patients. Critically ill adults admitted to ICU were included prospectively in the study and followed for 180 days until hospital discharge or death. Patients were assessed for glycemic gap, hypoglycemia, hyperglycemia, glycemic variability, and stress hyperglycemia ratio (SHR). A total of 542 patients were enrolled (30% with preexisting diabetes). Patients with glycemic gap >80 mg/dL had increased need for renal replacement therapy (RRT; 37.7% vs. 23.7%, p = 0.025) and shock incidence (54.7% vs. 37.4%, p = 0.014). Hypoglycemia was associated with increased mortality (54.8% vs. 35.8%, p = 0.004), need for RRT (45.1% vs. 22.3%, p < 0.001), mechanical ventilation (MV; 72.6% vs. 57.5%, p = 0.024), and shock incidence (62.9% vs. 35.8%, p < 0.001). Hyperglycemia increased mortality (44.3% vs. 34.9%, p = 0.031). Glycemic variability >40 mg/dL was associated with increased need for RRT (28.3% vs. 14.4%, p = 0.002) and shock incidence (41.4% vs.31.2%, p = 0.039). In this mixed sample of critically ill subjects, including patients with and without preexisting diabetes, glycemic gap, glycemic variability, and SHR were associated with worse outcomes, but not with mortality. Hypoglycemia and hyperglycemia were independently associated with increased mortality.

scholarly journals 2117. Fluconazole vs. Echinocandins as Initial Therapy for Candidemia Caused by Fluconazole-Susceptible Species in the Era of Rapid Diagnostic Testing

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S716-S716
Author(s):  
Danya Roshdy ◽  
Tyler Ginn ◽  
Rupal K Jaffa ◽  
William E Anderson ◽  
Elizabeth Green ◽  
...  
Keyword(s):  
Blood Culture ◽  
Critically Ill ◽  
Positive Blood Culture ◽  
Subgroup Analysis ◽  
Critically Ill Patients ◽  
Diagnostic Testing ◽  
Initial Therapy ◽  
Clinical Failure ◽  
Rapid Diagnostic Testing ◽  
All Cause Mortality

Abstract Background Echinocandins (ECH) are recommended first-line for initial therapy (IT) of candidemia (CD) over fluconazole (FLU) due to their broad spectrum of activity. This recommendation was made prior to widespread implementation of rapid diagnostic testing (RDT), allowing prompt species identification and targeted therapy. The objective of this study was to compare clinical outcomes in patients with CD caused by FLU-susceptible species who received either FLU or ECH as IT. Methods This was a multicenter, retrospective cohort study of adults with CD caused by C. albicans, C. tropicalis, or C. parapsilosis. Patients who received FLU or ECH as IT for at least 48 hours from May 2012 to October 2018 were included. Patients who died within 48 hours of first positive blood culture were excluded. The primary endpoint was the rate of clinical failure (persistent CD for >72 hours, recurrent infection within 30 days, change in therapy, and all-cause mortality within 30 days). Secondary endpoints included 90-day all-cause mortality and time to culture clearance. A subgroup analysis in critically ill patients was conducted. Results Of the 371 patients evaluated, 128 met criteria for inclusion, 57 received FLU and 71 received ECH. Patients in the ECH group had a higher incidence of sepsis at the time of first positive blood culture (45.1% vs. 19.3%, P = 0.002). A line-associated source was more common in the ECH group (56.3%) vs. urinary source in the FLU group (21.1%). C. albicans was most common in both groups (63%). Clinical failure was similar in the FLU and ECH groups (38.6% vs. 35.2%, P = 0.69). 90-day mortality and time to culture clearance (1.6 vs. 1.5 days, P = 0.63) did not yield significant differences. In the subgroup analysis of critically ill patients, there was a trend suggesting higher rate of failure in patients who received FLU vs. an ECH (60.9% vs. 47.7%, P = 0.31), though underpowered to detect such a difference. Length of stay (LOS) was shorter in patients who received FLU (12 vs. 18 days, P = 0.018). Conclusion FLU as IT for FLU-susceptible CD may be a reasonable option in non-critically ill patients in the setting of RDT. This may lead to shorter LOS given the availability of an oral formulation. Additional prospective studies are needed to validate these conclusions. Disclosures All authors: No reported disclosures.

Bloodstream Infection-Associated Sepsis and Septic Shock in Critically Ill Adults: A Population-Based Study

Infection ◽  
2004 ◽  
Vol 32 (2) ◽  
pp. 59-64 ◽  
Author(s):  
K. B. Laupland ◽  
H. D. Davies ◽  
D. L. Church ◽  
T. J. Louie ◽  
J. S. Dool ◽  
...  
Keyword(s):  
Septic Shock ◽  
Bloodstream Infection ◽  
Critically Ill ◽  
Population Based ◽  
Population Based Study ◽  
Critically Ill Adults ◽  
Sepsis And Septic Shock ◽  
Ill Adults

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

2020 ◽  
pp. 1-6
Author(s):  
Shawn J. Kram ◽  
Bridgette L. Kram ◽  
Jennifer M. Schultheis ◽  
Michelle M. Kuhrt ◽  
Andrew S. McRae ◽  
...  
Keyword(s):  
Bloodstream Infection ◽  
Critically Ill ◽  
Rectal Swab ◽  
Medical Center ◽  
Academic Medical Center ◽  
Predictive Performance ◽  
Predictive Values ◽  
Vancomycin Resistant ◽  
Critically Ill Adults ◽  
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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