Probative Value of the D-Dimer Assay for Diagnosis of Deep Venous Thrombosis in the Coronavirus Disease 2019 Syndrome.

OBJECTIVES: To describe the predictive utility of the D-dimer assay among patients with the coronavirus disease 2019 syndrome for unprovoked lower extremity deep venous thrombosis. DESIGN: Prospective observational study with retrospective data analysis. SETTING: Academic medical center surgical ICU. PATIENTS: Seventy-two intubated patients with critical illness from coronavirus disease 2019. INTERVENTIONS: Therapeutic anticoagulation after imaging diagnosis of the first three deep venous thrombosis cases was confirmed; therapeutic anticoagulation as prophylaxis thereafter to all subsequent ICU admissions. MEASUREMENTS AND MAIN RESULTS: Seventy-two patients with severe coronavirus disease 2019 were screened for deep venous thrombosis after ICU admission with 102 duplex ultrasound examinations, with 12 cases (16.7%) of lower extremity deep venous thrombosis identified. There were no differences between groups with respect to age, renal function, or biomarkers except for D-dimer (median, 12,858 ng/mL [interquartile range, 3,176-30,770 ng/mL] for lower extremity deep venous thrombosis vs 2,087 ng/mL [interquartile range, 638-3,735 ng/mL] for no evidence of deep venous thrombosis; p < 0.0001). Clinical screening tools (Wells score and Dutch Primary Care Rule) had no utility. The C-statistic for D-dimer concentration was 0.874 ± 0.065. At the model-predicted cutoff value of 3,000 ng/mL, sensitivity was 100%, specificity was 51.1%, positive predictive value was 21.8%, and negative predictive value was 100%. CONCLUSIONS: Lower extremity deep venous thrombosis is prevalent in coronavirus disease 2019 disease and can be present on ICU admission. Screening has been recommended in the context of the pro-inflammatory, hypercoagulable background milieu. D-dimer concentrations are elevated in nearly all coronavirus disease 2019 patients, and the test appears reliable for screening for lower extremity deep venous thrombosis at or above a concentration of 3,000 ng/mL (more than 13-fold above the normal range). Full anticoagulation is indicated if the diagnosis is confirmed, and therapeutic anticoagulation should be considered for prophylaxis, as all coronavirus disease 2019 patients are at increased risk.

Successful Cholecystectomy After Endoscopic Ultrasound Gallbladder Drainage Compared With Percutaneous Cholecystostomy, Can it Be Done?

BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage (EGBD) with a lumen apposing metal stent is becoming a widely accepted alternative to percutaneous gallbladder drainage (PTGD) for patients who are not candidates for cholecystectomy (CCY). In some patients, medical comorbidites can improve, allowing them to undergo CCY. We compare feasibility and outcomes of interval CCY after EGBD versus PTGD. METHODS: We conducted a multicentered international cohort study of patients who underwent EGBD or PTGD and then underwent interval CCY. Baseline patient demographics, procedural details, and follow-up data were recorded and compared. RESULTS: In total, 34 patients were included. Thirteen patients underwent EGBD followed by CCY (mean age, 53.77±17.27, 46.15% male), and 21 patients underwent PTGD followed by CCY (mean age, 62.14±13.06, 61.9% male). There was no statistically significant difference in mean Charlson Comorbidity Index (P=0.12) or etiology of cholecystitis (P=0.85) between the 2 groups. All patients had a technically successful CCY. There was no difference between rates of open versus laparoscopic CCY (P=1). In addition, there was no difference in postsurgical adverse events (P=0.23). CONCLUSIONS: Surgical CCY after EGBD with lumen apposing metal stent is safe and feasible for the management of cholecystitis. If patient's underlying medical conditions improve, previous EUS-GLB drainage should not preclude patients from undergoing CCY as part of standard of care.

Transcutaneous Endoscopic Necrosectomy for Walled-off Pancreatic Necrosis in the Paracolic Gutter.

BACKGROUND: Walled-off pancreatic necrosis (WON) is a sequelae of acute pancreatitis that requires debridement, once infected. Recently, endoscopic necrosectomy has become the mainstay for management. However, peripancreatic collections that extend to the paracolic gutter or lesser sac, are more challenging to treat endoscopically. We report an endoscopic method for management of necrotic collections that extend into the paracolic gutter. METHODS: Consecutive patients, with symptomatic WON extending into the retroperitoneum, were included in a prospective registry. Each patient underwent transcutaneous endoscopic necrosectomy (TEN) through a fully covered self-expanding esophageal metal stent. After resolution of the collection, the external stent was removed, and the cutaneous fistula was allowed to close by secondary intention. Clinical success was defined as resolution of the WON, and successful removal of all percutaneous drains. Patient demographics, procedural/periprocedural adverse events, and follow-up data, were collected. RESULTS: Nine patients underwent direct TEN. Patients initially underwent CT-guided percutaneous drainage, with an average of 31 days between initial drainage and endoscopic necrosectomy. All patients had a technically successful placement of a fully covered esophageal metal stent through the cutaneous fistula. After a median of 3 endoscopic debridement sessions, 8 of 9 (89%) patients had successful removal of all percutaneous drains, and resolution of necrotic collections. One patient died of multisystem organ failure from severe acute pancreatitis. CONCLUSIONS: TEN for infected WON is a safe and efficacious technique for patients with endoscopically inaccessible collections.

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank.

INTRODUCTION: While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims. PATIENTS AND METHODS: We conducted a retrospective analysis of the 2008-2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable "intent of injury." RESULTS: 3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18-59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults. CONCLUSIONS: Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.

Colonic diverticulitis in chemotherapy patients: should operative indications change? A retrospective cohort study.

INTRODUCTION: Management of the immunosuppressed patient with diverticular disease remains controversial. We report the largest series of colon cancer patients undergoing chemotherapy and hospitalized for acute diverticulitis, to determine whether recent treatment with systemic chemotherapy is associated with increased risk for/increased severity of recurrent diverticulitis. METHODS: Retrospective cohort study of adult patients hospitalized for an initial episode of acute colonic diverticulitis at Memorial Sloan Kettering Cancer Center, 1988-2004. Outcomes in patients receiving systemic chemotherapy within one month of admission for diverticulitis ("Chemo") were compared to outcomes of patients not receiving chemotherapy within the past month ("No-chemo"). RESULTS: A total 131 patients met inclusion criteria. Chemo patients did not differ significantly from No-chemo group in terms of severity of acute diverticulitis at index admission (13.2% vs. 4.4%, respectively, p = 0.12), resumption of chemotherapy (median 2 months), failure of non-operative management (13.2% vs 4.4%, respectively, p = 0.12), frequency of recurrence (20.5% vs 18.5%), hospital length of stay (p = 0.08), and likelihood of interval resection (24.0% vs. 16.2%, respectively, p = 0.39). Chemo patients recurred with more severe disease, were more likely to undergo emergent surgery (75.0% vs. 23.5%, respectively, p = 0.03), and were more likely to be diverted (100.0% vs. 25.0%, respectively, p = 0.03). Chemo patients were significantly more likely to incur a postoperative complication (100% vs 9.1% p < 0.01) following interval resection. Overall mortality was significantly higher in the Chemo vs. No-chemo group. Median survival in Chemo patients was 3.4 years; in No-chemo patients, median survival was not reached at 10 years. CONCLUSION: Our data do not support routine elective surgery for acute diverticulitis in patients receiving chemotherapy. Non-operative management in the acute or interval setting appears preferable whenever possible.

Spinning-induced Rhabdomyolysis and the Risk of Compartment Syndrome and Acute Kidney Injury: Two Cases and a Review of the Literature.

Exercise-induced rhabdomyolysis related to military training, marathon running, and other forms of strenuous exercise has been reported. The incidence of acute kidney injury appears to be lower in exercise-induced cases. We present 2 cases of exercise-induced rhabdomyolysis following spinning classes, one of which was further complicated by acute compartment syndrome requiring bilateral fasciotomies of the anterior thigh and acute kidney injury. With vigorous hydration and urine pH monitoring, both patients exhibited good mobility, sensation, and renal function on discharge.

Efficacy of therapy with recombinant human activated protein C of critically ill surgical patients with infection complicated by septic shock and multiple organ dysfunction syndrome.

BACKGROUND: Septic shock causing or complicating critical surgical illness results in high mortality. Drotrecogin alfa (activated), known also as recombinant human activated protein C (rhAPC) has become controversial as therapy, owing to persisting questions of efficacy and safety. We hypothesized rhAPC to be effective therapy for critically ill surgical patients with septic shock. METHODS: Open-label therapy with rhAPC (by predefined criteria) of 108 critically ill surgical patients. Treated patients were matched individually in prospect for age, gender, Acute Physiology and Chronic Health Evaluation (APACHE)-II and -III scores, site of infection, and organism (0-2 points each, maximum 12 points) with 108 patients from our 15,000-patient surgical intensive care unit database who did not receive rhAPC. No match was accepted if <6 points. Multiple organ dysfunction (MOD) scores and data regarding cortisol concentrations, bleeding complications, and transfusion requirements were collected. The primary endpoint was 28-day mortality, with mortality for hospitalization and resolution of organ dysfunction as secondary endpoints. Statistical analyses included ANOVA, c statistic, binary logistic regression, and Kaplan-Meier time-to-event and Cox proportional hazards analyses; α=0.05. RESULTS: The mean match score was 9.2±0.1 points (range, 6-12 points). Patients were well matched by all criteria, including baseline MOD score (9.5±0.7 vs. 9.8±0.3 points, p=0.66). Mean age was 68.1±1.1 years (p=0.49), Mean APACHE-III score was 99.6±1.5 points (p=0.87). Mean time to rhAPC administration was 25±3 h. Survival at 28 days after rhAPC was 71.3% vs. 49.1% (p=0.001); hospital survival was 57.4% vs. 40.7% (p=0.02). By logistic regression, rhAPC therapy resulted in improved 28-day survival (OR 2.57, 95% CI 1.46-4.52, p=0.001) (model χ2 11.244, p=0.001); and hospital survival (OR 1.96, 95% CI 1.14-3.36, p=0.015) (model χ2 6.03, p=0.014). The MOD score decreased significantly (p=0.012) during rhAPC therapy. CONCLUSION: Therapy with rhAPC appeared to improve survival in surgical ICU patients with life-threatening infection characterized by septic shock and organ dysfunction.

Contemporary predictors of conversion from laparoscopic to open appendectomy.

BACKGROUND: We defined the contemporary conversion rate from laparoscopic appendectomy (LA) to open appendectomy and identified pre-operative factors associated with conversion. METHODS: Retrospective review of 941 consecutive LAs performed for suspected acute appendicitis in a single urban university hospital between 2000 and 2007. Patient characteristics, clinical features, physical examination findings, laboratory values, computed tomography (CT) findings, surgeon identity, operative findings, and pathologic results were assessed. Categorical variables were compared in patients undergoing LA and those in whom conversion was necessary using the Fisher exact test; the Student t-test was used to compare continuous variables. Multivariable analysis was performed with binomial logistic regression. Statistical significance was established at α = 0.05. RESULTS: The overall conversion rate was 4.1% and did not change significantly over the course of the study. By univariable analysis, conversion was significantly associated with older age, male gender, American Society of Anesthesiologists (ASA) score >2 points, longer duration of symptoms, rigidity on physical examination, increased percentage of neutrophils on admission white blood cell differential count, extraluminal air on CT, inexperience of the attending surgeon with LA, retrocecal location of the appendix, gross necrosis or perforation, murky or purulent ascites, and microscopic evidence of perforation. By multivariable analysis, advanced age (hazard ratio [HR] 1.02 per year; 95% confidence interval [CI] 1.01-1.04, p = 0.02), ASA score >2 points (HR 11.2; 95% CI 5.6-24.4; p < 0.001), CT inflammation grade ≥ 4 (HR 4.8; 95% CI 1.9-12.3; p = 0.001), and attending surgeon inexperience (HR 7.4; 95% CI 2.6-20.8; p < 0.001) were independent predictors of conversion. CONCLUSION: The conversion rate during laparoscopic appendectomy has not changed significantly over the past seven years and remains ~4%. Independent pre-operative predictors of conversion are advanced age, ASA score >2 points, attending surgeon inexperience, and extensive inflammation observed on pre-operative CT scan. Proceeding directly with open appendectomy under these circumstances may reduce operative time, expense, and morbidity.

Acute acalculous cholecystitis.

Acute acalculous cholecystitis (ACC) can develop with or without gallstones after surgery and in critically ill or injured patients. Diabetes mellitus, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, shock, and cardiac arrest also have been associated with AAC. The pathogenesis of AAC is complex and multifactorial. Ultrasound of the gallbladder is most accurate for the diagnosis of AAC in the critically ill patient. CT is probably of comparable accuracy, but carries both advantages and disadvantages. Rapid improvement may be expected when AAC is diagnosed correctly and cholecystostomy is performed timely.

The pathogen of ventilator-associated pneumonia does not influence the mortality rate of surgical intensive care unit patients treated with a rotational antibiotic system.

BACKGROUND: Ventilator-associated pneumonia (VAP) is one of the leading causes of morbidity in critically ill surgical patients. Certain pathogens (e.g., methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa) have been associated with an excess mortality rate from sepsis in several studies, but not in the surgical setting specifically or when protocol-driven antibiotic therapy is administered. PURPOSE: We sought to determine which factors and, in particular, whether the individual pathogen affected the mortality rate in our surgical intensive care unit (ICU), where a rotational antibiotic system has been employed continuously since 1997. We hypothesized that the type of pathogen and illness severity were the primary influences on the mortality rate of patients with VAP. METHODS: A total of 198 consecutive patients from a university surgical ICU, with clinical signs of VAP confirmed by quantified isolation of significant numbers of a pathogen (> or =10(4) colony-forming units [cfu]/mL) from bronchoalveolar (BAL) fluid obtained by fiberoptic bronchoscopy, were identified prospectively from January 2001 to November 2004. The data collected were age, sex, Acute Physiology and Chronic Health Evaluation (APACHE) III score, multiple organ dysfunction score, unit day of diagnosis, time (h) to antibiotic administration (TTA), appropriateness of initial therapy (AIT), unit and hospital length of stay, and mortality rate. Pathogens were classified as non-lactose-fermenting gram-negative bacilli (NGNB), lactose-fermenting gram-negative bacilli (LGNB), methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus, yeast, community-acquired pneumonia (e.g., Streptococcus pneumoniae), or other pathogens. Patients with a polymicrobial isolate were placed in the "other" category. RESULTS: The overall mortality rate was 32.3% vs. 55% as predicted by APACHE III normative data. The overall AIT was 92%. The mortality rate for NGNB infections was 35.6% vs. 29.4% for LGNB infections (p = NS). By logistic regression, neither TTA, AIT, nor pathogen influenced the mortality rate. CONCLUSIONS: The type of pathogen does not influence death in surgical ICU patients with VAP diagnosed rigorously and treated by a rotational antibiotic system. The high proportion of AIT as a result of the rotational antibiotic administration system optimizes bacterial killing and negates the impact of bacterial resistance, contributing to better outcomes.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003-2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.

Implementation of tight glucose control for critically ill surgical patients: a process improvement analysis.

BACKGROUND: Tight glucose control has been advocated as a method to improve outcomes of surgical critical care. However, continuous infusion of insulin has potential morbidity (e.g., neurologic consequences of hypoglycemia), and it remains unclear to what degree the glucose concentration must be controlled. We examined our performance in instituting a protocol for tight glucose control in our surgical intensive care unit (ICU). METHODS: Prospective study of 220 consecutive patients (February, 2003-March, 2006) who received an infusion of insulin for glucose control for >24 h by protocol. Data collected included age, acuity (Acute Physiology and Chronic Health Evaluation [APACHE] III) score, sex, history of diabetes mellitus, organ dysfunction (Marshall), and death or survival. Infusion-related data included initial glucose concentration, time to glucose <120 mg/dL, h/day of glucose <110 mg/dL and <140 mg/dL, duration of infusion (days), insulin units/day, year of therapy, and complications. Analysis was performed by chi(2), analysis of variance, and logistic regression, with p < 0.05 considered significant. RESULTS: Insulin drips were required by 10.2% of patients (287/2,804); 29 of these (10.1%) had diabetes mellitus. The mean APACHE III score for the treated patients was 77 +/- 2 (standard deviation), and the mortality rate was 24%. Hypoglycemia (<60 mg/dL) occurred in 4.2% of patients. The trigger insulin concentration decreased over time (2003 vs. 2005) from 249 +/- 14 to 160 +/- 5 mg/dL, and the h/day of glucose <140 increased from 11 +/- 1 to 16 +/- 1. However, age, acuity, APACHE III, days of insulin, time to achieve glucose <120, h/day of glucose <110, and mortality rate were unchanged. By logistic regression, only the year of treatment (odds ratio [OR] 1.871; 95% confidence interval [CI] 1.177, 2.972; p = 0.008] predicted success in controlling the blood glucose concentration to <140 mg/dL; age, illness severity, diabetes history, and trigger glucose concentration [OR 0.996; 95% CI 0.992, 1.001; p = 0.11] did not. CONCLUSIONS: Success in implementing tight glucose control was modest, albeit improving, despite a specific protocol for administration. No medical reason could be identified for inability to achieve tight glucose control; therefore, successful implementation must be volitional. Education, particularly regarding hypoglycemia, and possible refinement of our protocol may improve our ability to control blood glucose in our ICU.

Multiple organ dysfunction syndrome in critical surgical illness.

BACKGROUND: Multiple organ dysfunction syndrome (MODS) is the leading cause of death in surgical patients and in trauma patients who survive the first 24 h. First observed systematically among Vietnam War-era battle casualties who began to survive previously fatal injuries owing to improved evacuation, triage, and resuscitation, only to develop catastrophic manifestations of organ failure never before seen, the syndrome was recognized formally in 1975 as "multiple organ failure." Ensuing observations and investigations, undertaken in large part by surgeon-scientists, have refined our current understanding of MODS, yielding better outcomes. METHODS: Review and synthesis of pertinent literature with personal observations and recollections of the senior investigator. RESULTS: The MODS is now recognized as a continuum of physiologic derangements, rather than an all-or-nothing phenomenon. The most common precipitant appears to be ischemia-reperfusion injury, although severe sepsis also is commonplace. Descriptive biology has enhanced the understanding of the pathogenesis and outcomes of MODS, although the therapy is largely supportive, making prevention of paramount importance. Measures such as drotrecogin alfa (activated), intensive insulin therapy, corticosteroids, and low tidal volume ventilation may be effective. CONCLUSIONS: Although current treatment of MODS remains primarily supportive, the mortality rate appears to be decreasing. Appreciation of the interrelations between the inflammatory and coagulation systems provides hope in the battle against this frequent, elusive, deadly, and costly syndrome.

Treatment of complicated skin and soft tissue infections.

BACKGROUND: Skin and soft tissue infections (SSTIs) may produce substantial morbidity and mortality rates, particularly those classified as complicated or necrotizing. OBJECTIVE: To weigh the strength of recommendations using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology and to provide evidence-based recommendations for diagnosis and management for SSTIs. DATA SOURCES: Computerized identification of published research and review of relevant articles. STUDY SELECTION: All published reports on the management of complicated and necrotizing SSTIs were evaluated by an expert panel of members of the Surgical Infection Society according to published guidelines for evidence-based medicine. The quality of the evidence was judged by the GRADE methodology and criteria. Practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis. DATA EXTRACTION: Information on demographics, study dates, microbiology findings, antibiotic type, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted. Results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document. DATA SYNTHESIS: Current surgical and antibiotic management of complicated SSTIs is based on a small number of studies that often have insufficient power to draw well-supported conclusions, with the exception of antimicrobial therapy for non-necrotizing soft tissue infections, for which ample data are available.

Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients?

BACKGROUND: Ventilator-associated pneumonia (VAP) is a leading cause of mortality in critically ill patients. Although previous studies have shown that de-escalation therapy (DT) of antibiotics may decrease costs and the development of resistant pathogens, minimal data have shown its effect in surgical patients or in any patients with septic shock. We hypothesized that DT for VAP was not associated with an increased rate of recurrent pneumonia (RP) or mortality in a high acuity cohort of critically ill surgical patients. METHODS: All surgical intensive care unit (SICU) patients from January 2005 to May 2007 with VAP diagnosed by quantitative bronchoalveolar lavage with a positive threshold of 10,000 CFU/mL were identified. Data collected included age, gender, Acute Physiologic and Chronic Health Evaluation Score III (A3), type of bacterial or other pathogen, antibiotics used for initial and final therapy, mortality, RP, and appropriateness of initial therapy (AIT). Patients were designated as receiving AIT, DT, or escalation of antibiotic therapy based on microbiology for their VAP. RESULTS: One hundred thirty-eight of 1,596 SICU patients developed VAP during the study period (8.7%). For VAP patients, the mean Acute Physiologic and Chronic Health Evaluation III score was 82.7 points with a mean age of 63.8 years. The RP rate was 30% and did not differ between patients receiving DT (27.3%) and those who did not receive DT (35.1%). Overall mortality was 37% (55% predicted by A3 norms) and did not differ between those receiving DT (33.8%) or not (42.1%). The most common pathogens for primary VAP were methicillin-resistant Staphylococcus aureus (14%), Escherichia coli (11%), and Pseudomonas aeruginosa (9%) whereas P. aeruginosa was the most common pathogen in RP. The AIT for all VAP was 93%. De-escalation of therapy occurred in 55% of patients with AIT whereas 8% of VAP patients required escalation of antibiotic therapy. The most commonly used initial antibiotic choice was vancomycin/piperacillin-tazobactam (16%) and the final choice was piperacillin-tazobactam (20%). Logistic regression demonstrated no specific parameter correlated with development of RP. Higher A3 (Odds ratio, 1.03; 95% confidence interval, 1.01-1.05) was associated with mortality whereas lack of RP (odds ratio, 0.31; 95% confidence interval, 0.12-0.80), and AIT reduced mortality (odds ratio, 0.024; 95% confidence interval, 0.007-0.221). Age, gender, individual pathogen, individual antibiotic regimen, and the use of DT had no effect on mortality. CONCLUSION: De-escalation therapy did not lead to RP or increased mortality in critically ill surgical patients with VAP. De-escalation therapy was also shown to be safe in patients with septic shock. Because of its acknowledged benefits and lack of demonstrable risks, de-escalation therapy should be used whenever possible in critically ill patients with VAP.