Multicenter Retrospective Cohort Analysis Research Articles

Bacteremia Prediction Model for Community-acquired Pneumonia: External Validation in a Multicenter Retrospective Cohort.

Many studies have described constructing a prediction model for bacteremia in community-acquired pneumonia (CAP), but these studies were not validated in external heterogeneous groups. The objective of this study was to test the generalizability of a previous bacteremia prediction model for CAP by external validation. This multicenter retrospective cohort analysis was performed in eight tertiary urban hospital emergency departments (EDs). We reviewed adult patients who were hospitalized after presentation to the ED with CAP. We categorized the enrolled patients into three groups according to the bacteremia prediction model score and calculated the number of patients with or without a blood culture-positive result. We performed a multivariable analysis to identify significant predictors for bacteremia. Among the enrolled 2,001 patients, 1,592 (79.6%), 371 (18.5%), and 38 (1.9%) were stratified to a low-, moderate-, and high-risk group, respectively, and this proportion was similar with previous study. Each group had a bacteremia-positive rate as follows: 1.2% for the low-risk group, 7.2% for the moderate-risk group, and 31.5% for the high-risk group. The area under the receiver operating characteristic curve for the bacteremia model in the external validation cohort was 0.81, and there was no significant difference with that of the previous internal validation cohort (p=0.246). Assuming that blood cultures were not performed in the low-risk patients, the sensitivity and specificity of this model were 0.68 and 0.81, respectively. Additionally, the positive predictive value and negative predictive value were 9.54 and 98.87%, respectively. A platelet count less than 130×109 cells/L, albumin less than 3.3 mg/dL, and C-reactive protein greater than 17 mg/dL were identified as significant predictors with a sensitivity and specificity of 0.70 and 0.83, respectively. The bacteremia prediction model was well validated in the general population and could help physicians make the decision to reduce the number of blood cultures in patients with CAP.

P5466Sex difference in the response to cardiac resynchronization therapy in patients with cardiac sarcoidosis: from Japanese multi-center retrospective cohort analysis

P5466Sex difference in the response to cardiac resynchronization therapy in patients with cardiac sarcoidosis: from Japanese multi-center retrospective cohort analysis

Short Length of Stay After Elective Transfemoral Transcatheter Aortic Valve Replacement is Not Associated With Increased Early or Late Readmission Risk.

BackgroundElderly patients undergoing transcatheter aortic valve replacement (TAVR) are at risk of hospital readmission postprocedure. It is not known whether the index hospital length of stay and, specifically, early discharge post‐TAVR is associated with an increased risk of readmission. We hypothesized a nonlinear relationship whereby both short and long lengths of stay were associated with increased readmission risk.Methods and ResultsWe performed a retrospective multicenter cohort analysis of patients undergoing elective transfemoral TAVR and surviving to discharge between January 2007 and March 2014. The exposure variable was hospital length of stay measured from the procedure date to the date of discharge and modeled as a continuous variable in a multivariable cause‐specific Cox regression. Main outcome measures were 30‐day and 1‐year all‐cause readmissions. The study population consisted of 709 patients with a median length of stay of 6 days (interquartile range, 4–8). At 30‐days and 1‐year, 13.5% and 44.0% of patients were readmitted, respectively. Although post‐TAVR length of stay was not associated with 30‐day all‐cause readmissions (P=0.925), there existed a significant association with 1‐year readmission (P=0.010) after adjustment for baseline clinical variables. The association between post‐TAVR length of stay and 1‐year readmission was linear (P=0.549 for nonlinearity) with no evidence supporting an increased readmission risk for shorter length of stays.ConclusionsAmong elderly survivors of elective transfemoral TAVR, a short postprocedural length of stay was not associated with an increased risk readmission within 30 days or 1 year. However, the risk of 1‐year readmission increased with longer post‐TAVR lengths of stay.

A hybrid strategy with bioresorbable vascular scaffolds and drug eluting stents for treating complex coronary lesions.

Due to the inherent limitations of current generation BVSs, complex coronary artery disease often contains BVS unsuitable segments. Our aim was to assess the feasibility of a hybrid approach using bioresorbable vascular scaffolds (BVSs) and drug-eluting stents (DESs) for the treatment of complex coronary artery lesions not suitable for a scaffolding only approach. A retrospective multicenter cohort analysis was performed on patients with complex de novo or in-stent restenosis lesions treated with a hybrid BVS (Absorb BVS, Abbott Vascular, Santa Clara, CA) and DES strategy. The primary endpoint was target lesion failure (TLF) defined as a composite of cardiac death, target-vessel myocardial infarction (MI) and target lesion revascularization (TLR). A total of 98 patients (105 lesions) were treated with the hybrid strategy. Isolated long lesions in which either proximal or distal reference vessel diameters were not suitable for BVS were an indication in 36.2% (n=38) of cases. In contrast, 28% (n=29) of lesions treated with the hybrid strategy were bifurcations in which the side branch was predominantly treated with DES (n=28). DES bailout after BVS implantation was an indication in 21.9% (n=23 lesions). The rates of type B2/C and long lesions (>28mm) were 95.2% and 74.3% respectively. The mean total BVS and DES lengths implanted were 37.5±24.1mm and 25.0±14.7mm respectively. The rate of TLF in the overall cohort of patients (median follow-up 405days [interquartile range 189-658]) was 11.4% at 1-year. This was primarily driven by TLR (9.5%), with rates of cardiac death and target vessel MI of 2.1% and 1.4% respectively. No cases of definite or probable BVS/DES thrombosis occurred. In conclusion, the use of a hybrid BVS/DES strategy was feasible and associated with acceptable outcomes at 1-year, considering the length and complexity of lesions treated. Further, larger studies with longer follow-up are needed to confirm our findings.

Abstract 179: Short Length of Stay After Elective Transfemoral Transcatheter Aortic Valve Replacement is Not Associated With Increased Early or Late Readmission Risk

Background: Elderly patients undergoing transcatheter aortic valve replacement (TAVR) are at risk of hospital readmission post-procedure. It is not known if the index hospital length of stay, and specifically early discharge after TAVR is associated with an increased risk of readmission. We hypothesized a non-linear relationship whereby both short and long lengths of stay were associated with increased readmission risk. Methods: We performed a retrospective multi-center cohort analysis of patients undergoing elective transfemoral TAVR and surviving to discharge between Jan 2007 and March 2014. The exposure variable was hospital length of stay measured from the procedure date to the date of discharge and modeled as a continuous variable in a multivariable cause-specific Cox regression. Main outcome measures were 30-day and 1-year all-cause readmissions. Results: The study population consisted of 709 patients with a median length of stay of 6 days (interquartile range: 4-8 days). At 30-days and 1-year, 13.5% (n=96) and 44.0% (n=312) of patients were readmitted, respectively. Although length of stay was not associated with 30-day all-cause readmissions (p=0.92), there existed a significant association with 1-year readmission (p=0.01) after adjustment for baseline clinical variables. The association between length of stay and 1-year readmission was linear (p=0.55 for non-linearity) with no evidence supporting an increased readmission risk for shorter length of stays. Conclusions: Among elderly survivors of elective transfemoral TAVR, a short length of stay was not associated with an increased readmission risk within 30 days or 1 year. The 1-year readmission risk increased with longer length of stay.

CRT-100.78 A Hybrid Strategy With Bioresorbable Vascular Scaffolds And Drug Eluting Stents For Treating Complex Coronary Lesions

Our aim was to assess the feasibility of a hybrid approach using bioresorbable vascular scaffolds (BVS) and drug-eluting stents (DES) for the treatment of complex coronary artery lesions not suitable for a scaffolding only approach. A retrospective multicenter cohort analysis was performed on

Global Trends in Extracorporeal Membranous Oxygenation Use and Survival of Patients With Influenza-Associated Illness.

To determine the overall use of extracorporeal membranous oxygenation for influenza-associated illness and describe risk factors associated with mortality in these patients. Retrospective multicenter cohort analysis. The international Extracorporeal Life Support Organization database was queried for patients with influenza-associated illness on extracorporeal membranous oxygenation from 1992 to 2014. In total, 1,654 patients with influenza-associated illness on extracorporeal membranous oxygenation. None. Demographic and clinical data collected included age, type of support, duration of support, type of microbial codetection, complications, and survival status at discharge. The primary outcome of interest was survival to hospital discharge. From 1992 to 2014, 1,688 (3%) of the 61,336 extracorporeal membranous oxygenation runs were due to influenza-associated illness reflecting 1,654 unique patients: 30 (2%) were neonates, 521 (31%) were pediatric patients, and 1,103 (67%) were adults. Extracorporeal membranous oxygenation use for influenza-associated illness increased from 1992 to 2014, with a marked increase in use after the 2009 H1N1 pandemic. Survival to hospital discharge of patients with influenza-associated illness on extracorporeal membranous oxygenation was 63% and was not affected by bacterial codetection. However, when patients with Staphylococcus aureus codetection were compared with those with another bacterial codetection, their survival to hospital discharge was significantly lower (52% vs 67%; p < 0.01). In a logistic regression model, the effect of S. aureus on in-hospital mortality varied by age group, with younger patients with S. aureus having increased in-hospital mortality. Extracorporeal membranous oxygenation use for individuals with influenza increased over time, particularly after the 2009 H1N1 pandemic, most notably among older adults. Survival to hospital discharge for patients with influenza on extracorporeal membranous oxygenation was slightly higher than survival to hospital discharge for respiratory illness due to any cause. Bacterial codetection was common among patients with influenza on extracorporeal membranous oxygenation and was associated with increased days on extracorporeal membranous oxygenation but not increased mortality. Only S. aureus codetection in children was associated with increased in-hospital mortality.

Survival impact of quality of lymphadenectomy in intermediate- or high-risk group of endometrioid type endometrial cancer: A multicenter retrospective cohort analysis

Survival impact of quality of lymphadenectomy in intermediate- or high-risk group of endometrioid type endometrial cancer: A multicenter retrospective cohort analysis

East Mediterranean region sickle cell disease mortality trial: retrospective multicenter cohort analysis of 735 patients.

Sickle cell disease (SCD), one of the most common genetic disorders worldwide, is characterized by hemolytic anemia and tissue damage from the rigid red blood cells. Although hydroxyurea and transfusion therapy are administered to treat the accompanying tissue injury, whether either one prolongs the lifespan of patients with SCD is unknown. SCD-related mortality data are available, but there are few studies on mortality-related factors based on evaluations of surviving patients. In addition, ethnic variability in patient registries has complicated detailed analyses. The aim of this study was to investigate mortality and mortality-related factors among an ethnically homogeneous population of patients with SCD. The 735 patients (102 children and 633 adults) included in this retrospective cohort study were of Eti-Turk origin and selected from 1367 patients seen at 5 regional hospitals. A central population management system was used to control for records of patient mortality. Data reliability was checked by a data supervision group. Mortality-related factors and predictors were identified in univariate and multivariate analyses using a Cox regression model with stepwise forward selection. The study group included patients with homozygous hemoglobin S (Hgb S) disease (67%), Hb S-β(0) thalassemia (17%), Hgb S-β(+) thalassemia (15%), and Hb S-α thalassemia (1%). They were followed for a median of 66 ± 44 (3-148) months. Overall mortality at 5years was 6.1%. Of the 45 patients who died, 44 (6%) were adults and 1 (0.1%) was a child. The mean age at death was 34.1 ± 10 (18-54) years for males, 40.1 ± 15 (17-64) years for females, and 36.6 ± 13 (17-64) years overall. Hydroxyurea was found to have a notable positive effect on mortality (p = 0.009). Mortality was also significantly related to hypertension and renal damage in a univariate analysis (p = 0.015 and p = 0.000, respectively). Acute chest syndrome, splenic sequestration, and prolonged painful-crisis-related multiorgan failure were the most common causes of mortality. In a multivariate analysis of laboratory values, only an elevated white blood cell count was related to mortality (p = 0.009). These data show that despite recent progress in the treatment of SCD, disease-related factors continue to result in mortality in young adult patients. Our results highlight the importance of evaluating curative treatment options for patients who have an appropriate stem cell donor in addition to improving patient care and patient education.

Survival impact based on the thoroughness of pelvic lymphadenectomy in intermediate- or high-risk groups of endometrioid-type endometrial cancer: A multi-center retrospective cohort analysis

ObjectiveTo investigate whether the number of lymph nodes obtained during lymphadenectomy affects the survival of patients with intermediate- or high-risk endometrioid-type endometrial cancer. MethodsA total of 476 patients who were diagnosed with FIGO stage IB to IIIC2 endometrioid adenocarcinoma through surgical staging, including hysterectomy and pelvic lymphadenectomy with or without paraaortic lymphadenectomy between 2000 and 2013 were retrospectively enrolled from four tertiary centers in Korea. Sentinel lymph node mapping was not performed in any patient. The number of nodes obtained and positive nodes, was extracted from pathologic report. ResultsParaaortic lymphadenectomy was performed in 298 (62.6%) patients and 164 (34.4%) had stage IIIC disease. The isolated paraaortic lymph node metastasis rate decreased as the number of pelvic nodes obtained increased. In the total study population, an increase of negative pelvic and paraaortic nodes was associated with improved recurrence-free survival (RFS) and overall survival (OS) independent of other prognostic factors. In the node-positive group, an increase of negative pelvic nodes was an independent prognostic factor for RFS [hazard ratio (HR), 0.946; 95% confidence interval (CI), 0.906–0.988] and OS [HR, 0.907; 95% CI, 0.849–0.968]. In stage IIIC2 patients, 14 or less negative pelvic nodes was associated with poor RFS and OS. ConclusionsRemoving as many pelvic nodes as possible is required to warrant accurate nodal staging and improve survival in patients with intermediate- or high-risk endometrial cancer. Sentinel lymph node mapping can be a resolution to minimize lymph node dissection without compromising staging accuracy.

Patient Characteristics Associated with Differences in Admission Frequency for Diabetic Ketoacidosis in United States Children's Hospitals

To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children's hospitals. Multicenter retrospective cohort analysis of 12,449 children 2-18 years of age with a diagnosis of DKA in 42 US children's hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals. In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥ 12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively. Across children's hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.

Abstract W P11: Factors Affecting Vascular Neurologists' Decisions to Pursue Endovascular Intervention of Acute Ischemic Stroke Patients

Background: Intra-arterial therapy (IAT) is an approach to promote recanalization in acute ischemic stroke (AIS) patients. While IAT continues to go through further evaluation in multiple phase III trials using new devices and focusing on time improvement, patients with LAO continue to be treated with IAT. Multiple clinical, radiographic and time factors go into vascular neurologists’ decisions whether to pursue IAT or not. We aimed to evaluate factors affecting determination of IAT for stroke amongst patients transferred to tertiary centers. Methods: A US multicenter retrospective cohort analysis was conducted on 313 consecutive transferred patients who met vessel criteria from 01/08-4/14. Collateral were measured by the collateral score (CS). ASPECTS decay was defined as a change from good (8-10) to poor (0-7) scores between center CT scans. IAT patients were compared with no IAT patients with regard to factors predictive of IAT. Results: Table 1 shows baseline characteristics of the two groups. Age was not a predictor of IAT. NIHSS was associated with IAT, but was not a predictor of IAT. For each escalating point on CS, the odds of IAT increased more than 4 times (OR 4.27, 95% CI 2.86-7.87, p&lt;0.0001). For each declining point on ASPECTS, the odds of IAT decreased by 22% (OR 0.78, 95% CI 0.72-0.85, p&lt;0.0001). ASPECTS decay was associated with an 83% reduction in the odds of IAT (OR 0.17, 95% CI 0.05-0.52, p&lt;0.0001). For every 30 minutes of time between centers, the odds of ASPECTS decay increased by 13% (OR 1.13, 95% CI 1.11-1.17 p=0.0004) and IAT chances reduced by 9% (OR 0.91, 95% CI 0.84-1.00, p=0.05). Conclusions: Infarction evolution measured by ASPECTS decay, collaterals status and time from stroke ictus are all major determinants of the vascular neurologist decision whether to proceed with IAT. Our findings further support the time-sensitivity of the process for transferring candidates for IAT.

Paper #16: A Multicenter Retrospective Cohort Analysis of Infection Characteristics and Rates With VEPTR Surgery: A Retrospective Cohort Analysis

Paper #16: A Multicenter Retrospective Cohort Analysis of Infection Characteristics and Rates With VEPTR Surgery: A Retrospective Cohort Analysis

Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality

Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality. We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome. From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001). GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines. Therapeutic/care management, level III.

A multicenter retrospective cohort analysis of therapeutic hypothermia in acute liver failure

Cerebral edema is a severe and life-threatening complication in acute liver failure (ALF). Concerns exist that therapeutic hypothermia (TH) may increase the risk of infection, worsen coagulopathy and inhibit hepatic regeneration. We therefore reviewed the experience in use of TH in participating US Acute Liver Failure Study Group (ALFSG) centers. The aims were to determine utilization of TH in ALF patients at high risk for cerebral edema (grade III or IV hepatic encephalopathy (HE)) and to determine its effect on survival and complication rates.

Adjunctive aerosolized colistin for multi-drug resistant gram-negative pneumonia in the critically ill: a retrospective study.

BackgroundThe incidence of multi-drug resistant (MDR) gram-negative (GN) organisms including Pseudomonas and Acinetobacter spp has increased in the last decade, prompting re-evaluation of colistin for the management of these infections. Aerosolized colistin as an adjunct to intravenous therapy is a current option for the management of MDR-GN pneumonia, although data supporting this practice is limited. This study evaluates the efficacy of adjunctive aerosolized colistin in combination with intravenous colistin in critically ill patients with MDR-GN pneumonia.MethodsA retrospective multi-center cohort analysis comparing critically ill patients with MDR-GN pneumonia who received intravenous colistin (IV) alone or in combination with adjunctive aerosolized colistin (IV/AER) with a primary endpoint of clinical cure at the end of colistin therapy. Secondary endpoints included microbiologic cure, duration of mechanical ventilation, length of stay, and hospital mortality. A post-hoc subgroup analysis was performed for patients with high quality cultures used for diagnosis of MDR-GN pneumonia. Dichotomous data were compared using Fisher’s exact test while the student’s t-test or Mann–Whitney U test were used for continuous variables.ResultsNinety-five patients met criteria for evaluation with 51 patients receiving IV and 44 receiving IV/AER. Baseline characteristics were similar between the two groups. Twenty patients (39.2%) receiving IV and 24 (54.5%) receiving IV/AER achieved clinical cure (p = 0.135). There was no difference in microbiologic cure rates between the IV and IV/AER colistin groups (40.7vs. 44.4%, p = 0.805). The IV group demonstrated a trend towards higher pneumonia attributable mortality (70.4 vs. 40%, p = 0.055). In the subgroup analysis of patients with high quality respiratory cultures, there was a significantly lower clinical cure rate for those in the IV group as compared to the IV/AER group (31.3 vs. 57.1%, p = 0.033).ConclusionsAddition of aerosolized colistin to IV colistin may improve clinical cure and mortality for patients with MDR-GN pneumonia. Larger, prospective trials are warranted to confirm the benefit of adjunctive aerosolized colistin in critically ill patients with MDR-GN pneumonia.

P3.009 Prevalence of Chlamydia Trachomatis and Neisseria Gonorrhoea Infection in Pregnant Women Enrolled in a Large Multicenter Clinical Trial

BackgroundPregnant women infected with sexually transmitted diseases are at higher risk for miscarriage, pre-term delivery, low birth weight, and morbidity in the neonate associated with transmission of pathogenic agents. Treatment...

Early cardiac outcomes following contemporary treatment for childhood acute myeloid leukemia: A north American perspective

Anthracycline agents are used for treatment of acute myeloid leukemia (AML) but may cause late-onset cardiomyopathy. Current frontline therapy for AML in North America, as reflected in the approach of the Children's Oncology Group (COG) and other pediatric consortia, is adapted from the anthracyline-intensive Medical Research Council (MRC) regimen. The purpose of this study was to describe early post-treatment cardiac function as a potential indicator of acute and long-term risk associated with this approach. A multi-center retrospective cohort analysis was conducted of AML survivors diagnosed from 2004 to 2009 and treated with MRC-based regimens. Change in left ventricular shortening fraction (LVSF) on echocardiogram was determined from baseline to latest post-treatment/pre-relapse value; associations with potential predictors were examined. This cohort of pediatric survivors (n = 52) was assessed at a median interval of 13 months from end of treatment. Mean cumulative anthracycline dose was 339 ± 14 mg/m(2) . Mean baseline and post-treatment LVSF were 39.3 ± 0.8% and 35.4 ± 0.9%, respectively; mean percent change for individuals was -8.4 ± 2.8% (P < 0.001). Cardiac-directed medications were initiated in four patients (7.7%). Decline in LVSF was significantly associated with cumulative anthracycline dose, increasing BMI and Hispanic ethnicity. Early, significant decline in LVSF was observed following treatment with these MRC-based regimens. Elevated BMI and Hispanic ethnicity were identified as new independent risk factors. Children and adolescents so treated are at substantial risk for late-onset cardiomyopathy, require monitoring with annual echocardiogram per current COG survivorship guidelines, and are good candidates for appropriate cardioprotection strategies.

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Introduction: Hospitalized patients with Clostridium difficile infection (CDI) have high rates of morbidity and mortality; however, the incidence and risk factors for hospital mortality among critically ill patients with this condition have not been systematically evaluated. The purpose of this analysis is to further define CDI epidemiology. Hypothesis: To describe the incidence of CDI and its associated morbidity and mortality in adult ICU patients at three academic institutions. Methods: This was a retrospective multicenter cohort analysis from 2009-2010 that evaluated 5,852 patients. The diagnosis of CDI was based on a positive stool toxin test. Included CDI episodes occurred during ICU stay or a period of up to 30 days after discharge from the ICU or hospital, whichever was sooner. Categorical variables were analyzed using the Chi-square test. Continuous variables were analyzed using the Student’s t-test for parametric data or the Mann-Whitney U test for nonparametric data. Results: Of the 5852 evaluated ICU patients, 386 (6.6%) had CDI. Patients with and without CDI were similar in age, gender, and ICU location. The overall rate of CDI was 5.4 cases per 1000 ICU days. Median (IQR) in-hospital treatment duration was 11 days (5-16), with 94.1%, 48.6%, and 46.8% receiving metronidazole, oral vancomycin, or combination therapy, respectively. Median (IQR) days of hospital and ICU length of stay were 23 (12-37) vs. 15 (9-25) and 12 (5-22) vs. 8 (5-15) for CDI vs. no-CDI, respectively (p<0.001 for both comparisons). Hospital mortality was 25.1% for CDI vs. 26.4% for no-CDI (p = NS). Stratification by APACHE II score did not alter this finding. Home discharge disposition was 26.1% for CDI patients vs. 32.9% for patients without CDI (p = 0.005). After discharge, skilled-nursing facility-like placement occurred in 42.4% of CDI patients vs. 31.9% of patients without CDI (p < 0.001). Conclusions: The incidence of CDI in critically ill adults was relatively low. CDI patients had significantly greater hospital and ICU LOS with resultant dependency on higher-level care after discharge. These findings may used to determine the impact of CDI on healthcare resources.

Invited Commentary

Given the efficacy of platelet inhibition by thienopyridine (adenosine 5′-diphosphate [ADP] receptor antagonists) anticoagulants (ie, clopidogrel, ticlopidine, and prasugrel) to reduce morbidity associated with acute coronary syndromes and other thrombotic disorders, the number of patients requiring cardiac operations after exposure to these drugs continues to increase. After ingestion, thienopyridines undergo metabolism to an active form that irreversibly inhibits platelet P2Y12 ADP receptors [1Patrono C. Rocca B. The future of antiplatelet therapy in cardiovascular disease.Annu Rev Med. 2010; 61: 49-61Crossref PubMed Scopus (22) Google Scholar]. In general, reversal of thienopyridine-mediated anticoagulant effects requires 4 to 10 days and proves dependent on the introduction of new platelets from the marrow and extramedullary sources; however, a common polymorphism of cytochrome P450, termed CYP2C19, reduces concentration of the active metabolite and may limit anticoagulant activity as well [1Patrono C. Rocca B. The future of antiplatelet therapy in cardiovascular disease.Annu Rev Med. 2010; 61: 49-61Crossref PubMed Scopus (22) Google Scholar]. Although bleeding risk attributable to thienopyridine anticoagulants in nonsurgical patients appears limited, evidence suggests that patients undergoing cardiac operations that require cardiopulmonary bypass (CPB) experience excess bleeding and transfusion exposures. In a recent multicenter retrospective cohort analysis, patients undergoing CPB within 5 days of clopidogrel exposure experienced increased risk for reoperation, major bleeding, and prolonged length of stay [2Berger J.S. Frye C.B. Harshaw Q. Edwards F.H. Steinhubl S.R. Becker R.C. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis.J Am Coll Cardiol. 2008; 52: 1693-1701Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar]. Similarly, a structured literature review incorporating 23 studies and more than 3500 patients reported that coronary artery bypass graft (CABG) operations within 7 days of clopidogrel exposure was associated with an increase in major bleeding and transfusion requirements [3Pickard S.A. Becker R.C. Schumock G.T. Frye C.B. Clopidogrel-associated bleeding and related complications in patients undergoing coronary artery bypass grafting.Pharmacotherapy. 2008; 28: 376-392Crossref PubMed Scopus (67) Google Scholar]. Although current practice guidelines recommend discontinuation of thienopyridines 5 to 7 days before cardiac operations, patient-to-patient variability in anticoagulant duration of these drugs suggests a potential for laboratory-based monitoring of the thienopyridine anticoagulant effect to influence surgical planning. In this issue of The Annals, Ranucci and colleagues [4Ranucci M. Baryshnikova E. Soro G. Ballotta A. De Benedetti D. Conti D. Multiple electrode whole-blood aggregometry and bleeding in cardiac surgery patients receiving thienopyridines.Ann Thorac Surg. 2011; 91: 123-130Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar] report that preoperative screening of ADP-mediated platelet aggregation using multiple electrode whole-blood aggregometry successfully categorized patients for bleeding risk after recent thienopyridine exposure. Preoperative assessment of bleeding risk proves challenging, given the potential for CPB to adversely affect coagulation. CPB-related hyperfibrinolysis, hemodilution, and hypothermia contribute to bleeding after cardiac operation and confound identification of preoperative predictors, as reflected by the limited positive predictive power commonly associated with preoperative testing of coagulation. In contrast, the negative predictive value (ie, 92%) associated with Ranucci and colleagues' approach suggests the potential to identify patients at low risk for excess bleeding after thienopyridine therapy. For elective cardiac operations, multiple electrode whole-blood aggregometry testing may provide a mechanism to reduce unnecessary surgical delays by assessing thienopyridine effect on platelet function and identifying those patients unlikely to bleed excessively due to thienopyridine exposure. Similarly, operations might be delayed beyond 5 days in the subset of patients experiencing prolonged platelet inhibition after thienopyridine discontinuation. Even in settings where the operation cannot be delayed, preoperative testing may prove useful in directing transfusion therapy postoperatively. Although ADP-based platelet aggregation testing appears logical for assessing platelet inhibitory effects of thienopyridines, the role for platelet function testing in directing overall postoperative transfusion therapy remains unclear. Given potential for platelet activation by multiple receptors and pathways, as yet no single measure of platelet function has proved superior [5Lippi G. Favaloro E.J. Salvagno G.L. Franchini M. Laboratory assessment and perioperative management of patients on antiplatelet therapy: from the bench to the bedside.Clin Chim Acta. 2009; 405: 8-16Crossref PubMed Scopus (30) Google Scholar]. Multiple Electrode Whole-Blood Aggregometry and Bleeding in Cardiac Surgery Patients Receiving ThienopyridinesThe Annals of Thoracic SurgeryVol. 91Issue 1PreviewPreoperative treatment with thienopyridines is associated with increased postoperative bleeding in cardiac surgery patients. Patients under treatment with thienopyridines have different levels of platelet dysfunction and the effects of discontinuation are not totally predictable. The present study aimed to determine if a preoperative assessment of platelet function in these patients could provide clinically relevant information regarding the risks of excessive postoperative bleeding and transfusion requirements. Full-Text PDF