Perhaps the most contentious debate in critical care is whether and when to transfuse blood to patients, especially those with acute lung injury and/or septic shock. FACTT showed less fluids (which could include blood) are better for ALI/ARDS, but transfusion wasn’t controlled and its contribution to the outcomes is unknown. Practicing physicians vary widely in [... read more]
Two kids under 5, one in Indiana and the other in Pennsylvania, have contracted a new reassorted swine flu: H3N2. The Pennsylvania child had had direct contact with a pig at an agricultural fair; the Indiana kid had been cared for by someone who had come in contact with a pig recently. Both children recovered [... read more]
Observational epidemiologic data on 132 California kids who caught pertussis (of 15,000 in a cohort), presented at the American Society for Microbiology meeting last week, suggested that protection from pertussis vaccination may wane as soon as 3 years after the last dose. Kids age 8-12 were most at risk (the last dose is given at [... read more]
Previous studies of tuberculosis screening using skin testing (TST) or interferon-gamma release assays (IGRA) suggested cost-effectiveness, but they were relying on outdated (inflated) pretest probability estimates from 1950s prevalence studies. In fact, using a Markov model with true population prevalence of TB plugged-in, Linas et al suggest that screening for TB is not very cost-effective [... read more]
Several favorable randomized trials and a meta-analysis have suggested procalcitonin is a reliable and useful biomarker of infection, including in the ICU. In contrast, Jensen et al report use of a procalcitonin-driven algorithm to guide antimicrobial therapy in 9 ICUs in Denmark seemed to cause a bit of harm. They randomized 1,200 patients to either [... read more]
Walker et al give us a nice picture and high-yield tutorial on the reversed halo sign, in this case from cryptogenic organizing pneumonia: J Thorac Imaging 2011;26:w80. (FREE)
Grijalva et al analyzed the Nationwide Inpatient Sample (data from U.S. hospitalizations) and found that the rate of hospitalization for parapneumonic empyema doubled from 3 per 100,000 in 1996, to 6 in 2008. The rate of empyemas due to Streptococcus pneumoniae was stable; the increases were in non-pneumococcal infections like Staphylococcus. Mortality was unchanged overall [... read more]
Antimicrobial Stewardship for the Community Hospital: Practical Tools & Techniques for Implementation. Clin Infect Dis 2011;53(suppl 1).
Obesity was named as a risk factor for severe H1N1 influenza during the pandemic. What about for influenza in general? Kwong et al analyzed community survey data in Ontario over 12 influenza seasons, 1996-2008. Severe obesity (BMI >= 35) carried an odds ratio of 2.1 for respiratory hospitalization during flu season. In those with no [... read more]
For 10 years, Zahar et al prospectively observed 3,588 patients developing severe sepsis & septic shock who ended up in French ICUs. Their sample captured a broad array of infections acquired in the community, the hospital ward, or the ICU (about 1/3 each). After multivariate assessment, they could not find an independent influence on mortality [... read more]
Schuetz et al review the 16 randomized controlled trials (n=4,647) testing procalcitonin-guided vs. standard care on the outcomes of antibiotic use, mortality, and infection control. Most of these studies were done in Europe; 6 were in ICU patients. Using procalcitonin reduced antibiotic use in all settings (primary care, emergency department, ICU) with no detectable differences [... read more]
Influenza, RSV, human metapneumovirus, CMV, EBV, herpesviruses, rhinovirus, coronavirus, adenovirus … viruses are increasingly recognized as a cause of pneumonia in adults. Read all about it in this special issue & review. Semin Resp Crit Care Med 2011; 4.
Johnson et al reviewed charts in a retrospective case-control cohort study on 754 consecutive patients at Barnes-Jewish with severe sepsis or shock due to Gram-negative bacteremia. The exposure was receipt of antibiotics in the previous 90 days. 310 of the bacteremic patients had received antibiotics previously. Compared to unexposed controls, the previously antibiotic-exposed had a [... read more]
Do inhaled steroids for COPD cause pneumonia, or cure it? Or both? The effects of inhaled corticosteroid use on pneumonia and mortality in people with COPD has been an area of simmering debate, ever since the TORCH trial. Using a wealth of observational data from VA databases, Chen et al add a key piece to [... read more]
In the “why didn’t I think of that?” department: Menzies et al performed pleural fluid sampling on 62 patients with clinical pleural infection, and sent samples to the lab in both standard tubes and in blood culture bottles inoculated at the bedside. 20 standard samples were culture-positive; adding the positive inoculated samples identified an additional [... read more]
Lu et al randomized 40 patients with Pseudomonas ventilator-associated pneumonia in France to receive ceftazidime & amikacin, either intravenously or by nebulizer for 8 days. There were no differences in treatment success or documented superinfection by other bugs. AJRCCM 2011;184:106-115. Enrollment began when microbiologic VAP was diagnosed (i.e., when BAL/mini-BAL culture results came back) and [... read more]
Update in Tuberculosis and Nontuberculous Mycobacterial Disease 2010. Yew WW et al. AJRCCM 2011;184:180-185.
In a prospective observational study of hospitalized patients with pneumonia, 20% met criteria for HCAP. Those with health care associated pneumonia were sicker of course, but it was impossible to tease out attributable mortality due to the multitude of interrelated confounders present. Antibiotic resistant organisms per se were not shown to cause death often enough [... read more]
Update in Pulmonary Infections 2010. Wunderlink RG, Waterer GW. AJRCCM 2011;184:186-190.
The new Xpert rapid MTB/RIF test is proving incredibly helpful in high-prevalence TB areas, esp. when HIV is also prevalent (i.e., Africa) and where delaying treatment for culture allows unchecked spread of TB. Sensitivity/specificity 95-99%, with a 55% sensitivity in smear-negative, culture-positive cases, report Theron et al. AJRCCM 2011;184:132-140.