Study of Empiric Antibiotic Prescription Patterns and Microbiological Isolates in Hemodynamically Stable and Unstable ICU Patients With Community-Acquired Sepsis.

Background: The efficacy of combination empiric antibiotic therapy for all intensive care unit (ICU) patients with community-acquired sepsis is a subject of ongoing debate in the era of increasing antibiotic resistance. This study was conducted to evaluate the patterns of antibiotic usage and microbial resistance in sepsis patients admitted to the ICU with both hemodynamically stable (HS) and unstable states and to analyze their clinical outcomes. Methods: In this observational study, patients aged 18 years and above who received antibiotics upon admission and had a culture report were included. These patients were categorized into the following groups: HS and hemodynamically unstable (HU), single or combined antibiotics group (more than one antibiotic used empirically to cover one or more groups of organisms), culture-positive and culture-negative group. The microbiological isolates were grouped according to their identified resistance patterns. The outcome parameters involved assessing the differences in empiric antibiotics use upon admission and microbial resistance with hemodynamic stability and investigating any associations with ICU and hospital outcomes. Results: The study included a total of 2675 patients, of which 70.3% were in the HS group, and 29.7% in the HU group. The use of combination antibiotics was significantly higher (p < 0 .0001) across all groups. Carbapenems were used more frequently in the single antibiotic group (p < 0 .001). The culture was positive in 27.8% (n = 747) of patients. A significantly higher number of patients in the HU group (p < 0 .001) were found to have carbapenem-resistant and multidrug-resistant organisms. The ICU and hospital mortality rates were significantly higher in the HU group (p < 0 .001), the culture-positive group with resistance (p < 0 .001), and the HS patients who received combination antibiotics. Conclusion: The usage of combination antibiotics, coupled with the presence of resistant organisms, emerged as an important variable in predicting ICU and hospital mortality rates in cases of community-acquired sepsis.

Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India.

Background: The current study aimed to assess any association between intensive care unit (ICU) and hospital outcomes with ICU admission timings of critically ill patients. Methods: Retrospective observational single-center study involving all adult admissions. Each patient admission was categorized in "after-hours" (08:00 p.m.-07:59 a.m.), or "normal-hours" (08:00 a.m.-07:59 p.m.), "Weekday" (Monday-Saturday), or "Weekend" (Sunday), "Same day" (admission directly to ICU) or "other day admission" (admission to ICU after a hospital stay of ≥24 hours). Intensive care unit and hospital mortality, length of stay (LOS), and ICU readmission were assessed for any association with different admission timings. Results: Among 3,029 patients, 54.2% (1,668) were male, with mean age 66.49 (SD ± 15.69) years, mean acute physiology and chronic health evaluation-IV (APACHE-IV) score 55.5 (SD ± 26.3). Around 86.1% of admission occurred during weekdays, 13.9% on weekends, 57.4% normal-hours, 42.6% after-hours, 66.3% same day and 33.7% other day admission. Intensive care unit and hospital mortality were 10.8 and 14.2% respectively. Neither ICU nor hospital mortality were significantly different among patients admitted normal vs after-hours (p = 0.32, 0.23), and weekdays vs weekends (p = 0.09, 0.93), nor was ICU LOS (p = 0.21, 0.74). Intensive care unit and hospital mortality (p = 0.001), DORB (p = 0.001), hospital LOS (p = 0.001), and readmission to ICU (p = 0.001) were significantly higher in the other day admission group compared to same-day admission. In a multivariate regression analysis age, APACHE IV score along with other day admission to ICU did have a significant effect on both ICU and hospital mortality. Conclusion: Intensive care unit and hospital mortality and LOS did not differ significantly with hours or days of ICU admission though they were significantly higher in other day admission groups. How to cite this article: Bhattacharyya M, Todi SK. Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India. Indian J Crit Care Med 2024;28(5):436-441.

Arterial Blood Gas Analysis: A New Look at the Old Formula.

How to cite this article: Todi S. Arterial Blood Gas Analysis: A New Look at the Old Formula. Indian J Crit Care Med 2023;27(10):699-700.

Unmet needs and practical solutions in the management of invasive mould infections in Asia.

Management of invasive mould infections (IMIs) is challenging in Asia, as awareness among medical practitioners can be low and resources are limited. Timely diagnosis and appropriate treatment of IMIs can mitigate the impact on morbidity and mortality, but diagnostic methods, as well as access to preferred antifungal medications, may vary throughout the region. Knowledge of local epidemiology and accurate diagnosis and identification of causal pathogens would facilitate optimal treatment but data in Asia are lacking. To address these unmet needs in the management of IMIs, this paper is a call for urgent action in the following areas: improving awareness of the threat of IMIs; providing education to frontline clinicians across a broad range of specialties on 'red flags' for suspicion of IMIs; prioritizing cost-effective rapid diagnostic testing; improving access to preferred antifungal medications; and closing the gaps in local epidemiological data on IMIs to inform local treatment guidelines.

Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics.

How to cite this article: Khilnani GC, Tiwari P, Zirpe KG, Chaudhary D, Govil D, Dixit S, et al. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022;26(S2):S77-S94.

Is It a Wave or a Tsunami? That is the Question.

How to cite this article: Todi S. Is It a Wave or a Tsunami? That is the Question. Indian J Crit Care Med 2021;25(12):1331-1332.

Clearing the Fog on the Use of N95 Mask.

How to cite this article: Todi S. Clearing the Fog on the Use of N95 Mask. Indian J Crit Care Med 2021;25(9):961-962.

Procalcitonin: "To Follow or Not to Follow" That's the Question.

How to cite this article: Todi SK. Procalcitonin: "To Follow or Not to Follow" That's the Question. Indian J Crit Care Med 2021;25(5):484-485.

A Comparative Study on the Outcomes of Mechanically Ventilated COVID-19 vs Non-COVID-19 Patients with Acute Hypoxemic Respiratory Failure.

BACKGROUND: Due to the coronavirus disease-2019 (COVID-19) pandemic, there has been a surge of patients requiring mechanical ventilation over a short period of time. The morbidity and mortality outcome in these patients have been variably reported in the published literature. Comparative analyses of ventilated COVID-19 and non-COVID-19 patients during the same time period have been lacking. MATERIALS AND METHODS: Prospective data for each mechanically ventilated patient was collected from both COVID-19 and non-COVID ICU for a period of 8 months. Their demographic details and disease severity scores were included. Risk-adjusted outcomes across two groups were analyzed using multivariable regression methods. RESULTS: Crude ICU and hospital mortality were similar in COVID-19- and non-COVID-19 ventilated groups (43.8 vs 40% and 43.8 vs 41.1%, respectively; p >0.05). After risk adjustment for the severity of illness by APACHE IV, no significant differences were observed in ICU mortality (OR 1.498; 95% CI 0.669-3.327; p =0.328) and hospital mortality (OR 1.574; 95% CI 0.707-3.504; p =0.267). However, mechanically ventilated COVID-19 patients had increased ICU stay (OR 6.261; 95% CI 3.778-8.744; p <0.001) as well as prolonged ventilatory support (OR 4.358; 95% CI 2.910-7.424; p <0.001) when compared to non-COVID-19 patients. CONCLUSION: In mechanically ventilated patients, no significant differences in terms of mortality were noted between COVID-19 and non-COVID-19 patients. Mechanically ventilated COVID-19 patients had longer ICU stay and more number of days on ventilation. HOW TO CITE THIS ARTICLE: Todi S, Ghosh S. A Comparative Study on the Outcomes of Mechanically Ventilated COVID-19 vs Non-COVID-19 Patients with Acute Hypoxemic Respiratory Failure. Indian J Crit Care Med 2021;25(12):1377-1381.

Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study.

BACKGROUND: We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010-2011. METHODS: An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs. RESULTS: On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality. CONCLUSIONS: Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care.Registered at clinicaltrials.gov (NCT03631927). HOW TO CITE THIS ARTICLE: Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093-1107.

Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Renal Replacement Therapy: A Multinational Survey of Critical Care Practitioners.

OBJECTIVES: To assess the attitudes of practitioners with respect to net ultrafiltration prescription and practice among critically ill patients with acute kidney injury treated with renal replacement therapy. DESIGN: Multinational internet-assisted survey. SETTING: Critical care practitioners involved with 14 societies in 80 countries. SUBJECTS: Intervention: MEASUREMENT AND MAIN RESULTS:: Of 2,567 practitioners who initiated the survey, 1,569 (61.1%) completed the survey. Most practitioners were intensivists (72.7%) with a median duration of 13.2 years of practice (interquartile range, 7.2-22.0 yr). Two third of practitioners (71.0%; regional range, 55.0-95.5%) reported using continuous renal replacement therapy with a net ultrafiltration rate prescription of median 80.0 mL/hr (interquartile range, 49.0-111.0 mL/hr) for hemodynamically unstable and a maximal rate of 299.0 mL/hr (interquartile range, 200.0-365.0 mL/hr) for hemodynamically stable patients, with regional variation. Only a third of practitioners (31.5%; range, 13.7-47.8%) assessed hourly net fluid balance during continuous renal replacement therapy. Hemodynamic instability was reported in 20% (range, 20-38%) of patients and practitioners decreased the rate of fluid removal (70.3%); started or increased the dose of a vasopressor (51.5%); completely stopped fluid removal (35.8%); and administered a fluid bolus (31.6%), with significant regional variation. Compared with physicians, nurses were most likely to report patient intolerance to net ultrafiltration (73.4% vs 81.3%; p = 0.002), frequent interruptions (40.4% vs 54.5%; p < 0.001), and unavailability of trained staff (11.9% vs 15.6%; p = 0.04), whereas physicians reported unavailability of dialysis machines (14.3% vs 6.1%; p < 0.001) and costs associated with treatment as barriers (12.1% vs 3.0%; p < 0.001) with significant regional variation. CONCLUSIONS: Our study provides new knowledge about the presence and extent of international practice variation in net ultrafiltration. We also identified barriers and specific targets for quality improvement initiatives. Our data reflect the need for evidence-based practice guidelines for net ultrafiltration.

Critical Care Research in Elderly Population: An Uncharted Territory.

How to cite this article: Todi S, Choudhuri R. Critical Care Research in Elderly Population: An Uncharted Territory. Indian J Crit Care Med 2020;24(7):500-501.

Trigger Tools for Adverse Drug Events: Useful Addition to the Quality Tool Box.

How to cite this article: Todi S, Saha A. Trigger Tools for Adverse Drug Events: Useful Addition to the Quality Tool Box. Indian J Crit Care Med 2020;24(3):151-152.

Clostridium difficile and Antibiotic-associated Diarrhea.

How to cite this article: Bhattacharyya M, Debnath AK, Todi SK. Clostridium difficile and Antibiotic-associated Diarrhea. Indian J Crit Care Med 2020;24(Suppl 4):S162-S167.

Glutamine Supplementation: The Pendulum Keeps on Swinging.

How to cite this article: Todi S. Glutamine Supplementation: The Pendulum Keeps on Swinging. Indian J Crit Care Med 2019;23(8):350-351.

Clotting Catastrophies in the Intensive Care Unit.

Clotting catastrophies are rarely encountered challenges in the Intensive Care Unit (ICU) and their presentation and progress maybe devastating and fulminant. Dramatic onset and involvement of multiple vascular beds should alert the clinician to look for these disorders. Outcomes may be improved with rapid diagnosis and prompt institution of specific therapies and interdisciplinary liaison holds the key to success. HOW TO CITE THIS ARTICLE: Sinha S, Todi SK. Clotting Catastrophies in the Intensive Care Unit. Indian J Crit Care Med 2019;23(Suppl 3):S197-S201.

Epidemiology of Adult-population Sepsis in India: A Single Center 5 Year Experience.

BACKGROUND AND AIMS: Sepsis is a major worldwide cause of morbidity and mortality. Most sepsis epidemiologic data are from the Western literature. Sparse data from India describe the epidemiology of infection rather than sepsis which is a host response to infection. This study describes the epidemiology of sepsis in the Intensive Care Unit (ICU) of an Indian tertiary care hospital. SUBJECTS AND METHODS: A prospective study conducted between June 2006 and May 2011. All consecutively admitted patients during the 5 year study >=18 years of age were included and data obtained from hospital in-patient records. Variables measured were the incidence of severe sepsis, ICU, hospital, and 28-day mortality, the median length of ICU stay, median Acute Physiology and Chronic Health Evaluation II (APACHE II) score, infection site, and microbial profile. RESULTS: There were 4711 admissions during the study with 282 (6.2%, 95% confidence interval 2.3, 13.1) admissions with severe sepsis. ICU mortality, hospital mortality, and 28-day mortality were 56%, 63.6%, and 62.8%, respectively. Predominant infection site was respiratory tract. The most common organisms were Gram-negative microbes. The most common microbe was Acinetobacter baumanni. Median APACHE II score on admission was 22 (interquartile range 16-28) and median length of ICU stay was 8 days. Severe sepsis attributable mortality was 85%. CONCLUSION: Severe sepsis is common in Indian ICUs and is mainly due to Gram-negative organisms. ICU mortality is high in this group and care is resource intensive due to increased length of stay.

Intensive Care in India: The Indian Intensive Care Case Mix and Practice Patterns Study.

AIMS: To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs). PATIENTS AND METHODS: An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs. RESULTS: On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality. CONCLUSIONS: The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.

Glycemic control in critically ill: A moving target.

Glycemic control targets in intensive care units (ICUs) have three distinct domains. Firstly, excessive hyperglycemia needs to be avoided. The upper limit of this varies depending on the patient population studied and diabetic status of the patients. Surgical patients particularly cardiac surgery patients tend to benefit from a lower upper limit of glycemic control, which is not evident in medically ill patient. Patient with premorbid diabetic status tends to tolerate higher blood sugar level better than normoglycemics. Secondly, hypoglycemia is clearly detrimental in all groups of critically ill patient and all measures to avoid this catastrophe need to be a part of any glycemic control protocol. Thirdly, glycemic variability has increasingly been shown to be detrimental in this patient population. Glycemic control protocols need to take this into consideration and target to reduce any of the available metrics of glycemic variability. Newer technologies including continuous glucose monitoring techniques will help in titrating all these three domains within a desirable range.