Sleeping with the enemy: Clostridium difficile infection in the intensive care unit

This article by Prechter et al was published in Critical Care in October 2017.  The full text of the article can be accessed via this link.

Over the last years, there was an increase in the number and severity of Clostridium difficile infections (CDI) in all medical settings, including the intensive care unit (ICU). The current prevalence of CDI among ICU patients is estimated at 0.4-4% and has severe impact on morbidity and mortality. An estimated 10-20% of patients are colonized with C. difficile without showing signs of infection and spores can be found throughout ICUs. It is not yet possible to predict whether and when colonization will become infection. Figuratively speaking, our patients are sleeping with the enemy and we do not know when this enemy awakens.  Most patients developing CDI in the ICU show a mild to moderate disease course. Nevertheless, difficult-to-treat severe and complicated cases also occur. Treatment failure is particularly frequent in ICU patients due to comorbidities and the necessity of continued antibiotic treatment. This review will give an overview of current diagnostic, therapeutic, and prophylactic challenges and options with a special focus on the ICU patient.  First, we focus on diagnosis and prognosis of disease severity. This includes inconsistencies in the definition of disease severity as well as diagnostic problems. Proceeding from there, we discuss that while at first glance the choice of first-line treatment for CDI in the ICU is a simple matter guided by international guidelines, there are a number of specific problems and inconsistencies. We cover treatment in severe CDI, the problem of early recognition of treatment failure, and possible concepts of intensifying treatment. In conclusion, we mention methods for CDI prevention in the ICU.

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Outcomes of Patient- and Family-Centered Care Interventions in the ICU: A Systematic Review and Meta-Analysis

This paper was published in Critical Care Medicine October 2017 by Goldfarb et al.
Objective:  To determine whether patient- and family-centered care interventions in the ICU improve outcomes.
Data Sources:  We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases from inception until December 1, 2016.
Study Selection:  We included articles involving patient- and family-centered care interventions and quantitative, patient- and family-important outcomes in adult ICUs.
Data Extraction:  We extracted the author, year of publication, study design, population, setting, primary domain investigated, intervention, and outcomes.
Data Synthesis:  There were 46 studies (35 observational pre/post, 11 randomized) included in the analysis. Seventy-eight percent of studies (n = 36) reported one or more positive outcome measures, whereas 22% of studies (n = 10) reported no significant changes in outcome measures. Random-effects meta-analysis of the highest quality randomized studies showed no significant difference in mortality (n = 5 studies; odds ratio = 1.07; 95% CI, 0.95-1.21; p = 0.27; I = 0%), but there was a mean decrease in ICU length of stay by 1.21 days (n = 3 studies; 95% CI, -2.25 to -0.16; p = 0.02; I = 26%). Improvements in ICU costs, family satisfaction, patient experience, medical goal achievement, and patient and family mental health outcomes were also observed with intervention; however, reported outcomes were heterogeneous precluding formal meta-analysis.
Conclusions:  Patient- and family-centered care-focused interventions resulted in decreased ICU length of stay but not mortality. A wide range of interventions were also associated with improvements in many patient- and family-important outcomes. Additional high-quality interventional studies are needed to further evaluate the effectiveness of patient- and family-centered care in the intensive care setting.
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Neutrophil-to-Lymphocyte Ratio Predicts Death in Acute-on-Chronic Liver Failure Patients Admitted to the Intensive Care Unit: A Retrospective Cohort Study

This article was published in the September issue of the journal Shock by Moreau and colleagues.

The neutrophil-to-lymphocyte ratio (NLR) is an inflammation score recognized as associated with outcome. While inflammation has been shown to correlate with the development of acute-on-chronic liver failure (ACLF), we sought to investigate the role of NLR in predicting 90-day mortality in cirrhotic patients experiencing ACLF.  We performed a retrospective cohort study involving a total of 108 consecutive cirrhotic patients admitted in the intensive care unit (ICU). NLR, clinical and biological data were recorded.  Of the total, 75 patients had ACLF. The 90-day mortality rate was 53%. ACLF patients displayed higher NLR values in comparison with cirrhotic patients without ACLF throughout the ICU stay. NLR proved more elevated in non-survivors ACLF patients, with mortality correlating with increasing quartiles of NLR. On multivariable Cox regression analysis, NLR was found to be a predictor of mortality along with the Sequential Organ Failure Assessment (SOFA) score and mechanical ventilation requirement. The model for end-stage liver disease (MELD) score was not predictive of 90-days mortality.  Performance analysis revealed an area under curve (AUC) of 0.71 [95% CI: 0.59-0.82] regarding NLR capacity to predict 90-days mortality. When including NLR, SOFA score, and mechanical ventilation requirement into the final model, the AUC was significantly higher (0.81 [95% CI: 0.72-0.91]).These findings suggest that NLR is associated with mortality in ACLF patients admitted to the ICU. Combining NLR, SOFA score, and the need for mechanical ventilation could be a useful prognostic tool to identify ACLF patients at a higher risk of mortality.

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Impact of Discontinuing Contact Precautions for MRSA and ESBLE in an Intensive Care Unit: A prospective non-inferiority before and after study

The article by Renaudin et al was published in the September 2017 issue of “Infection Control and Hospital Epidemiology”

Objective:  To compare incidence densities of methicillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBLE) acquisition in the intensive care unit (ICU) before and after discontinuation of contact precautions (CP) and application of standard precautions (SP).

Design:  Prospective non-inferiority before-and-after study comparing 2 periods: January 1, 2012, to January 31, 2014 (the CP period) and February 1, 2014, to February 29, 2016 (the SP period).

Setting:  A 16-bed polyvalent ICU in France with only single-bed rooms with dedicated equipment and reusable medical devices. Patients:  All patients admitted to the ICU during the CP and SP periods were included: 1,547 and 1,577 patients, respectively.

Methods:  Incidence densities of ICU-acquired MRSA or ESBLE were determined per 1,000 patient days. Other studied factors included (1) patient characteristics, (2) incidence densities of MRSA or ESBLE carried at admission, (3) compliance with hand hygiene protocols, and (4) antibiotic consumption.

Results:  Incidence densities of ICU-acquired MRSA were 0.82 (95% confidence interval [CI], 0.31-1.33) and 0.79 (95% CI, 0.30-1.29) per 1,000 patient days during the CP and SP periods, respectively. For ESBLE, values were 2.7 (95% CI, 1.78-3.62) and 2.06 (95% CI, 1.27-2.86) per 1,000 patient days. These rates were significantly non-superior during the SP period compared to CP period, with a margin of 1 per 1,000 patient days for both MRSA (P=.002) and ESBLE (P=.004). Other factors were comparable during the 2 periods. Only ESBLE carried at admission was inferior during the SP period. We observed a high level of compliance to hand hygiene protocols.

Conclusions:  Discontinuing CP did not increase acquired MRSA and ESBLE in our ICU with single rooms with dedicated equipment, strict application of hand hygiene, medical and paramedical leadership, and good antibiotic stewardship.

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Critical Care Reviews Newsletter 24th September 2017 Issue 302

The 302nd Critical Care Reviews Newsletter brings you the best critical care research and open access articles frcritcal care reviewsom across the medical literature over the last week. “With the 30th Annual ESICM Congress just starting in Vienna, there are a host of trials released, with more to come over the next few days. As a result, it is a massive newsletter, with no less than 10 RCTs in total, including the EAT-ICU trial, evaluating early goal-directed nutrition, an interesting trial on airway pressure release ventilation, with results that seem a little too good to be true (or maybe I’m just a skeptic about APRV…), spontaneous breathing trials and a biomarker-based strategy for early discontinuation of empirical antifungal treatment. There are also great guidelines, including one on the management of cardiogenic shock and another on paediatric mechanical ventilation.

The full newsletter can be accessed via this link.

Can a Novel ICU Data Display Positively Affect Patient Outcomes and Save Lives?

This article by Olchanski et al was published in the September issue of Journal of Medical Systems.

The aim of this study was to quantify the impact of ProCCESs AWARE, Ambient Clinical Analytics, Rochester, MN, a novel acute care electronic medical record interface, on a range of care process and patient health outcome metrics in intensive care units (ICUs).  ProCCESs AWARE is a novel acute care EMR interface that contains built-in tools for error prevention, practice surveillance, decision support and reporting. We compared outcomes before and after AWARE implementation using a prospective cohort and a historical control. The study population included all critically ill adult patients (over 18 years old) admitted to four ICUs at Mayo Clinic, Rochester, MN, who stayed in hospital at least 24 h. The pre-AWARE cohort included 983 patients from 2010, and the post-AWARE cohort included 856 patients from 2014. We analyzed patient health outcomes, care process quality, and hospital charges. After adjusting for patient acuity and baseline demographics, overall in-hospital and ICU mortality odds ratios associated with AWARE intervention were 0.45 (95% confidence interval 0.30 to 0.70) and 0.38 (0.22, 0.66). ICU length of stay decreased by about 50%, hospital length of stay by 37%, and total charges for hospital stay by 30% in post AWARE cohort (by $43,745 after adjusting for patient acuity and demographics). Better organization of information in the ICU with systems like AWARE has the potential to improve important patient outcomes, such as mortality and length of stay, resulting in reductions in costs of care.

 

The full text of this article will usually be only available via the internet to those who have a personal subscription though some articles may be available freely without a password.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this linkSupplementary material published online is available via this link.

Critical Care Reviews Newsletter 17th September 2017 Issue 301

critcal care reviewsWelcome to the 301st Critical Care Reviews Newsletter, which bringing you the best critical care research from across the medical literature over the past seven days. The highlights of this week are randomised controlled trials on checklists for endotracheal intubation of critically ill adults, nebulized vs intravenous amikacin for hospital and ventilator-acquired pneumonia and transfusions in burns; a new European / Latin American guideline on the management of hospital-acquired pneumonia and ventilator-associated pneumonia; plus reviews on heart-lung interactions, ARDS and critical illness-associated diaphragm weakness.

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