Multi-Drug Resistant Gram-Negative Infections Among Critically Ill Patients: Analysis of Baseline Characteristics and Factors Associated with Mortality

Abstract BackgroundBacterial infections are a frequent cause of hospitalization and a leading cause of death, particularly with the emergence of antibiotics resistance. The emergence of Carbapenem resistance among gram-negative bacteria (GNB) is one of the evolving alerts as its use is considered the last resort of treatment [1]. Therefore, this urged studying the risk factors for the development of multi-drug resistant [2] GNB, identify the clinical outcomes and factors associated with mortality, especially among critically ill patients who are expected to have the worst outcomes.Materials/methodsThis is a retrospective observational study of critically ill patients who had an infection with Carbapenem-resistant Enterobacteriaceae (CRE), or MDR Pseudomonas aeruginosa, or MDR Acinetobacter spp. between May 2016- Nov 2018. Baseline demographics, co-morbidities, and clinical outcomes were collected and were evaluated for association with 28 days mortality. ResultsA total of 255 patients with MDR Gram-negative cultures were screened, 77 patients met the inclusion criteria. Pseudomonas aeruginosa was the most common index organism (53% of patients), followed by Acinetobacter spp. and CRE, respectively. The mortality rate at 28 days was (59.7%). Non-survivors were significantly older (mean age 64 vs. 44 years, P= 0.0001), had significantly worse disease severity scores on ICU admission, higher incidence of chronic kidney disease (CKD) (43% vs. 16%, P= 0.010), required more continuous renal replacement therapy (CRRT) (54% vs. 13% P= 0.0001), had longer hospital length of stay prior to infection (median 34 vs. 13 days, P= 0.018), and required longer inotropic and vasopressors support (median 19 vs. 8 days, P = 0.0001). In multivariate logistic regression the following factors were significantly associated with mortality; requirement of inotropic support [OR 10.01 (95% CI 1.55-64.77); P= 0.015], age [OR 1.05 (95% CI 1.0-1.1); P=0.01], APACHE IV score on ICU admission [OR 1.03 (95% CI 1.0- 1.06); P= 0.04], and ICU length of stay [OR 1.03 (95% CI 1.0- 1.06); P= 0.035].ConclusionMDR Gram-negative infection is associated with significant in-hospital mortality among critically ill patients. Old age, high APACHE IV score, higher ICU length of stay, and higher hemodynamic support are associated with higher mortality.Trial registrationretrospectively registered.

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ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE)IV ICU LENGTH OF STAY BENCHMARKS FOR TODAY'S CRITICALLY ILL PATIENTS

CHEST Journal ◽

10.1378/chest.128.4_meetingabstracts.297s ◽

2005 ◽

Vol 128 (4) ◽

pp. 297S ◽

Cited By ~ 2

Author(s):

Jack E. Zimmerman ◽

Andrew A. Kramer ◽

Douglas S. McNair ◽

Fern M. Malila

Keyword(s):

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Chronic Health Evaluation ◽

Health Evaluation ◽

Chronic Health ◽

Icu Length Of Stay ◽

Apache Iv

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Outcomes of non-COVID-19 critically ill patients during the COVID-19 pandemic

Wiener klinische Wochenschrift ◽

10.1007/s00508-021-01857-4 ◽

2021 ◽

Author(s):

Răzvan Bologheanu ◽

Mathias Maleczek ◽

Daniel Laxar ◽

Oliver Kimberger

Keyword(s):

Intensive Care ◽

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Medical Specialty ◽

Routine Care ◽

Treatment Pathways ◽

Icu Length Of Stay ◽

Matched Study ◽

The Impact

Summary Background Coronavirus disease 2019 (COVID-19) disrupts routine care and alters treatment pathways in every medical specialty, including intensive care medicine, which has been at the core of the pandemic response. The impact of the pandemic is inevitably not limited to patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their outcomes; however, the impact of COVID-19 on intensive care has not yet been analyzed. Methods The objective of this propensity score-matched study was to compare the clinical outcomes of non-COVID-19 critically ill patients with the outcomes of prepandemic patients. Critically ill, non-COVID-19 patients admitted to the intensive care unit (ICU) during the first wave of the pandemic were matched with patients admitted in the previous year. Mortality, length of stay, and rate of readmission were compared between the two groups after matching. Results A total of 211 critically ill SARS-CoV‑2 negative patients admitted between 13 March 2020 and 16 May 2020 were matched to 211 controls, selected from a matching pool of 1421 eligible patients admitted to the ICU in 2019. After matching, the outcomes were not significantly different between the two groups: ICU mortality was 5.2% in 2019 and 8.5% in 2020, p = 0.248, while intrahospital mortality was 10.9% in 2019 and 14.2% in 2020, p = 0.378. The median ICU length of stay was similar in 2019: 4 days (IQR 2–6) compared to 2020: 4 days (IQR 2–7), p = 0.196. The rate of ICU readmission was 15.6% in 2019 and 10.9% in 2020, p = 0.344. Conclusion In this retrospective single center study, mortality, ICU length of stay, and rate of ICU readmission did not differ significantly between patients admitted to the ICU during the implementation of hospital-wide COVID-19 contingency planning and patients admitted to the ICU before the pandemic.

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Steady‐state pharmacokinetic and pharmacodynamic profiling of colistin in critically ill patients with multi‐drug–resistant gram‐negative bacterial infections, along with differences in clinical, microbiological and safety outcome

Basic & Clinical Pharmacology & Toxicology ◽

10.1111/bcpt.13482 ◽

2020 ◽

Vol 128 (1) ◽

pp. 128-140

Author(s):

Kishna Ram ◽

Salim Sheikh ◽

Rahul Kumar Bhati ◽

Chakra Dhar Tripathi ◽

Jagdish Chander Suri ◽

...

Keyword(s):

Steady State ◽

Critically Ill ◽

Critically Ill Patients ◽

Bacterial Infections ◽

Drug Resistant ◽

Gram Negative ◽

Safety Outcome

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Hypophosphatemia and Outcomes in ICU: A Systematic Review and Meta-Analysis

Journal of Intensive Care Medicine ◽

10.1177/0885066620940274 ◽

2020 ◽

pp. 088506662094027

Author(s):

Jeremy Cheuk Kin Sin ◽

Lillian King ◽

Emma Ballard ◽

Stacey Llewellyn ◽

Kevin B. Laupland ◽

...

Keyword(s):

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Meta Analysis ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Cochrane Library ◽

Secondary Outcome ◽

Icu Length Of Stay ◽

Newcastle Ottawa Scale

Purpose: Hypophosphatemia is reported in up to 5% of hospitalized patients and ranges from 20% to 80% in critically ill patients. The consequences of hypophosphatemia for critically ill patients remain controversial. We evaluated the effect of hypophosphatemia on mortality and length of stay in intensive care unit (ICU) patients. Methods: MEDLINE, EMBASE, Cochrane Library (Reviews and Trials), and PubMed were searched for articles in English. The primary outcome was mortality and secondary outcome was length of stay. The quality of evidence was graded using a modified Newcastle-Ottawa Scale. Results: Our search yielded 828 articles and ultimately included 12 studies with 7626 participants in the analysis. Hypophosphatemia was associated with increased hospital length of stay (2.19 days [95% CI, 1.74-2.64]) and ICU length of stay (2.22 days [95% CI, 1.00-3.44]) but not mortality (risk ratio: 1.13 [95% CI, 0.98-1.31]; P = .09). Conclusions: Hypophosphatemia in ICU was associated with increased hospital and ICU length of stay but not all-cause mortality. Hypophosphatemia appears to be a marker of disease severity. Limited number of available studies and varied study designs did not allow for the ascertainment of the effect of severe hypophosphatemia on patient mortality.

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Short- and Long-term Outcomes of Critically Ill Patients With Cancer and Prolonged ICU Length of Stay

CHEST Journal ◽

10.1378/chest.08-0359 ◽

2008 ◽

Vol 134 (3) ◽

pp. 520-526 ◽

Cited By ~ 56

Author(s):

Márcio Soares ◽

Jorge I.F. Salluh ◽

Viviane B.L. Torres ◽

Juliana V.R. Leal ◽

Nelson Spector

Keyword(s):

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

Long Term Outcomes ◽

Patients With Cancer ◽

Icu Length Of Stay ◽

Short And Long Term

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Appropriateness of Heparin-Induced Thrombocytopenia (HIT) Testing and the Reliability of 4-Ts Scoring in Critically Ill Patients

Blood ◽

10.1182/blood-2018-99-114788 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4988-4988

Author(s):

Phyo Thazin Myint ◽

Amani Erra ◽

Taha Alrifai ◽

Salman Syed ◽

Bibek Singh Pannu ◽

...

Keyword(s):

Length Of Stay ◽

Critically Ill ◽

Critically Ill Patients ◽

False Positive ◽

High Probability ◽

Icu Patients ◽

Heparin Induced Thrombocytopenia ◽

Common Cause ◽

Icu Length Of Stay ◽

Low Probability

Abstract Introduction: Thrombocytopenia is a common occurrence in critically ill patients and results in an array of diagnostic workup. Heparin induced thrombocytopenia (HIT) is one of the most frequently ordered tests in this scenario, although it is a less common cause (0.02-0.5%) The over testing and treatment of HIT in Intensive Care Unit (ICU) can lead to a change in medications, and result in side effects, increased ICU length of stay and increased costs. Current guidelines recommend 4-Ts criteria to evaluate the clinical HIT probability in general population, but it may also be used in Intensive Care Unit (ICU) patients. Here, we want to analyze the the usage of 4Ts score in a community hospital and to understand its correlation with HIT testing to see if HIT testing could have been avoided. Methods: We performed a retrospective chart review of adult patients who underwent testing for Heparin Induced Thrombocytopenia anti-platelet factor 4 antibody (anti- PF4 Ab) in ICU at our institution from 03/01/2012 to 02/01/2018. The primary outcomes were set to identify (1) the extent of inappropriate of HIT testing and its consequences in patients with low 4Ts scores, and (2) if 4Ts score as a potential predictor of length of stay and mortality in ICU. As a secondary outcome, we assessed if Body Mass Index (BMI) and Recent Surgery are related to false positive anti-PF4 Ab test. Kruskal-Wallis test and Fisher Exact test were used. Results: A total of 66 patients were identified. The mean age was 64 yr and the male-female ratio was similar. 40 patients had recent surgery in the past 3 months. The cause of thrombocytopenia other than HIT was possible or definite in 62 patients with sepsis being the most common cause (56.45%). 30 patients had low probability 4-Ts scores, 28 had intermediate and 7 had high probability. HIT was confirmed (Serotonin Release Assay-SRA positive) in 0%, 7.14% and 12.5% of patients with low, intermediate and high probability 4Ts scores, respectively. In the patients with low probability 4Ts and anti-PF4 Ab testing, heparin was held in 24 (80%) and the anti-coagulation was switched (to either fondaparinux or argatroban) in 10 (33.33%). In those patients with anticoagulation switch, 3 had minor bleeding. There was no difference in the ICU length of stay (p=0.1712) and mortality (p=0.149) between patients with low, intermediate and high probability 4Ts scores. Patients with BMI ≥40 kg/m2 had twice the percentage of false positive anti-PF4 Ab testing compared with the rest, but the results were not significant (p=0.285). Recent surgery was not related to the false positive anti-PF4 Ab testing (p=1). Conclusion: As no patient with low-probability 4Ts score had confirmed HIT, low 4Ts may be a good estimator of the unlikeliness of HIT even in critically ill patients. We found discrepancy in the recommendations and usage of Anti-PF4 Ab testing in our institution. This has resulted in switching of heparin to other, more expensive anti-coagulations. This may very well be the situation in many other similar institutions. This could partly be due to lack of awareness of HIT testing guidelines in the critical care setting. We recommend the use of 4Ts scoring and more sensible testing and treatment of HIT in ICU patients. Although we could not demonstrate the statistical association between morbid obesity and false positive anti-PF4 Ab, our study might have been underpowered by low subgroup population of such patients. We propose further studies about HIT testing and treatment to include morbidly obese patients as a separate sub-group. Disclosures No relevant conflicts of interest to declare.

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Use of Intravenous Vitamin C in Critically Ill Patients With COVID-19 Infection

Journal of Pharmacy Practice ◽

10.1177/08971900211015052 ◽

2021 ◽

pp. 089719002110150

Author(s):

Matthew Li ◽

Tsung Han Ching ◽

Christopher Hipple ◽

Ricardo Lopez ◽

Asad Sahibzada ◽

...

Keyword(s):

Length Of Stay ◽

Vitamin C ◽

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Primary Objective ◽

Primary Study ◽

Protective Effects ◽

Icu Length Of Stay ◽

Intravenous Vitamin

Introduction The pathophysiology for Coronavirus Disease 2019 (COVID-19) infection is characterized by cytokine oxidative stress and endothelial dysfunction. Intravenous (IV) vitamin C has been utilized as adjuvant therapy in critically ill patients with sepsis for its protective effects against reactive oxygen species and immunomodulatory effects. The primary objective of this study was to evaluate the effects of IV vitamin C in critically ill patients with COVID-19 infection. Methods Retrospective observational cohort study with propensity score matching of intensive care unit (ICU) patients who received 1.5 grams IV vitamin C every 6 hours for up to 4 days for COVID-19 infection. The primary study outcome was in-hospital mortality. Secondary outcomes included vasopressor requirements in norepinephrine equivalents, ICU length of stay, and change in Sequential Organ Failure Assessment (SOFA) score. Results Eight patients received IV vitamin C and were matched to 24 patients. Patients in the IV vitamin C group had higher rates of hospital mortality [7 (88%) vs. 19 (79%), P = 0.049]. There was no difference in the daily vasopressor requirement in the treatment group or between the 2 groups. The mean SOFA scores post-treatment was higher in the IV vitamin C group (12.4 ± 2.8 vs. 8.1 ± 3.5, P < 0.005). There was no difference in ICU length of stay between the treatment and control groups. Conclusion Adjunctive IV vitamin C for the management of COVID-19 infection in critically ill patients may not decrease the incidence of mortality, vasopressor requirements, SOFA scores, or ventilator settings.

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