Incidence Of Septic Shock Research Articles

1060 The Use of Albumin in Cirrhotics: Data From a Tertiary Care Center

INTRODUCTION: Human albumin solution is an expensive colloid preparation commonly used in cirrhotics’ management. Approved indications of albumin administration in cirrhotics include large volume paracentesis (LVP), hepatorenal syndrome (HRS), and spontaneous bacterial peritonitis (SBP). Albumin use is not routinely recommended in inflammatory and hypovolemic states. The aim of this study is to identify albumin utilization patterns in a tertiary care center and to assess potential areas of improvement in albumin prescribing strategies. METHODS: We performed a retrospective chart review of 342 cirrhotic patients who received 25% albumin solution during their admission from January 2016 to January 2018. Baseline demographics, etiology of cirrhosis, and severity was noted. Indications for albumin administration were reviewed and other clinical variables were gathered. Patients with and without indications for albumin were compared using chi-square tests for categorical variables and two-sample t-tests for continuous variables. RESULTS: There were 342 cirrhotic patients included in this study. 187 (55%) were male, 227 (66%) were Caucasian and the mean age was 59 ± 11 years. The most common cirrhotic etiologies were Alcohol (n = 95, 28%), Nonalcoholic steatohepatitis (NASH) (n = 84, 25%) and Hepatitis C (n = 72, 21%). There were 187 (55%) patients who had at least one approved indication for albumin; out of those patients, 167 (48.4%) had HRS, 66 (19%) had SBP, and 77 (23%) underwent LVP. African Americans were more likely to receive albumin in the absence of an indication, as compared to Caucasians (P = 0.047). Patients who received albumin without an indication had a higher incidence of septic shock (34% vs 21%, P = 0.008); sepsis with acute kidney injury (AKI) (22% vs 12% P = 0.017); and history of HRS (35% vs 19% P = 0.0005) or SBP (37% vs 25% P = 0.018). No differences were detected between the two groups for age, gender, BMI, MELD, MELD NA, and etiology. CONCLUSION: There is a high rate of non-indicated albumin administration in cirrhotic patients. Apart from approved indications which have mortality benefit, shock, hypovolemia, or a history of SBP/HRS are influencing physicians to use albumin in cirrhotics. It is important to establish clinical protocols for judicial use of this expensive and limited resource.

Efficacy and safety of glucocorticoids in the treatment of severe community-acquired pneumonia: A meta-analysis.

Background:Recent clinical trials have shown that adjunctive glucocorticoids is associated with inhibiting excessive inflammatory response and modulating cytokines release offering several advantages over conventional therapy on relieving clinical symptoms, reducing mortality, and improving prognosis. However, given the severe complications triggered by glucocorticosteroid, whether similar benefits may be achieved by patients undergoing glucocorticosteroid intervention remains controversial. Our meta-analysis aimed to investigate the efficacy and safety of adjunctive glucocorticoids in the treatment of severe community acquired pneumonia.Methods:A search of PubMed, EMBASE, Cochrane Library, EBASO, Medline, Google Scholar, Science Dicet, CBM, and CNKI databases was performed to analyze all relevant randomized controlled trials (RCTs) of corticosteroids in patients with severe community acquired pneumonia (CAP) up to January 2018. All-cause mortality, C-reactive protein (CRP) level, incidence of septic shock, and requirement of mechanical ventilation were selected as efficacy outcomes. Major adverse events involving super infection, upper gastrointestinal bleeding, and hyperglycemia were safety outcomes. Meta-analysis was conducted with RevMan 5.3 software.Results:A total of 10 RCTs comprising 665 patients were included for analysis. Regarding efficacy outcomes, adjunctive corticosteroid seemed to be superior compared with conventional treatment in terms of all-cause mortality (relative risk [RR]: 0.47, 95% confidence interval [CI], 0.3–0.74, P = .001), CRP level on day 8 after administration (standard mean difference [SMD]: −0.8, 95% CI, −1.11 to −0.5, P < .001), incidence of septic shock (odds ratio [OR] 0.15, 95% CI, 0.07–0.29, P < .001) and requirement for mechanical ventilation (OR: 0.32, 95% CI, 0.20–0.52, P < .001). Meanwhile, we found that low dose (≤86 mg) (RR: 0.41, 95% CI, 0.21–0.82, P = .01) and prolonged (>5 days) (RR: 0.35, 95% CI, 0.15–0.81, P = .01) use of corticosteroids in dosage modus of a maintenance dose after a bolus (RR: 0.28, 95% CI, 0.14–0.55, P = .002) obtained better results in death through subgroup analysis. Regarding safety outcomes, no difference was observed between 2 groups in terms of upper gastrointestinal bleeding (OR: 0.83, 95% CI, 0.27–2.52, P = .74), hyperglycemia (OR: 1.3, 95% CI, 0.68–2.49, P = .42), and super infection (OR: 1.11, 95% CI, 0.14–9.13, P = .92).Conclusion:Adjunctive corticosteroid yielded favorable outcomes in the treatment of severe community acquired pneumonia (SCAP) as evidenced by decreased all-cause mortality, incidence of septic shock, and requirement for mechanical ventilation without increasing risk of adverse events. Low dose (≤86 mg/d), prolonged use (>5 days) of corticosteroid in dosage modus of a maintenance dose after a bolus can be recommended as preferred regimen to guard against SCAP.

PS1278 LACTATE CLEARANCE AS A SURVIVAL PREDICTOR IN PATIENTS WITH HEMATOLOGIC DISEASES WITH SEPTIC SHOCK

Background:Infectious complications are one of the main causes of mortality in patients with hematological diseases. Neutropenia is common adverse effect of antitumor treatment. These patients have high risks of development severe infectious complications (sepsis and septic shock). It is known, that poor lactate clearance is associated with increased mortality in the general population of patient's. We evaluated the prognostic value of lactate clearance in patients with neutropenia grade 4 (CTCAE v4.0)Aims:To evaluate the clinical outcomes of septic shock treatment in patients with myelotoxic agranulocytosis depending on the clearance of lactate.Methods:127 patients with septic shock were included (between July 2015 and December 2018). A prospective and retrospective diagnosis of septic shock was established on the basis of Sepsis 3 criteria: arterial hypotension in combination with an increase in lactate of more than 2.0 mmol / l. The highest incidence of septic shock (up to 35%) was registered in high‐risk group patients: during the induction remission of acute myeloid leukemia and recipients of allogeneic hematopoietic stem cells. 88 percent cases were associated with gram‐negative bacteria (Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, Serratia spp. and E. coli). The median duration of neutropenia before the development of septic shock was 15.1 (13.26–17.06) and 17.72 (16.33–19.12) days in patients who died and survived (p = 0.03, Log Rank). The levels of C‐reactive protein and procalcitonin did not differ.Results:The median lactate values at the time of diagnosis of septic shock in survivors and non‐survivors patients were 2.9 (3.071 ‐ 3.997) and 4.26 (3.665–4.867) mmol / l (p = 0.05, Log rank). 30 ‐ day overall survival (OS) in patients with a lactate level of more than 4.0 mmol/l was 34%, with a lactate level of 2.0–4.0 mmol/l was 56% (p &lt;0.001, Log Rank). All patients received serial lactate measurements were divided into lactate clearance &gt;10% (n = 26), &gt;20% (n = 46), and &lt;10% (n = 55) groups. Patients with a lactate clearance of more than 10% had higher 30‐day OS (68% vs. 29%, p &lt; 0.01, Log Rank). The rate of lactate elimination (more than 10% versus more than 20%) did not have an additional effect on OS. In multivariate analysis with an additional assessment of the venous‐to‐arterial carbon dioxide tension, absolute lactate values, the prognostic value was shown only for the lactate clearance.Summary/Conclusion:Achieving lactate clearance during the first 6 hours treatment septic shock more than 10% is associated with improved 30‐day OS in patients with severe neutropenia. The advantage of this marker is an early assessment of the effectiveness of therapy. In the future, on the basis of lactate kinetics, it is possible to create the strategy of ”Early Goal‐Directed Therapy“.image

Time to positivity of blood culture is a risk factor for clinical outcomes in Staphylococcus aureus bacteremia children: a retrospective study

BackgroundStaphylococcus aureus (S. aureus) is a common cause of bacteremia, which leads to significant morbidity and mortality. We investigated the relationship between time to positivity (TTP) and clinical outcomes in children with S.aureus bacteremia in the China.MethodsA retrospective study of Staphylococcus aureus bacteremia inpatient was performed in Children’s Hospital of Chongqing Medical University in China between 29 January 2014 and 29 August 2017. TTP and clinical parameters were determined and analyzed. The receiver operating characteristic (ROC) curves were plotted for optimal cut-off selection, multivariate logistic regression tests were performed to evaluate the association between TTP and clinical outcomes.ResultsOverall, 84 cases were enrolled. We stated that in-hospital mortality is significantly higher in the early TTP (≤17 h) than in the late TTP (> 17 h) group (57.14% vs 7.14%, P = 0.000). Septic shock occurred in 57.14% of patients with early TTP and in 18.57% of patients with late TTP (P = 0.002). Detailed multivariate and statistical analysis revealed that early TTP, need for vasoactive agent were independent risk factors of in-hospital mortality; early TTP, need for vasoactive agent and APACHE II score ≥ 15 were independent risk factors of septic shock incidence in S. aureus bacteremia children.ConclusionsOverall, TTP of ≤17 h appeared to correlate with the worse outcomes for S. aureus bacteremia children. These results have important implications in the assessments and management of pediatric S. aureus bacteremia in a clinical setting.Trial registrationRetrospectively registered.

The impact of abnormal BMI on surgical complications after pediatric colorectal surgery

Background/PurposeWhile childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after elective colorectal procedures. MethodsChildren ages 2–18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts. Results858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p=0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p=0.04). Incremental increase in BMI by 1.0kg/m2 was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS. ConclusionsIncreasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications. Level of EvidenceIII

Comparison of interleukin-6, interleukin-10, procalcitonin and C-reactive protein in identifying high-risk febrile illness in pediatric cancer patients: A prospective observational study

The aim of this study is to systematically compare the performance of C-reactive protein (CRP), procalcitonin (PCT) and serum cytokines in identifying pediatric cancer patients with high-risk infection. A prospective observational study was performed from January 2014 through December 2016. Consecutive pediatric cancer patients who experienced febrile illness during hospitalization were enrolled. The CRP, PCT, interleukin (IL)-6, IL-10, tumor necrosis factor (TNF)-α and interferon (IFN)-γ were determined within 6 h of fever onset. A total of 3118 episodes of febrile illness were included, with 13.1% episodes documented as bloodstream infection (BSI) and 3.5% diagnosed as septic shock. Patients with BSI presented much higher levels of PCT, IL-6, IL-10 and TNF-α than patients with other types of fever and have much higher incidence of septic shock (11.2% vs. 2.3%, P < 0.001). IL-6 and IL-10 showed better performance in identifying patients with gram-negative bacteremia (GNB) and septic shock than CRP and PCT, respectively. The area under the curve (AUCs) of receiver operating characteristic (ROC) curve for septic shock prediction were 0.65, 0.78, 0.89 and 0.87 for CRP, PCT, IL-6 and IL-10, respectively. Furthermore, elevation of IL-6 and IL-10 were strongly associated with the development of GNB and septic shock. Our results indicate that BSI, especially GNB, is a high-risk form of infection which results in high incidence of septic shock. IL-6 and IL-10 performance better than CRP and PCT in identifying patients with high-risk febrile illness.

Analysis on risk factors of methicillin-resistant staphylococcus aureus enterocolitis after gastrointestinal surgery

To investigate the risk factors of methicillin-resistant Staphylococcus aureus(MRSA) enterocolitis after gastrointestinal surgery. Clinical and pathological data of 17 cases with MRSA enteritis after gastrointestinal surgery from March 2015 to March 2017 at Department of General Surgery of Affiliated Drum Tower Hospital were retrospectively analyzed. (1) age of 18 to 80 years;(2) with history of gastrointestinal surgery; (3) diarrhea symptoms within 7 days after gastrointestinal surgery; (4) use of antibiotics before diarrhea; (5) fecal smear showing a large number of gram positive cocci; (6) fecal culture suggested the presence of MRSA; (7) application of antibiotic therapy against MRSA was effective. (1)clostridium difficile toxin positive; (2) toxic shock syndrome caused by food poisoning. According to gender, age, and inpatient ward, 1:2 pairing was performed, and 34 patients with non-MRSA enteritis from the hospitalized cases in the same ward were selected as the control group for retrospective case-control study. There were no significant differences in the gender, age, and constitution index between two groups (all P>0.05), indicating that the two groups were comparable. The χ² test was used to perform univariate analysis on 11 factors, including the nature of the primary disease, colorectal surgery, emergency surgery, use of multiple antibiotics, preoperative bowel preparation, perioperative hormone, intraoperative intraperitoneal chemotherapy, perioperative nasogastric tube, diabetes history, intensive care unit stay, and previous infectious disease hospitalization, and then multivariate logistic regression analysis was performed. MRSA enteritis occurred 3 to 5 days after surgery in all the 17 cases, and 4 cases developed septic shock rapidly. Univariate analysis showed that the operation site (colorectal surgery) (χ²=4.747, P=0.029) and use of two antibiotics before MRSA enteritis (χ²=3.959, P=0.047) were associated with MRSA enteritis after gastrointestinal surgery. Multivariate logistic regression analysis revealed that colorectal surgery was the only independent risk factor for MRSA enteritis after gastrointestinal surgery(OR=5.526, 95%CI: 1.350-22.602,P=0.017), while the use of two antibiotics was not (OR=0.204, 95%CI:0.051-0.819, P=0.025). MRSA enteritis has a rapid onset, and a high incidence of septic shock, which requires immediate attention. Colorectal surgery is an independent risk factor for MRSA enteritis.

The significance of the immediate drainage in urinary stones with infection

Objective To discuss drainage as soon as possible for the treatment of urinary stones with infection on the necessity and importance and security. Methods Between December 2015 and December 2016, clinical data of 45 patients with urinary stones with infection were analyzed, 22 patients were treated by percutaneous nephroscope and 23 cases of patients underwent ureteral stent implantation. All patients admitted to hospital with different degree of fever, different degrees of perirenal exudation in the affected sides of the patients and routine blood WBC, neutrophil percentage(NEU%), C-reactive protein(CRP), Serum procalcitonin(PCT), higher routine urine white blood cells increased. All patients were performed micro-colostomy drainage under local anesthesia by percutaneous nephroscope or ureteral stent implantation under cystoscope within 2-24 h after preoperative examination, and stage II endoscopic lithotripsy after controlling infection. Results All patients were successfully completed surgery. Preoperative temperature (38.60±0.87)℃, the third day after the body temperature of (36.80±0.21)℃ were found, compared with preoperative body temperature, there was significant difference(P<0.05). Preoperative routine blood leukocytes was (18.2±1.2)×109/L, three days after treatment was (5.6±1.4)×109/L, there was significant difference(P<0.05). There was significant difference in neutrophil percentage, CRP and PCT preoperation and third day after operation[(91.3±4.1)% vs.(65.2±6.2)%, (96.3±21.4)mg/L vs.(21.3±3.2) mg/L, (8.3±2.2) vs.(0.07±0.01), P<0.05]. No septic shock occurred in all patients. Conclusions Immediate drainage on urinary stones with infection is crucial, it should control infection as soon as possible to reduce the incidence of septic shock. Key words: Urinary Calculi; Cross Infection; Drainage

Sepsis incidence and mortality are underestimated in Australian intensive care unit administrative data

To compare estimates of the incidence and mortality of sepsis and septic shock among patients in Australian intensive care units (ICUs) according to clinical diagnoses or binational intensive care database (ANZICS CORE) methodology. Prospective inception cohort study (3-month inception period, 1 October - 31 December 2016, with 60-day follow-up); daily screening of all patients in a tertiary hospital 60-bed multidisciplinary ICU. Diagnoses of sepsis and septic shock according to clinical criteria and database criteria; in-hospital mortality (censored at 60 days). Of 864 patients admitted to the ICU, 146 (16.9%) were diagnosed with sepsis by clinical criteria and 98 (11%) according to the database definition (P < 0.001); the sensitivity of the database criteria for sepsis was 52%, the specificity 97%. Forty-nine patients (5.7%) were diagnosed with septic shock by clinical criteria and 83 patients (9.6%) with the database definition (P < 0.001); the sensitivity of the database criteria for septic shock was 65%, the specificity 94%. In-hospital mortality of patients diagnosed with sepsis was greater in the clinical diagnosis group (39/146, 27%) than in the database group (17/98, 17%; P = 0.12); for septic shock, mortality was significantly higher in the database group (18/49, 37%) than in the clinical diagnosis group (13/83, 16%; P = 0.006). When compared with the reference standard - prospective clinical diagnosis - ANZICS CORE database criteria significantly underestimate the incidence of sepsis and overestimate the incidence of septic shock, and also result in lower estimated hospital mortality rates for each condition.

National perioperative outcomes of flap coverage for pressure ulcers from 2005 to 2015 using American College of Surgeons National Surgical Quality Improvement Program.

BackgroundComplication rates after flap coverage for pressure ulcers have been high historically. These patients have multiple risk factors associated with poor wound healing and complications including marginal nutritional status, prolonged immobilization, and a high comorbidities index. This study utilizes the National Surgical Quality Improvement Program (NSQIP) to examine perioperative outcomes of flap coverage for pressure ulcers.MethodsData from the NSQIP database (2005–2015) for patient undergoing flap coverage for pressure ulcers was identified. Demographic, perioperative information, and complications were reviewed. One-way analysis of variance and Pearson chi-square were used to assess differences for continuous variables and nominal variables, respectively. Multivariate logistic regression was performed to identify independent risk factors for complications.ResultsThere were 755 cases identified: 365 (48.3%) sacral ulcers, 321 (42.5%) ischial ulcers, and 69 (9.1%) trochanteric ulcers. Most patients were older male, with some degree of dependency, neurosensory impairment, high functional comorbidities score, and American Society of Anesthesiologists class 3 or above. The sacral ulcer group had the highest incidence of septic shock and bleeding, while the trochanteric ulcer group had the highest incidence of superficial surgical site infection. There was an overall complication rate of 25% at 30-day follow-up. There was no statistical difference in overall complication among groups. Total operating time, diabetes, and non-elective case were independent risk factors for overall complications.ConclusionsDespite patients with poor baseline functional status, flap coverage for pressure ulcer patients is safe with acceptable postoperative complications. This type of treatment should be considered for properly selected patients.

Impact of predictive analytics based on continuous cardiorespiratory monitoring in a surgical and trauma intensive care unit.

Predictive analytics monitoring, the use of patient data to provide continuous risk estimation of deterioration, is a promising new application of big data analytical techniques to the care of individual patients. We tested the hypothesis that continuous display of novel electronic risk visualization of respiratory and cardiovascular events would impact intensive care unit (ICU) patient outcomes. In an adult tertiary care surgical trauma ICU, we displayed risk estimation visualizations on a large monitor, but in the medical ICU in the same institution we did not. The risk estimates were based solely on analysis of continuous cardiorespiratory monitoring. We examined 4275 individual patient records within a 7month time period preceding and following data display. We determined cases of septic shock, emergency intubation, hemorrhage, and death to compare rates per patient care pre-and post-implementation. Following implementation, the incidence of septic shock fell by half (p < 0.01 in a multivariate model that included age and APACHE) in the surgical trauma ICU, where the data were continuously on display, but by only 10% (p = NS) in the control Medical ICU. There were no significant changes in the other outcomes. Display of a predictive analytics monitor based on continuous cardiorespiratory monitoring was followed by a reduction in the rate of septic shock, even when controlling for age and APACHE score.

Characteristics of ventilator-associated pneumonia due to hypervirulent Klebsiella pneumoniae genotype in genetic background for the elderly in two tertiary hospitals in China

BackgroundAerobactin is a critical factor for the hypervirulent Klebsiella pneumoniae (hvKp), but data for the aerobactin-positive genotype of hvKp in elderly persons with ventilator-associated pneumonia (VAP) is limited. The purpose of this study is to understand the risk factors and characteristics of the hvKp genotype for elderly patients with VAP.MethodsA retrospective study of 73 elderly patients with Kp was conducted from November 2008 to December 2017 in two tertiary hospitals. The clinical and microbiological data, including inflammatory reaction, nutritional status, antimicrobial susceptibility testing, string test, extended-spectrum-β-lactamase (ESBL) production, virulence-associated gene (capsular serotype-specific gene and rmpA/A2,magA,aerobaction) and multilocus sequence typing, of the hvKp group defined as aerobactin positive were compared with those of classic Kp strains.ResultsOf 73 Kp isolates, 46.6% were hvKp. ST23 is highly prevalent in two hospitals but is not highly associated with hvKp in different hospitals. Additionally, ST23, ST37 and ST2906 are more likely to induce lethal VAP. Most hvKp strains are sensitive to common antibiotics, but the number of multidrug-resistant (MDR) hvKp is increasing. Importantly, 38.2% of hvKp isolates produced ESBLs. Hypermucoviscosity and virulence-associated genes (K1,magA and rmpA/A2) were highly clustered in the hvKp group (P < 0.001). Cancer (P = 0.004), digestive disease (P = 0.038) and surgery (P = 0.023) within 1 month are strongly associated with the VAP-hvKp group. The incidence of septic shock (P = 0.016) and Sequential Organ Failure Assessment (SOFA) scores (P < 0.001) are significantly higher in the hvKp group. Multivariate analysis indicated that cancer (odds ratio [OR] = 5.365) is an independent risk factor for VAP-hvKp infection.ConclusionsThe morbidity for elderly patients with VAP due to hvKp is high. MDR-HvKp is emerging, which is a great challenge for clinical practice.

Prognostic value of the biomarkers serum amyloid A and nitric oxide in patients with sepsis

ObjectiveSepsis is a major cause of mortality among critically ill patients in the intensive care unit (ICU). Alterations in serum amyloid A (SAA) and nitric oxide (NO) levels have been associated with mortality in critically ill patients. In the present study, we investigated the predictive value of SAA and/or NO compared to traditional predictive markers such as C-reactive protein (CRP) and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Methods100 adult patients with sepsis and 25 without sepsis were enrolled in a prospective, randomized study in our ICU. The APACHE II score was calculated, and their peripheral venous blood SAA, NO and CRP levels were evaluated on days 1, 3, and 7 after sepsis was diagnosed. The patients were sorted based on incidence of septic shock into septic shock (A) and non-septic shock (B) groups. Comparative analyses of altered levels of these indicators between the two groups were performed, and correlations between SAA, NO, and the more traditional APACHE II score were probed. Patients were sorted based on survival status into death (D) and survival (S) groups based on death endpoint within 28 days after admission. ResultsWe observed that the difference in APACHE II score, SAA and CRP levels were statistically significantly (p < 0.05) between groups A and B on days 1, 3 and 7 post-diagnosis, while inter-group NO level significantly differed (p < 0.05) on days 1 and 3 post-diagnosis, no apparent difference was observed on day 7 post-diagnosis. For groups D and S, SAA, CRP and NO levels significantly differed (p < 0.05) on days 3 and 7 post-diagnosis, with no apparent difference on day 1. APACHE II score was significantly different on day 7 (p < 0.05), however the difference on days 1 and 3 were non-significant. We also demonstrated a positive correlation between APACHE II scores, SAA levels on days 1, 3, and 7, as well as NO levels on days 1 and 3. In addition, for the D and S groups, SAA at all time points, NO on day 3 and CRP on day 7 positively correlated with increased death events. ConclusionThe dynamic monitoring of SAA and NO serum levels with APACHE II scores better reflect the severity of sepsis than traditional indicators like CRP and may serve as independent prognosticators of sepsis in critically ill patients, shorten time to diagnosis confirmation and improve therapeutic decision-making.

Values of Procalcitonin for Predicting Outcome of Infection in Acute Leukemia Patients with Bacterial Bloodstream Infection

To investigate the effects of serum procalcitonin(PCT) levels for predicting the outcome of bacteria bloodstream infection in acute leukemia patients. Clinical data from 236 patients with acute leukemia accompanied by bacterial bloodstream infection during July 2014 to November 2017 were retrospectively analyzed, 236 patients were divided into 5 groups (<0.05 ng/ml, 0.05- <0.5 ng/ml, 0.5- <2.0 ng/ml, 2.0- <10.0 ng/ml and >10.0 ng/ml) according to PCT concentrations. The median age of patients was 40(13-73) years old. The male 123 cases(52.1%) and female 113 cases(47.9%) in 236 patients. The incidence of infection-related dealth in 5 groups was 0%, 1.4%, 13.8%, 25.0% and 33.3%, respectively; the incidence of septic shock and other serious complications in 5 groups was 0%, 2.1%, 13.8%, 25.0%, 33.3% and 6.4%, 7.0%, 24.1%, 41.7%, 50.0%, respectively, showing the concentration dependent manner and statistically significant difference (u=2127, P=0.000; u=2234, P=0.000; u=4102, P=0.000). Further analysis showed that with the increase of PCT concentration, the cumulative incidence of septic shock, infection-related death and other serious complications was gradually increased with statistically significance (HR=2.887, P=0.000, 95%CI:1.960-4.260; HR=3.158, P=0.000, 95%CI: 2.100-4.740; HR=2.158, P=0.000, 95%CI:1.550-3.000) respectively. Increased procalcitonin level is an independent risk factor for septic shock and infection-related death (HR=2.517, P=0.000, 95%CI: 1.520-4.168; HR=2.881, P=0.000, 95%CI: 1.692-4.904)respectively. Serum procalcitonin level positively correlates with the incidence of serious bacteria bloodstream infection complications in the patients with acute leukemia. Increased procalcitonin level is an independent risk factor for septic shock and infection-related death, indicating that procalcitonin may be an important prognostic factor for infection outcome in acute leukemia patients with bacteremia.

Outcomes of Vancomycin plus a β-Lactam versus Vancomycin Only for Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia.

The objective of this retrospective study was to compare the rates of treatment failure, which was a composite of clinical and microbiologic failure, of patients receiving vancomycin and a β-lactam to those receiving vancomycin only for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Patients 16 to 89 years of age with MRSA bacteremia admitted to a university-affiliated hospital from 1 January 2014 to 31 December 2016 were screened for study inclusion. Patients were eligible if they received >48 h of vancomycin and a β-lactam (combination group) or vancomycin only (standard group) within 48 h after bacteremia onset. A total of 182 patients were screened: 47 were included in the standard group, and 63 were in the combination group. The combination group had a higher baseline body mass index (29.2 ± 8.0 kg/m2 versus 25.8 ± 7.1 kg/m2, P = 0.022), acute physiologic assessment and chronic health evaluation-II (APACHE-II) score (median [interquartile range], 21 [15 to 26] versus 16 [10 to 22], P = 0.003), and incidence of septic shock (31.8% versus 14.9%, P = 0.047). Using multivariate analysis, combination therapy was the only variable that decreased treatment failures (odds ratio [95% confidence interval], 0.337 [0.142 to 0.997]), while vancomycin MIC > 1 mg/liter and male gender increased treatment failures (4.018 [1.297 to 12.444] and 2.971 [1.040 to 8.488], respectively). The 30-day mortality rates (15.0% versus 14.9%, P = 1.000) and the incidence of adverse drug events (19.1% versus 23.4%, P = 0.816) were not statistically different between the combination and standard groups. Combination therapy of vancomycin with a β-lactam led to significantly fewer treatment failures than vancomycin monotherapy for MRSA bacteremia.

Rhinovirus is associated with severe adult community-acquired pneumonia in China.

Human rhinovirus (HRV) is one of the most common viral etiologies detected in community-acquired pneumonia (CAP) adult cases. However, few is known about the characteristics of HRV-associated CAP. To describe the clinical features of HRV-associated CAP in immunocompetent adults admitted to multiple medical centers in mainland China over a 2-year period. A total of 383 patients admitted to hospitals for CAP were enrolled from 46 medical centers in mainland China between January 2013 and December 2014. Multiplex real-time polymerase chain reaction (RT-PCR) assays for viral detection and DNA-based quantitative loop-mediated isothermal amplification (qLAMP) assays for bacterial detection were implemented to all lower respiratory tract specimens obtained from the patients. Twenty-eight cases (28/383, 7.3%) revealed HRV-positive PCR results. Patients with bronchoalveolar lavage (BAL) HRV-positive PCR results (n=20) were further enrolled and divided into two groups depending on the status of bacterial co-infection (viral group, n=12; viral-Bacterial group, n=8). Demographic, clinical and microbiological data were reviewed and compared in detail. Cases with HRV-infection were remarkably correlated with respiratory failure (14/20) and most of them (13/14) received mechanical ventilation. Fever (17/20), productive cough (15/20) and dyspnea (6/20) were common symptoms while flu-like symptoms were rarely observed in the cohort. Streptococcus pneumoniae (3/8), Klebsiella pneumoniae (3/8) and Mycoplasma pneumoniae (2/8) were most frequently identified bacterium in the viral-bacterial group. Compared with the viral group, higher incidence of septic shock (3/8 vs. 1/12, P=0.255), longer ICU length of stay (LOS) (10.0 vs. 6.5 days, P=0.686), longer hospital LOS (18.5 vs. 13.0 days, P=0.208) and higher 28-day mortality (2/8 vs. 2/12, P=1) were observed in the Viral-Bacterial group, although without statistically significant difference. HRV is a common etiology in CAP among China adults, especially in severe CAP. Clinicians should be vigilant considering of the poor outcome. Highly qualified multiplex PCR techniques with invasive sampling are needed to increase the detection rate.

Abstract: Outcomes of Sternal Rigid Plate Fixation from 2005–2015 Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)

INTRODUCTION: Sternotomy is the most common osteotomy and has been traditionally closed with wire cerclage. A newer alternative, rigid plate fixation (RPF), has been used in high-risk cases to prevent mediastinitis, sternal nonunion, and malunion with promising results. We used data from the National Surgical Quality Improvement Program to examine 30 day postoperative complications. METHODS: All patient undergoing sternal RPF from 2005–2015 were identified. Demographic, perioperative information, and complication rates were reviewed. Primary RPF cases were classified as treatment group, those done concurrently with other procedures as prophylactic group. Complication rates were compared between two groups using chi-square test. A logistic regression analysis was performed to identify risk factors for postoperative complications. RESULTS: There were 333 cases of RPF identified using the study period, the majority of which were after 2008. Most cases were done as primary or treatment procedure n=202 (62%). RPF was most frequently performed in conjunction with endocrine procedure, myocutaneous flap, and cardiac bypass. Complication rates included dehiscence n=6 (1.8%), infection n=50 (15%), bleeding n=79 (23.7%), on ventilation >48 hours n=61 (18.3%), and no graft failure. Risk factors for infection were non-elective procedure (OR 2.5, p=0.02); for bleeding were open wound at the time of surgery (OR 2.2, p=0.028), ASA class 3 and 4 (3.4, p=0.035), operating time (OR=1.008, p<0.001); for on ventilation greater than 48 hours were open wound (OR 3.4, p=0.002), non-elective procedures (OR 10, p<0.001), and history of dyspnea (OR 2.8, p=0.005). There were no differences in postoperative complications between treatment group and prophylactic group except for incidence of septic shock and overall complications; septic shock was higher in treatment group (p=0.04) while overall complication was higher in prophylactic group (p=0.037) CONCLUSION: The use of sternal RPF is increasing and moreover, it is also used among patients with open wound. Postoperative complication profile associated with RPF is acceptable.

Estimating Ten-Year Trends in Septic Shock Incidence and Mortality in United States Academic Medical Centers Using Clinical Data: Kadri SS, Rhee C, Strich JR, et al. Chest 2017;151(2):278-285

Estimating Ten-Year Trends in Septic Shock Incidence and Mortality in United States Academic Medical Centers Using Clinical Data: Kadri SS, Rhee C, Strich JR, et al. Chest 2017;151(2):278-285

Fluoroquinolone prophylaxis in autologous hematopoietic stem cell transplant recipients.

Although fluoroquinolone prophylaxis is frequently utilized in autologous hematopoietic stem cell transplant (AHSCT) patients, its impact on morbidity and mortality is uncertain. This study investigates the role of quinolone prophylaxis after AHSCT in recent years. We conducted a retrospective review of 291 consecutive adult patients who underwent AHSCT for malignant disorders, between June 2013 and January 2015. Outcomes were compared between patients who received norfloxacin prophylaxis and those who did not. The endpoints were mortality during prophylaxis and at 100days after transplant, frequency of ICU admissions, and incidence and type of bacteremia. Of 291 patients, 252 patients received norfloxacin prophylaxis and 39 patients did not. The mortality during prophylaxis and at 100days as well as the median number of days of hospitalization following AHSCT did not differ between the two groups. No differences were noted in the frequency of ICU admission, incidence of septic shock, and duration of ICU stay. Patients who did not receive prophylaxis had a significantly higher rate of neutropenic fever (97%) than patients who received prophylaxis (77%) (p=0.005). The patients with prophylaxis demonstrated a significantly higher rate of gram-positive bacteremia as compared to those without prophylaxis (p=0.002). Frequency of Clostridium difficile infection was similar during and post-prophylaxis. More antibiotic use was noted among patients without prophylaxis [97%; median 9 (range, 5-24) days] compared to patients with prophylaxis [79%; median 7 (range, 3-36) days, p=0.04]. Although fluoroquinolone prophylaxis reduced the incidence of neutropenic fever and antibiotic use in AHSCT, it did not alter mortality or morbidity.

Antibiotic therapy prior to hospital admission is associated with reduced septic shock and need for mechanical ventilation in patients with community-acquired pneumonia

A subgroup of patients admitted to the hospital with a diagnosis of community-acquired pneumonia (CAP) have received antibiotic therapy prior to admission for the current episode of pneumonia. The objective of this study was to assess the clinical course of patients receiving antibiotics prior to admission, compared to patients not previously treated. An observational cohort of 3364 CAP patients consecutively admitted to our hospital, and prospectively included, were studied. We collected clinical, microbiological and biochemical parameters, focusing on recent antibiotics received prior to admission. 610 (18%) patients received antibiotics prior to hospital admission for the current CAP episode. Patients with previous antibiotic use developed septic shock less frequently (4% vs. 7%, p=0.007) and required invasive ventilation less often (3% vs. 6%, p=0.002). After adjustment by different covariate factors and propensity score, antibiotic therapy was still independently associated with a lower incidence of septic shock at admission (OR 0.54 [95% CI 0.31-0.95], p=0.03) and less need for invasive ventilation (OR 0.38 [95% CI 0.16-0.91], p=0.03). In this cohort, recent use of antibiotics before hospital admission in CAP seems to be associated with a lower incidence of septic shock on admission and a lower need for invasive ventilation.