Outcomes of mechanically ventilated patients with COVID-19 associated respiratory failure.

PURPOSE: The outcomes of patients requiring invasive mechanical ventilation for COVID-19 remain poorly defined. We sought to determine clinical characteristics and outcomes of patients with COVID-19 managed with invasive mechanical ventilation in an appropriately resourced US health care system. METHODS: Outcomes of COVID-19 infected patients requiring mechanical ventilation treated within the Inova Health System between March 5, 2020 and April 26, 2020 were evaluated through an electronic medical record review. RESULTS: 1023 COVID-19 positive patients were admitted to the Inova Health System during the study period. Of these, 164 (16.0%) were managed with invasive mechanical ventilation. All patients were followed to definitive disposition. 70/164 patients (42.7%) had died and 94/164 (57.3%) were still alive. Deceased patients were older (median age of 66 vs. 55, p <0.0001) and had a higher initial d-dimer (2.22 vs. 1.31, p = 0.005) and peak ferritin levels (2998 vs. 2077, p = 0.016) compared to survivors. 84.3% of patients over 70 years old died in the hospital. Conversely, 67.4% of patients age 70 or younger survived to hospital discharge. Younger age, non-Caucasian race and treatment at a tertiary care center were all associated with survivor status. CONCLUSION: Mortality of patients with COVID-19 requiring invasive mechanical ventilation is high, with particularly daunting mortality seen in patients of advanced age, even in a well-resourced health care system. A substantial proportion of patients requiring invasive mechanical ventilation were not of advanced age, and this group had a reasonable chance for recovery.

Clinical outcomes and financial impacts of malnutrition in sepsis.

BACKGROUND: In the United States in 2014 approximately 1.7 million adults were hospitalized with sepsis, resulting in about 270,000 deaths. Malnutrition in hospitalized patients contributes to increased morbidity, mortality, and costs, especially in the critically ill population. AIM: Our goal was to investigate the prevalence of malnutrition in sepsis and the impact it has on clinical and financial outcomes in our most critically ill patients. METHODS: We implemented nutritional screening by a registered dietitian of 1000 patients admitted with sepsis to specialized care units. We calculated the prevalence of malnutrition, and compared outcomes including mortality, length of stay, and financial costs. RESULTS: About 10% of patients with sepsis admitted to our specialized care units were diagnosed with malnutrition on admission after implementation of mandatory assessment. CONCLUSIONS: Although mortality did not reach statistical significance, these patients had more comorbidities, longer hospital stays, and higher total costs.

Multiple organ dysfunction syndrome and death secondary to Cyberlindnera fabianii.

Cyberlindnera fabianii is a yeast present in soil rarely associated with invasive infection. Due to advanced diagnostic and therapeutic techniques, pathogenicity is increasingly recognized. A 37-year-old male with B cell lymphoma on rituximab developed multiple organ dysfunction syndrome secondary to C. fabianii bacteremia. Specialized species identification techniques were required after failure of standard methods. Despite extracroporeal membrane oxygenation (ECMO) the patient died on day 26 after admission.

The epidemiologic characteristics, temporal trends, predictors of death, and discharge disposition in patients with a diagnosis of sepsis: A cross-sectional retrospective cohort study.

PURPOSE: To assess recent epidemiologic characteristics, temporal trends, and predictors of death and discharge disposition in patients with sepsis. MATERIAL AND METHODS: This is a cross-sectional retrospective cohort study using the US National Inpatient Sample (NIS) data from 2009 to 2012. The study population included adults (18years and older) with sepsis-related International Classification of Diseases, Ninth Revision, Clinical Modification codes at the time of discharge. Factors associated with in-hospital mortality and patient discharge disposition were derived from multivariate analyses using multinomial logistic models by SAS PROC LOGISTIC with GLOGIT link. RESULTS: Of 1 303 640 patients admitted, 15% died, 30% were discharged to home without home care, 34% were transferred to a skilled outpatient facility, and 4% were transferred to another short-term hospital. In-hospital mortality decreased from 16.5% to 13.8% (P<.001) across time. Length of stay also decreased from 6.7 to 5.9days (P<.001). Reductions in mortality and length of stay were seen despite an increase in the number of comorbidities (P<.001). Multivariate analysis revealed that the strongest predictors of in-hospital mortality were respiratory, cardiovascular, and hepatic failures, and neurologic events. The predictors of transfer to an outpatient facility were a major operative procedure, neurologic event, respiratory failure, and weight loss. Weight loss was also an independent predictor of in-hospital mortality. CONCLUSION: Certain comorbidities and organ failures were associated with death and discharge to a skilled outpatient facility.

Impact of electronic order management on the timeliness of antibiotic administration in critical care patients.

OBJECTIVE: To examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients. METHODS: We used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated. RESULTS: The overall turnaround time from ordering to administration significantly decreased from a median of 100 min before order management implementation to a median of 64 min after implementation. The first part of the medication use process, i.e., from order entry to pharmacy processing, improved significantly whereas no change was observed in the phase from pharmacy processing to medication administration. DISCUSSION: The implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time.

The obesity paradox.

The term "obesity paradox" refers to the observation that, although obesity is a major risk factor in the development of cardiovascular and peripheral vascular disease, when acute cardiovascular decompensation occurs, for example, in myocardial infarction or congestive heart failure, obese patients may have a survival benefit. In addition, it has been suggested that obese patients tend to fare better after certain surgical procedures, such as coronary artery bypass surgery. Moreover, it appears that obese men with chronic hypertensive heart disease live longer than men of normal weight. Mounting evidence shows that obesity alone may confer a survival benefit independent of age, medical care, or therapy. Perhaps the definition of obesity needs to be revisited, and it is also possible that all fat is not equal.

A survey of clinicians addressing the approach to the management of severe sepsis and septic shock in the United States.

PURPOSE: Mortality in severe sepsis and septic shock (SS/SS) remains high. Surviving Sepsis Campaign (SSC) guidelines were published in 2004 with the goal of improving outcomes in SS/SS. We tested the hypothesis that adherence to SSC guidelines and management of patients with SS/SS were influenced by physician specialty. MATERIALS AND METHODS: A survey was mailed to 4998 randomly selected physicians, 1666 each for emergency medicine (EM), critical care medicine (CCM), and internal medicine (IM) from the American Medical Association database. Demographics, compliance with SSC guidelines, and approaches to management of patients with SS/SS were analyzed by specialty. RESULTS: Four hundred ninety-nine respondents were included for final analysis. There were no differences between 3 specialties in obtaining blood cultures and in administering intravenous fluids, pressors, and antibiotics. The CCM physicians were more likely to measure serum lactate and central venous pressure, use corticosteroids and drotrecogin α, and aim for normoglycemia and plateau pressures less than 30 cm H(2)O in mechanically ventilated patients (all P < .001). CONCLUSIONS: We observe that adherence with SSC guidelines continues to be a challenge for CCM, IM, and EM physicians. Significant differences in management of SS/SS exist for the 3 specialties. Because guideline implementation impacts patient outcomes, further evaluation of these differences is warranted.

Propionibacterium acnes as a cause of prosthetic valve aortic root abscess.

Propionibacterium acnes isolates usually have relatively low virulence and are often classified as contaminants when isolated from blood and tissue cultures. We report a patient with Propionibacterium acnes bacteremia and late prosthetic valve endocarditis, complicated by an aortic root abscess.

Synergistic killing of Streptococcus pneumoniae with the bacteriophage lytic enzyme Cpl-1 and penicillin or gentamicin depends on the level of penicillin resistance.

A combination of Cpl-1, a bacteriophage lytic enzyme, and penicillin, gentamicin, levofloxacin, or azithromycin was tested against Streptococcus pneumoniae strains with various susceptibilities to penicillin. Activities of Cpl-1 and gentamicin were increasingly synergistic with a decreasing penicillin MIC, while Cpl-1 and penicillin showed synergy against an extremely penicillin-resistant strain.

Phage lytic enzyme Cpl-1 as a novel antimicrobial for pneumococcal bacteremia.

Streptococcus pneumoniae is becoming increasingly antibiotic resistant worldwide, and thus new antimicrobials are badly needed. We report the use of Cpl-1, the lytic enzyme of a pneumococcal bacteriophage, as an intravenous therapy for pneumococcal bacteremia in a mouse model. A 2000- microg dose of Cpl-1 reduced pneumococcal titers from a median of log(10) 4.70 CFU/ml to undetectable levels (