The 280th Critical Care Reviews Newsletter provides the best critical care research and open access articles from across the medical literature over the past seven days. The highlights of this week’s edition are a randomised controlled trial examining immunoglobulin G for patients with necrotising soft tissue infection and a feasibility trial investigating corticosteroids in paediatric septic shock; review articles on arginine in the critically ill, nutrition and metabolism in burn patients and pre-hospital ultrasound; as well as three excellent study critiques on FLORALI, HELMET-NIV and targeted temperature management in deceased organ donors.
Diaz, T.L. et al. American Journal of Infection Control. Published online: 23 January 2017
- A quality improvement project was developed to evaluate the pre/post effects of standardized placement and supply of oral care equipment in patient rooms.
- Daily audits were performed to assess nursing behavior related to the performance of oral care on intubated patients with components from a 24 hour kit.
- Increasing supply and creating uniform placement of oral care tools in patient rooms contributes to increased performance of oral hygiene interventions by nurses.
Read the full abstract here
Düzkaya, D.S. et al. (2016) Critical Care Nurse. 36(6) pp. e1-e7
Background: Bloodstream infections related to use of catheters are associated with increased morbidity and mortality rates, prolonged hospital lengths of stay, and increased medical costs.
Conclusions: Use of chlorhexidine-impregnated dressings reduced rates of catheter-related bloodstream infections, contamination, colonization, and local catheter infection in a pediatric intensive care unit but was not significantly better than use of standard dressings.
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Frost, S.A. et al. Critical Care. Published online: 23 November 2016
Background: Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths . Importantly, infections acquired during a hospital stay have been shown to be preventable. In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes.
Conclusion: This meta-analysis of the effectiveness of CHG bathing to reduce infections among adults in the ICU has found evidence for the benefit of daily bathing with CHG to reduce CLABSI and MRSA infections. However, the effectiveness may be dependent on the underlying baseline risk of these events among the given ICU population. Therefore, CHG bathing appears to be of the most clinical benefit when infection rates are high for a given ICU population.
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Al-Omari, A. et al. (2016) Annals of Intensive Care. 6:110
Image shows artist’s interpretation of a human cytomegalovirus virion based on cryo-electron microscopy images
Cytomegalovirus (CMV) infection is increasingly recognized in critically ill immunocompetent patients.
Some studies have demonstrated an association between CMV disease and increased mortality rates, prolonged intensive care unit and hospital length of stay, prolonged mechanical ventilation, and nosocomial infections. However, there is a considerable controversy whether such association represents a causal relationship between CMV disease and unfavorable outcomes or just a marker of the severity of the critical illness.
Detection of CMV using polymerase chain reaction and CMV antigenemia is the standard diagnostic approach. CMV may have variety of clinical manifestations reflecting the involvement of different organ systems. Treatment of CMV in critical care is challenging due to diagnostic challenge and drug toxicity, and building predictive model for CMV disease in critical care setting would be promising to identify patients at risk and starting prophylactic therapy.
Our objective was to broadly review the current literature on the prevalence and incidence, clinical manifestations, potential limitations of different diagnostic modalities, prognosis, and therapeutic options of CMV disease in critically ill patients.
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Swan, J.T. et al. (2016) Critical Care Medicine. 44(10) pp. 1822–1832
Objective: To test the hypothesis that compared with daily soap and water bathing, 2% chlorhexidine gluconate bathing every other day for up to 28 days decreases the risk of hospital-acquired catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection in surgical ICU patients.
Design: This was a single-center, pragmatic, randomized trial. Patients and clinicians were aware of treatment-group assignment; investigators who determined outcomes were blinded.
Setting: Twenty-four–bed surgical ICU at a quaternary academic medical center.
Patients: Adults admitted to the surgical ICU from July 2012 to May 2013 with an anticipated surgical ICU stay for 48 hours or more were included.
Interventions: Patients were randomized to bathing with 2% chlorhexidine every other day alternating with soap and water every other day (treatment arm) or to bathing with soap and water daily (control arm).
Measurements and Main Results: The primary endpoint was a composite outcome of catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection. Of 350 patients randomized, 24 were excluded due to prior enrollment in this trial and one withdrew consent. Therefore, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Patients acquired 53 infections. Compared with soap and water bathing, chlorhexidine bathing every other day decreased the risk of acquiring infections (hazard ratio = 0.555; 95% CI, 0.309–0.997; p = 0.049). For patients bathed with soap and water versus chlorhexidine, counts of incident hospital-acquired infections were 14 versus 7 for catheter-associated urinary tract infection, 13 versus 8 for ventilator-associated pneumonia, 6 versus 3 for incisional surgical site infections, and 2 versus 0 for primary bloodstream infection; the effect was consistent across all infections. The absolute risk reduction for acquiring a hospital-acquired infection was 9.0% (95% CI, 1.5–16.4%; p = 0.019). Incidences of adverse skin occurrences were similar (18.9% soap and water vs 18.6% chlorhexidine; p = 0.95).
Conclusions: Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.
El-Kersh, K. et al.American Journal of Infection Control. Published online: 7 July 2016
Infectious complications in the intensive care unit (ICU) are associated with higher morbidity, mortality, and increased health care use. Here, we report the results of implementing 2 different models (open vs closed) on infectious complications in the ICU.
The closed ICU model was associated with 52% reduction in ventilator-associated pneumonia rate (P = .038) and 25% reduction in central line-associated bloodstream infection rate (P = .631).
We speculate that a closed ICU model allows clinical leadership centralization that further facilitates standardized care delivery that translates into fewer infectious complications.
Read the abstract here