We retrospectively evaluated whether initial procalcitonin (PCT) levels can predict early antibiotic treatment failure (ATF) in patients with gram-negative bloodstream infections (GN-BSI) caused by urinary tract infections from January 2018 to November 2019. Early ATF was defined as the following: (1) hemodynamically unstable or febrile at Day 3; (2) the need for mechanical ventilation or continuous renal replacement therapy at Day 3; (3) patients who died within 3 days (date of blood culture: Day 0). The study included 189 patients; 42 showed early ATF. Independent risk factors for early ATF were initial admission to the intensive care unit (odds ratio: 7.735, 95% confidence interval: 2.567–23.311; P < 0.001) and PCT levels ≥30 ng/mL (odds ratio: 5.413, 95% confidence interval: 2.188–13.388; P < 0.001). Antibiotic factors were not associated with early ATF. Initial PCT levels may be helpful to predict early ATF in these patients.

The first FDA-approved test to assess risk for acute kidney injury (AKI), [TIMP-2]•[IGFBP7], is clinically available in many parts of the world, including the USA and Europe. We sought to understand how the test is currently being used clinically. We invited a group of experts knowledgeable on the utility of this test for kidney injury to a panel discussion regarding the appropriate use of the test. Specifically, we wanted to identify which patients would be appropriate for testing, how the results are interpreted, and what actions would be taken based on the results of the test. We used a modified Delphi method to prioritize specific populations for testing and actions based on biomarker test results. No attempt was made to evaluate the evidence in support of various actions however. Our results indicate that clinical experts have developed similar practice patterns for use of the [TIMP-2]•[IGFBP7] test in Europe and North America. Patients undergoing major surgery (both cardiac and non-cardiac), those who were hemodynamically unstable, or those with sepsis appear to be priority patient populations for testing kidney stress. It was agreed that, in patients who tested positive, management of potentially nephrotoxic drugs and fluids would be a priority. Patients who tested negative may be candidates for “fast-track” protocols. In the experience of our expert panel, biomarker testing has been a priority after major surgery, hemodynamic instability, or sepsis. Our panel members reported that a positive test prompts management of nephrotoxic drugs as well as fluids, while patients with negative results are considered to be excellent candidates for “fast-track” protocols.

Background Sepsis management guidelines endorse use of biomarkers to support clinical assessment and treatment decisions in septic patients. The impact of biomarkers on improving patient outcomes remains uncertain. Methods Retrospective observational study of adult sepsis discharges between January 1, 2012, and December 31, 2015, from Premier Healthcare Database hospitals. Sepsis was defined by an All Patients Refined Diagnosis-Related Group code of 720 (septicemia and disseminated infections). Use of four biomarker strategies was evaluated based on hospital records: (i) >1 procalcitonin (PCT), (ii) 1 PCT, (iii) no PCT but ≥1 C-reactive protein (CRP) and/or lactate and (iv) no sepsis biomarkers. Associations between biomarker use and clinical and cost outcomes were examined. The primary outcome was impact of biomarker strategy on hospital costs per day. Results Among 933,591 adult sepsis discharges during the study period, 731,392 (78%) had biomarker tests ordered. In multivariable analyses, discharges with >1 PCT had higher hospital costs per day ($1,904; 95% confidence interval [CI] $1,896–$1,911) compared with discharges with no sepsis biomarkers ($1,606; 95% CI $1,658–$1,664). Discharges with >1 PCT also had greater illness severity and antimicrobial exposure compared with other biomarker-use groups. The adjusted odds of dying during hospital stay compared with being discharged were significantly lower for sepsis discharges with >1 PCT (0.64; 95% CI 0.61–0.67) and 1 PCT (0.88; 95% CI 0.85–0.91) compared with no sepsis biomarker use. The proportion of discharges with ≥1 PCT increased almost six-fold during the study; use of other biomarkers remained constant. Conclusions Between 2012 and 2015, PCT use among sepsis discharges increased six-fold while lactate and CRP use remained unchanged. PCT use was associated with decreased odds of in-hospital mortality but increased hospital costs per day. Serial biomarker monitoring may be associated with improved patient outcomes in the most critically ill septic patients.

INTRODUCTION:Close monitoring and repeated risk assessment of sepsis patients in the intensive care unit (ICU) is important for decisions regarding care intensification or early discharge to the ward. We studied whether considering plasma kinetics of procalcitonin, a biomarker of systemic bacterial infection, over the first 72 critical care hours improved mortality prognostication of septic patients from two US settings.METHODS:This retrospective analysis included consecutively treated eligible adults with a diagnosis of sepsis from critical care units in two independent institutions in Clearwater, FL and Chicago, IL. Cohorts were used for derivation or validation to study the association between procalcitonin change over the first 72 critical care hours and mortality.RESULTS:ICU/in-hospital mortality rates were 29.2%/31.8% in the derivation cohort (n=154) and 17.6%/29.4% in the validation cohort (n=102). In logistic regression analysis of both cohorts, procalcitonin change was strongly associated with ICU and in-hospital mortality independent of clinical risk scores (Acute Physiology, Age and Chronic Health Evaluation IV or Simplified Acute Physiology Score II), with area under the curve (AUC) from 0.67 to 0.71. When procalcitonin decreased by at least 80%, the negative predictive value for ICU/in-hospital mortality was 90%/90% in the derivation cohort, and 91%/79% in the validation cohort. When procalcitonin showed no decrease or increased, the respective positive predictive values were 48%/48% and 36%/52%.DISCUSSION:In septic patients, procalcitonin kinetics over the first 72 critical care hours provide prognostic information beyond that available from clinical risk scores. If these observations are confirmed, procalcitonin monitoring may assist physician decision-making regarding care intensification or early transfer from the ICU to the floor.

PURPOSE: Studies have shown decreased mortality for specific illnesses (CAD, COPD, sepsis, pneumonia, etc.) in patients on statin therapy. The purpose of this study was to determine if there was an all-cause mortality benefit for patients already receiving statin therapy prior to ICU admission.

PURPOSE: The signs of sepsis are relatively non specific making identification of infection in critically ill patients difficult. Since the risk of adverse effects from the delay in treatment is high, patients without infection are subjected to the potential toxic effects of antibiotics without individual benefit. Procalcitonin levels are reported to predict the presence or absence of infection.

PURPOSE: To date there has been little evidence to guide clinicians in their choice of ventilator settings for non-ARDS patients. Approximately 40 years ago, Mead et al, developed an equation that calculates an optimal respiratory rate (ORR) to minimize work of breathing. We attempt to verify this equation in a mechanically ventilated mixed medical/surgical ICU patient population.

Society of Critical Care Medicine; 28th Educational and Scientific Symposium; San Francisco, California, USA; January 23-27, 1999: Poster Presentations: Poster Hall

OBJECTIVE:To formulate recommendations for the development of early intensive care unit (ICU) discharge criteria for low-risk monitor patients.DESIGN:Literature review of published reports over the period 1966 to 1991 pertaining to ICU discharge criteria.PATIENTS:Studies identifying patients admitted to ICUs who could be characterized as low risk. Patient populations of interest included adults (> or = 18 years of age) with low-risk medical or mixed medical/surgical conditions; cardiac care unit and burn patients were excluded.MEASUREMENTS AND MAIN RESULTS:Of 1,492 articles identified as being pertinent to ICU discharge, only 2 studies (by the same group of investigators) were found that distinguished low-risk populations among medical and mixed medical/surgical ICU patients. The physiologic component of the Acute Physiology and Chronic Health Evaluation (APACHE) was used in both of these studies to ascertain the degree of risk. No studies were found that compared outcomes of low-risk patients remaining in the ICU after 24 h with those transferred to other hospital locations.CONCLUSIONS:Objective methods (such as APACHE III) should be used to identify low-risk patients at 24 h post-ICU admission. A multicenter study should be conducted to compare outcomes on patients identified as low risk who are randomly assigned to alternative hospital locations for treatment versus those assigned to continued ICU treatment until routine ICU discharge. Mortality and quality of life data should be used as outcome measures (prior to ICU admission and 6 months post-ICU discharge).

To formulate recommendations for the development of intensive care unit (ICU) admission policies.Literature review of published reports over the period 1966 to 1991 pertaining to admission criteria for intensive care or coronary care units (CCUs).Studies identifying patients least likely to benefit from ICU or CCU admission were analyzed. Patient populations of interest included adults (> or = 18 years of age) with medical conditions possibly requiring intensive care; trauma patients were excluded.Of 970 articles identified as being pertinent to intensive care, only two case-control studies used the direct method of measuring the effect of ICU intervention on mortality. No studies were found that compared outcomes of low-risk patients treated in a CCU vs those treated in alternative hospital locations, and none identified patients with a very high probability of a bad outcome.The use of decision-making models for ICU and CCU admissions must be tested in prospective, randomized clinical trials. Critical care units and ICUs should be studied separately. Existing studies of early discharge from CCUs need to be summarized and evaluated. The triaging of ICU patients to alternative hospital locations needs to be evaluated, as do existing predictive models for early triage decision-making.

Objective: To formulate recommendations for the development of intensive care unit (ICU) admission policies.Design: Literature review of published reports over the period 1966 to 1991 pertaining to admission criteria for intensive care or coronary care units (CCUs).Patients: Studies identifying patients least likely to benefit from ICU or CCU admission were analyzed. Patient populations of interest included adults (greater-than-or-equal-to 18 years of age) with medical conditions possibly requiring intensive care; trauma patients were excluded.Measurements and main results: Of 970 articles identified as being pertinent to intensive care, only two case-control studies used the direct method of measuring the effect of ICU intervention on mortality. No studies were found that compared outcomes of low-risk patients treated in a CCU vs those treated in alternative hospital locations, and none identified patients with a very high probability of a bad outcome.Conclusions: The use of decision-making models for ICU and CCU admissions must be tested in prospective, randomized clinical trials. Critical care units and ICUs should be studied separately. Existing studies of early discharge from CCUs need to be summarized and evaluated. The triaging of ICU patients to alternative hospital locations needs to be evaluated, as do existing predictive models for early triage decision-making.

Study objective: Our objective was to compare the efficacy of ultrahigh frequency ventilation (UHFV) (frequencies >3 Hz) with respect to oxygenation, airway pressures, and hemodynamic parameters in patients with adult respiratory distress syndrome (ARDS) who were not responding to conventional ventilation.Design: We used a prospective, multicenter, nonrandomized study design in which each patient served as his own control.Setting: Three university-affiliated, tertiary-care medical centers participated.Patients: Persons aged 16 to 79 years old with ARDS and unresponsive to conventional ventilation, as defined by a Food and Drug Administration (FDA) approved protocol, were included.Interventions: Ninety patients who were not responding to conventional ventilation were changed to UHFV using a microcomputer-controlled device.Measurements and results: The patient's blood gas, hemodynamic, and airway pressure variables were measured just before, and at 1 and 24 h after the switch to UHFV. We demonstrated clinically significant improvements in arterial oxygen tension (PaO2) and reductions in peak and mean inspiratory pressures.Conclusions: In a multicenter study, UHFV improved respiratory gas exchange and reduced airway pressure variables at both 1 h and 24 h after the onset of UHFV when compared with conventional ventilation just prior to the change and without hemodynamic deterioration, in patients with severe ARDS.

Gluck, Eric H.; Balk, B.; Barkoviak, J.; Casey, L; Nawas, Y; Silver, M.; Bone, R Author Information

OBJECTIVES:Clinical decision-making in the intensive care setting frequently requires the physician to obtain additional resource information. Physicians typically consult with colleagues, use personal medical books or files, or use library materials. Clinical librarians may also be used. This study evaluates the effectiveness of an ongoing clinical librarian program in the intensive care setting. DESIGN/SETTING:During a 3-month period, house officers in the medical and coronary ICUs in a major teaching hospital asked the clinical librarian 66 patient-care questions. Attached to the information selected by the clinical librarian was a questionnaire asking how the information was applied. MAIN RESULTS:There was an overall response rate of 65.1%. House officers indicated that the information: a) aided in diagnosis (37.2%), b) contributed to a better understanding of the therapy (51.2%), and c) resulted in improved patient management (30.2%). In some instances, the information was multibeneficial. The clinical librarian spent an average of 47 mins/question, and accumulated an average computer charge of $3.59. Personnel and on-line charges over the 3-month study period averaged $45/question. CONCLUSIONS:Clinical librarian programs may deliver patient-specific information in a timely, cost-effective manner. This information has an impact in the intensive care setting.