Impact of Stress Ulcer Prophylaxis Discontinuation Guidance in Mechanically Ventilated, Critically Ill Patients: A Pre-Post Cohort Study.

Purpose: Recent data highlight unclear efficacy and potential negative sequelae of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU). Minimizing SUP exposure has pertinent clinical and other implications. This study assessed medication use and clinical outcomes before and after implementation of a practice guideline promoting early discontinuation of SUP in mechanically ventilated ICU patients.

Antibiotic Optimization in the Intensive Care Unit.

Effective antimicrobial therapy remains paramount to successful treatment of patients with critical illness, such as pneumonia and sepsis. Unfortunately, critically ill patients often exhibit altered pharmacokinetics and pharmacodynamics (PK/PD) that make this endeavor challenging. Particularly in sepsis, alterations in volume of distribution (Vd) and protein binding lead to unpredictable effects on serum levels of various antimicrobials.

Short- Versus Standard-Course Nonmacrolide Antibiotic Treatment in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Retrospective, Observational Cohort Study.

Purpose: In critically ill patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and without positive microbiological data, the efficacy and tolerability of short-course nonmacrolide antibiotics are ill-described and have pertinent implications in antimicrobial stewardship. This study compared the efficacy and tolerability of nonmacrolide antibiotic strategies in critically ill patients with AECOPD and without pertinent positive microbiological testing.

Methods: This single-center, retrospective cohort study was conducted in culture-negative critically ill adults admitted to an intensive care unit (ICU) between July 1, 2014, and July 1, 2019, for the treatment of AECOPD.

New Perspectives on Antimicrobial Agents: Ceftolozane-Tazobactam.

Ceftolozane-tazobactam (C/T) is a new fifth-generation cephalosporin/beta-lactamase inhibitor combination approved by the Food and Drug Administration and the European Medicines Agency for treatment of complicated intraabdominal infections, complicated urinary tract infections, and hospital-acquired pneumonia in adult patients. This review will briefly describe the pharmacology of C/T and focus on the emerging clinical trial and real-world data supporting its current utilization. Additionally, our synthesis of these data over time has set our current usage of C/T at Barnes-Jewish Hospital (BJH).

Racial Disparities in Readmissions Following Initial Hospitalization for Sepsis.

Objectives: To assess whether Black race is associated with a higher rate of all-cause readmission compared with White race following community-onset sepsis.

Design: Retrospective cohort study.

Setting: One-thousand three-hundred bed urban academic medical centers.

The Feasibility and Validity of Objective and Patient-Reported Measurements of Cognition During Early Critical Illness Recovery.

Background: Cognitive outcomes are an important determinant of quality of life after critical illness, but methods to assess early cognitive impairment and cognition recovery are not established. The objective of this study was to assess the feasibility and validity of objective and patient-reported cognition assessments for generalized use during early recovery from critical illness.

Methods: Patients presented from the community with acute onset of either intracerebral hemorrhage (ICH) or sepsis as representative neurologic and systemic critical illnesses.

Circadian Gene Expression Rhythms During Critical Illness.

Objectives: Core clock genes regulate tissue-specific transcriptome oscillations that synchronize physiologic processes throughout the body, held in phase by the central circadian rhythm. The central circadian rhythm rapidly dampens with onset of critical illness, but the effect of critical illness on gene expression oscillations is unknown. The objective of this study was to characterize the rhythmicity and phase coherence of core clock genes and the broader transcriptome after onset of critical illness.

Factors Disrupting Melatonin Secretion Rhythms During Critical Illness.

Objectives: The circadian system modulates many important physiologic processes, synchronizing tissue-specific functions throughout the body. We sought to characterize acute alterations of circadian rhythms in critically ill patients and to evaluate associations between brain dysfunction, systemic multiple organ dysfunction, environmental stimuli that entrain the circadian rhythm (zeitgebers), rest-activity rhythms, and the central circadian rhythm-controlled melatonin secretion profile.

Design: Prospective study observing a cohort for 24-48 hours beginning within the first day of ICU admission.

Stress-Induced Behavioral Quiescence and Abnormal Rest-Activity Rhythms During Critical Illness.

Objectives: To characterize acute alterations of circadian and ultradian rest-activity rhythms in critically ill patients and their association with brain dysfunction, systemic multiple organ dysfunction, and melatonin rhythms.

Design: Prospective study observing a cohort for 48 hours beginning within the first day of ICU admission.

Setting: ICUs within an academic medical center.

Rapid Detection of Methicillin-Resistant Staphylococcus aureus in BAL: A Pilot Randomized Controlled Trial.

Background: Guidelines recommend empirical vancomycin or linezolid for patients with suspected pneumonia at risk for methicillin-resistant Staphylococcus aureus (MRSA). Unneeded vancomycin or linezolid use may unnecessarily alter host flora and expose patients to toxicity. We therefore sought to determine if rapid testing for MRSA in BAL can safely decrease use of vancomycin or linezolid for suspected MRSA pneumonia.

Osmotic Shifts, Cerebral Edema, and Neurologic Deterioration in Severe Hepatic Encephalopathy.

Objectives: We sought to determine the effect of acute electrolyte and osmolar shifts on brain volume and neurologic function in patients with liver failure and severe hepatic encephalopathy.

Design: Retrospective analysis of brain CT scans and clinical data.

Setting: Tertiary care hospital ICUs.

Impact of Multiple Daily Clinical Pharmacist-Enforced Assessments on Time in Target Sedation Range.

Objectives: Incorporation of a single daily assessment by a clinical pharmacist to improve adherence with a sedation protocol is associated with reduced duration of mechanical ventilation and intensive care unit (ICU) length of stay (LOS). We test the feasibility of incorporating a clinical pharmacist into more frequent sedation assessments and observed whether there are any potential differences in the sedatives administered.

Methods: Prospective, quasi-experimental, pilot study of patients admitted to the medical ICU.

Refining Prognosis for Intracerebral Hemorrhage by Early Reassessment.

Background: Prognostic assessments, which are crucial for decision-making in critical illnesses, have shown unsatisfactory reliability. We compared the accuracy of a widely used prognostic score against a model derived from clinical data obtained 5 days after admission for patients with intracerebral hemorrhage (ICH), a condition for which prognostication has proven notoriously challenging and prone to bias.

Methods: Patients enrolled in a prospective observational cohort study of spontaneous ICH underwent hourly Glasgow Coma Scale (GCS) assessment.

Impact of body mass index on clinical outcomes in patients with gram-negative bacteria bloodstream infections.

Introduction: Excess body mass index (BMI) is associated with a higher risk of death in many disease states, yet less is known about the impact of higher BMIs on clinical outcomes of serious bacterial infections. We sought to quantify the risk of all-cause mortality and/or organ failure following Gram negative bacteria bloodstream infections (GNBSI) according to BMI.

Materials And Methods: We retrospectively reviewed the charts of patients with confirmed GNBSI who received ≥48 h of active antimicrobial therapy.

Tree-Based Models for Predicting Mortality in Gram-Negative Bacteremia: Avoid Putting the CART before the Horse.

Increasingly, infectious disease studies employ tree-based approaches, e.g., classification and regression tree modeling, to identify clinical thresholds.

23.4% Saline Decreases Brain Tissue Volume in Severe Hepatic Encephalopathy as Assessed by a Quantitative CT Marker.

Objective: Cerebral edema is common in severe hepatic encephalopathy and may be life threatening. Bolus 23.4% hypertonic saline improves surveillance neuromonitoring scores, although its mechanism of action is not clearly established.

Preadmission statin use does not improve functional outcomes or prevent delayed ischemic events in patients with spontaneous subarachnoid hemorrhage.

Study Objective: To determine whether preadmission statin use in patients with spontaneous subarachnoid hemorrhage (SAH) is associated with improved functional outcomes and a lower incidence of delayed cerebral ischemic events compared with statin-naive patients with SAH.

Design: Prospective cohort study.

Setting: Neurosciences intensive care unit of a tertiary care hospital.

Management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration.

Purpose: The management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration (CVVH) is reported.

Summary: A 46-year-old African-American woman with New York Heart Association class IV, American College of Cardiology- American Heart Association stage D heart failure arrived from an outside facility with complaints of dyspnea after minimal exertion, orthopnea, and lower-extremity edema. A transthoracic echocardiogram revealed an estimated left ventricular ejection fraction of 15%.

Extended-infusion eptifibatide to prevent stent thrombosis in a patient undergoing orthopedic surgery.

Objective: To report the use of extended-infusion eptifibatide in a patient who had undergone placement of a drug-eluting stent and required repeat intervention of a hip fracture following mechanical failure.

Case Summary: An 82-year-old female with an extensive history of coronary disease who had undergone placement of a drug-eluting stent was admitted following continued problems with her surgically repaired right hip. Radiographic imaging of the area revealed mechanical failure of the surgically repaired hip, requiring intervention.