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Conducting clinical research during a 2-year critical care fellowship is a challenging endeavor. Fellows are often met with multiple barriers when considering clinical research projects during fellowship, including time, mentorship, resources, and clinical support. This paper presents the perspective and experiences of a group of critical care fellows who conducted the DRIVE-SAFE (Driving Pressure in Assisted Ventilation as a Predictor for Successful Liberation from Invasive Mechanical Ventilation) feasibility study, which aimed to determine measurable physiological variables that could be associated with lung injury and affect duration of mechanical ventilation. This paper provides a guide for trainees on how to conduct prospective clinical research at the bedside. We describe three key steps, including formulating a research question, developing appropriate methodology, and establishing outcomes. We also present the challenges that trainees may encounter when conducting prospective studies and how to overcome these challenges with proper mentorship, training, and collaboration with key stakeholders. These perspectives may provide useful guidance for current and future trainees interested in conducting prospective clinical research at the bedside.
RESUMO
BACKGROUND: Candida colonization is a risk factor for the development of invasive candidiasis. This study sought to estimate the magnitude of this association, and determine if this information can be used to guide empirical antifungal therapy initiation in critically ill septic patients. METHODS: PubMed/MEDLINE and Embase were systematically reviewed for all published studies evaluating predictors of invasive candidiasis in ICU patients with sepsis. Meta-analysis was used to determine the pooled odds ratio for invasive candidiasis among colonized versus non-colonized patients. Sensitivity (SN), specificity (SP), positive and negative predictive values (PPV, NPV), and positive and negative likelihood ratios (+LR, -LR) were then calculated by considering the presence/absence of Candida colonization as the diagnostic test, and the presence/absence of invasive candidiasis as the disease of interest. RESULTS: Out of 9825 patients in the 10 eligible studies, 3886 (40%) were colonized with Candida and 462 patients (4.7%) developed invasive candidiasis. Meta-analysis indicated that critically ill patients with sepsis who are colonized with candida are more likely to develop invasive candidiasis (odds ratio 3.32; 95% CI 1.68-6.58) compared with non-colonized patients. The pooled SN was 75.2% (95% CI 59.6-86.2%), while the pooled SP was 49.2% (95% CI 33.2-65.3%).The NPV of Candida colonization was high (96.9%; 95% CI 92.0-98.9%), but the PPV was low (9.1%; 95% CI 5.5-14.6%). CONCLUSION: Candida colonization is strongly associated with the likelihood of invasive candidiasis among ICU patients with sepsis. Available data argue against initiating empirical antifungal treatment in non-neutropenic septic patients without prior documented Candida colonization.
