Implications of culture collection after the first antimicrobial dose in septic emergency department patients.

BACKGROUND: Previous research has illustrated the importance of collection of microbiologic cultures prior to first antimicrobial dose (FAD) in septic patients to avoid sterilization of pathogens and thus allowing confirmation of infection, identification of pathogen(s), and de-escalation of antimicrobial therapy. There is currently a lack of literature characterizing the implications and clinical courses of patients who have cultures collected after FAD. METHODS: In this single-center, retrospective chart review of 163 sepsis cases in the emergency department, the primary outcome was positive-cultures from appropriate sources. Secondary outcomes included time to FAD (TFAD); ICU and hospital lengths of stay (LOS); rate of antibiotic restart; secondary infection rate; readmission; and mortality. Cases were divided based on culture timing relative to FAD: culture-first (CF) or antimicrobial-first (AF) cohorts. RESULTS: Cultures were more frequently positive in the CF cohort vs. AF cohort overall (80.4% vs. 46.7%, p < 0.005). TFAD was greater in the CF cohort (202 min vs. 153 min, p = 0.036) and these cases trended toward shorter ICU and hospital LOS (6.8 days vs. 8.4 days, p = 0.122; 11.5 days vs. 13.5 days, p = 0.218). Antibiotic restart was less frequent in the CF cohort (10.7% vs. 17.8%, p < 0.005). C. difficile infection and mortality trended toward lower incidence in the CF cohort, and readmission rates were similar. CONCLUSIONS: Sepsis patients who have cultures obtained after FAD (represented in the AF cohort) had less positive-cultures, shorter TFAD, a trend toward longer ICU and hospital LOS, and perhaps higher risk of C. difficile infection, and mortality.

The cardio-renal-anemia syndrome in elderly subjects with heart failure and a normal ejection fraction: a comparison with heart failure and low ejection fraction.

The prevalence and severity of anemia and renal dysfunction in heart failure patients with a normal ejection fraction (HFNEF) is uncharacterized. Two hundred eighty-five consecutive patients admitted to a community hospital with heart failure were stratified by the presence or absence of anemia and a normal or reduced ejection fraction. Comparisons of clinical variables were performed. In this sample, 62% of subjects were anemic, with no difference between those with a normal and a reduced ejection fraction (63% vs. 61%). Anemic HFNEF subjects had a lower glomerular filtration rate (37 +/- 21 mL/min vs. 52 +/- 35 mL/min; p < 0.05) and more severe self-reported symptom scores than nonanemic HFNEF subjects. Multivariate analysis confirmed the association of renal dysfunction and anemia. The authors conclude that the degree and magnitude of anemia in elderly inpatients with heart failure does not differ by ejection fraction. Worse symptoms and more severe renal dysfunction were seen in HFNEF subjects with anemia than in HFNEF subjects without anemia.

The effect of erythropoietin on exercise capacity, left ventricular remodeling, pressure-volume relationships, and quality of life in older patients with anemia and heart failure with preserved ejection fraction.

A prospective, open-label, 3-month study was conducted to evaluate the feasibility and short-term clinical effect of subcutaneous erythropoietin injections in patients with anemia and heart failure with preserved ejection fraction (ejection fraction, 55%+/-2%). Using a dose-adjusted algorithm to effect a rate of rise in hemoglobin not to exceed 0.4 g/dL /wk, hemoglobin (10.8+/-0.3 to 12.2+/-0.3 g/dL) and red blood cell volume (1187+/-55 to 1333+/-38 mL) increased with an average weekly dose of 3926 units. Functional measures increased from baseline (6-minute walk test [289+/-24 to 331+/-22 m], exercise time [432+/-62 to 571+/-51 s], and peak oxygen consumption [8.2+/-0.7 to 9.4+/-0.9 mL/kg/min], all P<.05). End-diastolic volume declined significantly (8% volumetric decrease, 108+/-3 to 100+/-3 mL, P =.03), but there were no significant changes in left ventricular mass or estimated left ventricular end-diastolic pressure. Pressure-volume analysis demonstrated a reduction in ventricular capacitance at an end-diastolic pressure of 30 mm Hg without significant changes in contractile state.

Comparison of blood volume characteristics in anemic patients with low versus preserved left ventricular ejection fractions.

Anemia is a significant co-morbidity in patients with heart failure (HF) irrespective of the ejection fraction and is routinely quantified by hemoglobin concentration. Hemodilution as a cause of anemia has been described in systolic HF. The aim of this study was to further investigate the effects of plasma volume in patients with HF by (1) assessing the prevalence of dilutional anemia in patients with anemia and preserved ejection fractions and (2) exploring the relation between hemoglobin and red cell volume in these patients. Forty-six patients with anemia (as determined by standard hemoglobin measurement), 22 with HF and low ejection fractions (HFLEF) and 24 with HF and preserved ejection fractions (HFPEF), all underwent plasma volume measurement with iodine-131-labeled albumin. Hemoglobin values did not differ between subjects with HFLEF and those with HFPEF (10.8 +/- 1.0 vs 11.0 +/- 1.0 g/dl, p = 0.55), but a red cell deficit was found in 88% of patients with HFPEF compared with 59% of those with HFLEF (p = 0.04). This was the result of a higher prevalence of an expansion of plasma volume in patients with HFLEF (100%) compared with those with HFPEF (71%). Among all patients, no correlation was found between hemoglobin and red cell volume (r = 0.09, p = 0.54), but a correlation did exist in patients with normal blood volumes (r = 0.55, p = 0.02). In conclusion, dilutional anemia caused by an expansion in plasma volume without a red cell deficit occurs more commonly in patients with HFLEF than those with HFPEF, and hemoglobin does not correlate with red cell volume in patients with anemia and HF.