Resistance to Carbapenem Antibiotics Doubled in Intensive Care Units

MedicalResearch.com Interview with:

Eilish McCann, PhD</strong> Director, Outcomes Research (Center for Observational and Real-World Evidence) Merck

Dr. Eilish McCann

Eilish McCann, PhD
Director, Outcomes Research (Center for Observational and Real-World Evidence)
Merck

MedicalResearch.com: What is the background for this study?

Response: One of the most pressing challenges facing medicine today is the emergence of bacterial resistance to antibiotics. One area of high concern is the increasing prevalence of resistance to powerful antibiotics like carbapenems, as patients with infections due to carbapenem-resistant bacteria have very few alternate effective treatment options.

In this study we used real-world data from a Becton, Dickinson and Company electronic research data set to analyze over 140,000 bacterial isolates from patients at 342 hospitals across the United States, so that we could investigate where the burden of carbapenem resistance is most acute. Importantly analysis of real-world data in this way allows us to gain insights from a large number of hospitals, giving a broad and nationally representative picture of the resistance burden.

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Risk Factors for Unplanned Transfer to the ICU after ED Admission

MedicalResearch.com Interview with:
Marleen Boerma MD
Department of Emergency Medicine
Elisabeth-Tweesteden Hospital
Tilburg, The Netherlands

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Unplanned Intensive Care Unit (ICU) admission has been used as a surrogate marker of adverse events, and is used by the Australian Council of Healthcare Accreditation as a reportable quality indicator. If we can identify independent variables predicting deterioration which require ICU transfer within 24 hours after emergency department (ED) admission, direct ICU admission should be considered. This may improve patient safety and reduce adverse events by appropriate disposition of patients presenting to the ED.

This study shows that there were significantly more hypercapnia patients in the ICU admission group (n=17) compared to the non-ICU group (n=5)(p=0.028). There were significantly greater rates of tachypnea in septic patients (p=0.022) and low oxygen saturation for patients with pneumonia (p=0.045). The level of documentation of respiratory rate was poor.

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In-Bed Cycling Feasible for ICU Patients on Ventilation

MedicalResearch.com Interview with:

Michelle Kho, PT, PhD</strong> Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation Assistant Professor School of Rehabilitation Science McMaster University

Dr. Michelle Kho

Michelle Kho, PT, PhD
Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation
Assistant Professor
School of Rehabilitation Science
McMaster University

MedicalResearch.com: What is the background for this study?

Response: Patients who survive the ICU are at risk for muscle weakness and can experience physical functional disability lasting 5 to 8 years after the ICU. From a study conducted in Belgium, patients who were randomized to receive cycling after being in ICU for 2 weeks walked farther at ICU discharge than those who did not. Other research supported physiotherapy starting within days of starting mechanical ventilation to improve functional outcomes. Our CYCLE research program combines these 2 concepts – Can we start cycling very early in a patient’s ICU stay, and will this improve functional outcomes post-ICU?

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Expensive Intensive Care Units Often Overutilized

MedicalResearch.com Interview with:

Dr. Dong W. Chang, MD MS</strong> Division of Respiratory and Critical Care Physiology and Medicine Los Angeles Biomed Research Institute at Harbor-University of California Los Angeles, Medical Center Torrance California

Dr. Dong Chang

Dr. Dong W. Chang, MD MS
Division of Respiratory and Critical Care Physiology and Medicine
Los Angeles Biomed Research Institute at Harbor-University of California
Los Angeles, Medical Center
Torrance California

MedicalResearch.com: What is the background for this study?

Response: The study was based on our overall impression that ICU care is often delivered to patients who are unlikely to derive long-term benefit (based on their co-morbidities/severity of illness, etc.). However, what surprised us was the magnitude of this problem. Our study found more than half the patients in ICU at a major metropolitan acute-care hospital could have been cared for in less expensive and invasive settings.

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Mechanical Ventilation Doubles For Persons With Advanced Dementia

MedicalResearch.com Interview with:

Joan M. Teno, MD, MS Department of Gerontology and Geriatrics, Cambia Palliative Care Center of Excellence University of Washington Medicine Seattle, Washington

Dr. Joan Teno

Joan M. Teno, MD, MS
Department of Gerontology and Geriatrics,
Cambia Palliative Care Center of Excellence
University of Washington Medicine
Seattle, Washington

MedicalResearch.com: What is the background for this study?

Response: An important challenge for our health care system is effectively caring for persons that high-need, high-cost — persons afflicted with advanced dementia and severe functional impairment are among these persons, with substantial need and if hospitalized in the ICU and mechanically ventilated are high cost patients, who are unlikely to benefit from this level of care and our best evidence suggest the vast majority of persons would not want this care. In a previous study, we interviewed families of advance dementia with 96% starting the goals of care are to focus comfort. Mechanical ventilation in some cases may be life saving, but in cases such as those with advanced dementia and severe functional impairment, they may result in suffering without an improvement in survival.

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Extubating Patients From Ventilators At Night Linked To Higher Mortality

MedicalResearch.com Interview with:

Hayley B. Gershengorn, MD Associate Professor, Albert Einstein College of Medicine Attending Physician, Montefiore Medical Center Bronx, NY 10467

Dr. Hayley Gershengorn

Hayley B. Gershengorn, MD
Associate Professor, Albert Einstein College of Medicine
Attending Physician, Montefiore Medical Center
Bronx, NY 10467

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Little was previously known about the timing of extubations for mechanically ventilated intensive care unit patients or whether extubating patients overnight is safe. In this retrospective cohort study of mechanically ventilated intensive care unit adult patients in the United States, 20.1% were extubated overnight. Overnight extubation was associated with significantly higher hospital mortality.

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Antibacterial Gloves May Reduce Cross Contamination In ICU Setting

Ojan Assadian, M.D., DTMH Professor for Skin Integrity and Infection Prevention Institute for Skin Integrity and Infection Prevention School of Human & Health Sciences University of Huddersfield Queensgate, Huddersfield UKMedicalResearch.com Interview with:
Ojan Assadian, M.D., DTMH
Professor for Skin Integrity and Infection Prevention
Institute for Skin Integrity and Infection Prevention
School of Human & Health Sciences
University of Huddersfield
Queensgate, Huddersfield UK

MedicalResearch: What is the background for this study? What are the main findings?

Prof. Assadian: Although medical gloves serve as an important mechanical barrier to prevent healthcare workers’ hands from getting contaminated with potentially pathogenic microorganisms, their inappropriate and incorrect use may support microbial transmission, eventually resulting in indirect horizontal cross-contamination of other patients.

We conducted a clinical study designed to determine the efficacy of a newly developed synthetic antibacterial nitrile medical glove coated with an antiseptic, polyhexamethylen-biguanid hydrochloride (PHMB), on its external surface, and compared this antibacterial glove to an identical non-antibacterial glove in reducing surface contamination after common patient care measures in an intensive care unit.

We found significantly lower numbers of bacteria on surfaces after performing typical clinical activities such as intravenous fluid handling, oral toilet, or physiotherapy, if touched with antibacterial gloves.

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Benzodiazepines May Adversely Affect ICU Patients On Ventilators

Nick Lonardo, PharmD Pharmacy, Clinical Coordinator Department of Pharmacy Services Salt Lake City, Utah 84132MedicalResearch.com Interview with:
Nick Lonardo, PharmD
Pharmacy, Clinical Coordinator
Department of Pharmacy Services
Salt Lake City, Utah 84132

Medical Research: What are the main findings of the study?

Dr. Lonardo: To our knowledge, this is the first, large, multicenter, retrospective cohort study to show that continuous infusion benzodiazepines are independently associated with increased mortality in mechanically ventilated ICU patients. In addition, benzodiazepines were associated with an increased time of mechanical ventilation and ICU length of stay.

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Effect of High-Dose Vitamin D Supplementation In Critically Ill Patients

Karin Amrein, MD, MSc Assistant Professor Department of Internal Medicine Division of Endocrinology and Metabolism Medical University of Graz 8036 Graz, AustriaMedicalResearch.com Interview with:
Karin Amrein, MD, MSc
Assistant Professor Department of Internal Medicine
Division of Endocrinology and Metabolism
Medical University of Graz
8036 Graz, Austria

Medical Research: What are the main findings of the study?

Dr. Amrein: This is the first large clinical trial on vitamin D in critical care. In a double-blind, randomized, placebo-controlled clinical trial, a population of mixed adult ICU patients with vitamin D deficiency (defined as 25-hydroxyvitamin D [25(OH)D] level ≤ 20ng/ml) was assigned to receive either vitamin D3 or placebo. We used a high loading dose of vitamin D3 followed by monthly maintenance doses of 90,000 IU for a total of 5 months. Because of a substantially increased risk for skeletal complications below 12ng/ml of 25-hydroxyvitamin D, we used this threshold for a predefined subgroup analysis.

Overall, high-dose vitamin D3 compared with placebo did not reduce hospital length of stay (primary endpoint), intensive care unit (ICU) length of stay, hospital mortality, or 6 month-mortality

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Do Arterial Catheters Improve ICU Patient Care?

Hayley Gershengorn MD Assistant Professor, Department of Medicine (Critical Care) Assistant Professor, The Saul R. Korey Department of Neurology Albert Einstein College of Medicine Bronx, NY 10461MedicalResearch.com Interview with:
Hayley Gershengorn MD
Assistant Professor, Department of Medicine (Critical Care)
Assistant Professor, The Saul R. Korey Department of Neurology
Albert Einstein College of Medicine
Bronx, NY 10461

Medical Research:  What are the main findings of the study?

Dr. Gershengorn: Using a large national database, we found there to be no association between the use of arterial catheters and mortality in mechanically ventilated medical intensive care unit patients. Similarly, we found no beneficial association between arterial catheters and mortality in any of the eight other critically ill subgroups evaluated.
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Quality Program Improved Outcomes in Neonatal ICUs

Dr Prakesh S Shah MSc, MBBS, MD, DCH, MRCP, FRCPC Professor, Departments of Paediatrics and HPME Mount Sinai Hospital and University of Toronto CIHR Applied Research Chair in Reproductive and Child Health Services and Policy Research Director, Canadian Neonatal Network Toronto Ontario Canada M5G 1X5MedicalResearch.com Interview with:
Dr Prakesh S Shah MSc, MBBS, MD, DCH, MRCP, FRCPC
Professor, Departments of Paediatrics and HPME
Mount Sinai Hospital and University of Toronto
CIHR Applied Research Chair in Reproductive and Child Health Services and Policy Research
Director, Canadian Neonatal Network
Toronto Ontario Canada M5G 1X5

Medical Research: What are the main findings of the study?

Dr. Shah: The main findings of our study are that by embracing collaborative quality improvement program in 25 of 28 Neonatal ICUs in the country, we were able to show significant reduction in adverse outcomes of necrotizing enterocolitis, severe retinopathy of prematurity and nosocomial infections among preterm neonates born at less than 29 weeks of gestation. This resulted in significant overall reduction of composite outcome of mortality or severe morbidities and improved overall outcomes over 3 years of study period.
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ICU Admission For Pulmonary Embolism Varies By Hospital

Dr. Colin Cooke MD, MSc, MS Assistant Professor, Department of Internal Medicine University of Michigan Center for Healthcare Outcomes and Policy Ann Arbor, MIMedicalResearch.com Interview with:
Dr. Colin Cooke MD, MSc, MS
Assistant Professor, Department of Internal Medicine
University of Michigan
Center for Healthcare Outcomes and Policy
Ann Arbor, MI

Medical Research: What are the main findings of the study?

Dr. Cooke: We determined that when patients who are hospitalized for pulmonary embolism (PE), a blood clot in the lung, approximately 1 in 5 will be admitted to an intensive care unit (ICU). However, the chances that a patient will go to an ICU is highly dependent upon which hospital they are admitted to. For example, some hospitals admitted only 3% of patients with pulmonary embolism to an ICU while others admitted almost 80%.

Importantly, the differences in how hospitals use their ICU for patients with pulmonary embolism was not entirely related to the patient’s need for life support measures, the things that the ICU is designed to deliver. For example, the ICU patients in high ICU-use hospitals tended to receive fewer procedures, including mechanical ventilation, arterial catheterization, central lines, and medications to dissolve blood clots. This suggest that high utilizing hospitals are admitting patients to the ICU with weaker indications for ICU admission.
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Pneumonia: Improved Antibiotic Strategies and Decreased Mortality

MedicalResearch.com Interview with:
Dr Simone Gattarello
Vall d’Hebron Hospital, Critical Care Department
Universitat Autonoma de Barcelona and Medicine Department, Spain

MedicalResearch.com: What are the main findings of the study?

Dr. Gattarello: The main findings from the present study are a 15% decrease in ICU mortality due to severe community-acquired pneumonia caused by Streptococcus pneumoniae in the last decade; moreover, several changes in antibiotic prescription practices were detected and an association between improved survival and both earlier antibiotic administration and increased combined antibiotic therapy were identified. In summary, in severe pneumococcal pneumonia combined antibiotic therapy and early antibiotic administration are associated with lower mortality.
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ICU: Increased EEG Brain Wave Monitoring and Survival

MedicalResearch.com Interview with:
John Ney, MD, MPH
Clinical Assistant Professor,
Department of Neurology,
University of Washington
neyj@uw.edu

MedicalResearch.com: What are the main findings of the study?

Dr. Ney: My colleagues and I used a large, publicly available dataset to examine the usage and effectiveness of electroencephalography (EEG) in adult intensive care units (ICUs) in the United States over a five year period.  We compared routine EEG, which consists of a portable machine hooked up to the patient to record brainwaves for a short duration, usually 20-40 minutes, with continuous EEG monitoring, where a patient’s brainwaves are recorded continuously for 24 hours or more and examined, ideally in real-time.  Because most patients in the ICU are comatose, we have generally poor and crude indicators of their brain function.  ICU patients are particularly at risk for non-convulsive seizures, where the brain is seizing, but there are few outward signs of a seizure.  EEG is the only means of detecting non-convulsive seizures, and is useful in determining the brain’s reactions to drugs, monitoring for stroke and other abnormal activity.

Our main finding is that ICU patients receiving continuous EEG monitoring was associated with increased survival relative to those who received routine EEG only.    In our sample, 39% of ICU patients who received routine EEG died compared to only 25% of those with continuous EEG monitoring. This finding was both substantial and statistically significant, even after adjustment for age and other demographics, clinical disease comorbidity severity measures, and hospital factors.  Although continuous EEG monitoring was more expensive, the increase in hospital charges were not significant after adjustment.

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Hypovolemic Shock: Fluid Resuscitation with Colloids vs Crystalloids

Professor Djillali Annane MD, PhD Raymond Poincaré Hospital, Garches, France CH d’Etampes, Etampes, FranceMedicalResearch.com with:
Professor Djillali Annane MD, PhD
Raymond Poincaré Hospital, Garches, France
CH d’Etampes, Etampes, France

 

MedicalResearch.com: What are the main findings of the study?

Answer: The CRISTAL trial was designed in 2002 to clarify whether correction of acute hypovolemia in critically ill patients with colloids may increase the risk of death as compared to resuscitation with crystalloids. The trial has enrolled 2857 patients in 57 ICUs in France, Belgium, Canada and North Africa.  The relative risk of death was at 28 day of 0.96 (95% CI: 0.88 to 1.04; P=0.26), and at 90 day of 0.92 (95%CI: 0.86 to 0.99; P=0.03) in favor of colloids. Colloids-treated patients had  more days alive and off mechanical ventilation and off vasopressor both within 7 days and 28 days of randomization. There was no evidence for increased risk of kidney injury with colloids.

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ICU Critical Care: Costs and Perceived Futility

Thanh N. Huynh, MD, MSHS Clinical Instructor UCLA Division of Pulmonary Critical CareMedicalResearch.com Interview with:
Thanh N. Huynh, MD, MSHS
Clinical Instructor
UCLA Division of Pulmonary Critical Care

MedicalResearch.com: What are the main findings of the study?

Dr. Huynh: Our study shows that it is common for ICU doctors to recognize that futile treatment is provided to patients who cannot benefit from it.  In our study, 11% of ICU patients were perceived as receiving futile treatment.  The outcomes of these 123 patients were uniformly poor, with 85% dying within 6 months.  Advances in critical care medicine has allowed us to save lives, but it has also allowed us provide aggressive life-sustaining treatments that may not benefit all patients.  When aggressive treatment is poorly matched with a patient’s prognosis, doctors will consider such treatment as futile and our study shows that this is not an uncommon occurrence in our health system.

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