Development of a combination antibiogram for Pseudomonas aeruginosa bacteremia in an oncology population.

PURPOSE: Development of a combination antibiogram to identify combinations of antibiotics that have the highest likelihood of attaining one active agent in the empiric management of presumed Pseudomonas aeruginosa bacteremia. METHODS: Patients with cancer and P. aeruginosa bacteremia from January 1 to December 31, 2012 were included in this analysis. The primary outcome was identification of effective combinations of beta-lactam and non-betalactam agents. An effective combination was defined as one which achieved in-vitro activity to greater than or equal to 85% of isolates collected. Furthermore, the addition of the non-beta-lactam agent was required to increase the in-vitro activity by at least 5% over beta-lactam monotherapy. Multiple secondary outcomes were evaluated. RESULTS: One hundred and twenty-three P. aeruginosa isolates were included from 99 patients. Single agent beta-lactam sensitivities ranged from 72.4 to 79.7%. Combination regimen sensitivities ranged from 73.5 to 96.7%. All combination regimens that included a beta-lactam plus an aminoglycoside were found to be effective per the study definition. Independent risk factors for MDR P. aeruginosa were receipt of intravenous (IV) antibiotics within 90 days and hospital length of stay (LOS) greater than or equal to five days. Increasing the number of antibiotics received was associated with a decrease in survival to hospital discharge. CONCLUSIONS: Effective combination regimens included all beta-lactam aminoglycoside regimens. Receipt of IV antibiotics within 90 days and hospital LOS greater than or equal to five days were independent risk factors for MDR isolates.

Prolonged propofol use in a critically ill pregnant patient.

OBJECTIVE: To describe the prolonged use of propofol for sedation of a critically ill pregnant patient in her second trimester. CASE SUMMARY: A 20-year-old pregnant woman at 14 weeks' gestation with non-Hodgkin's lymphoma required intubation and mechanical ventilation secondary to tumor-related airway obstruction. Immediately after intubation, propofol was initiated for sedation and maintained for 51 days with only one 5-day interruption in therapy. Over the course of the patient's stay in the intensive care unit, systemic chemotherapy was administered, resulting in a reduction in tumor burden and allowing for successful extubation. Ultimately, the fetus was deemed nonviable and the pregnancy was terminated. DISCUSSION: Propofol is an intravenous anesthetic agent commonly used for the sedation of mechanically ventilated patients and is the only sedative agent that carries a pregnancy category B rating. Fetal outcomes following long-term use of propofol during the first trimester have not been formally evaluated and few reports of propofol use outside of early pregnancy termination, outpatient procedures, or parturition exist in the medical literature. Our patient required early termination of pregnancy; however, we were unable to determine whether fetal loss was a result of propofol use, chemotherapy administration, the use of other pharmacologic agents, or perhaps a combined effect. CONCLUSIONS: Despite propofol's pregnancy category B rating, data are lacking in humans regarding its safe use during pregnancy and long-term developmental outcomes in children after exposure to propofol in utero. The safety of propofol as a sedative agent for critically ill pregnant patients remains unknown.

Validation Study of Energy Requirements in Critically Ill, Obese Cancer Patients.

BACKGROUND: Current guidelines from the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine (ASPEN/SCCM) regarding caloric requirements and the provision of nutrition support in critically ill, obese adults may not be suitable for similar patients with cancer. We sought to determine whether the current guidelines accurately estimate the energy requirements, as measured by indirect calorimetry (IC), of critically ill, obese cancer patients. MATERIALS AND METHODS: This was a retrospective validation study of critically ill, obese cancer patients from March 1, 2007, to July 31, 2010. All patients ≥18 years of age with a body mass index (BMI) ≥30 kg/m(2) who underwent IC were included. We compared the measured energy expenditure (MEE) against the upper limit of the recommended guideline (25 kcal/kg of ideal body weight [IBW]) and MEE between medical and surgical patients in the intensive care unit. RESULTS: Thirty-three patients were included in this study. Mean MEE (28.7 ± 5.2 kcal/kg IBW) was significantly higher than 25 kcal/kg IBW (P < .001), and 78% of patients had nutrition requirements greater than the current guideline recommendations. No significant differences in MEE between medical and surgical patients in the ICU were observed. CONCLUSIONS: Critically ill, obese cancer patients require more calories than the current guidelines recommend, likely due to malignancy-associated metabolic variations. Our results demonstrate the need for IC studies to determine the energy requirements in these patients and for reassessment of the current recommendations.