Safety of megadose meropenem in the empirical treatment of nosocomial sepsis: a pilot randomized clinical trial.

Objective: To evaluate the safety of megadose meropenem as empirical treatment of nosocomial sepsis. Materials & methods: Critically ill patients diagnosed with sepsis received either high-dose (2 g every 8 h) or megadose (4 g every 8 h) meropenem as an intravenous infusion over 3 h. Results: A total of 23 patients with nosocomial sepsis were eligible and included in the megadose (n = 11) or high-dose (n = 12) group. No treatment-related adverse events were observed during a 14-day follow-up. Clinical response was also comparable between the groups. Conclusion: Megadose meropenem may be considered for empirical treatment of nosocomial sepsis without serious concern regarding its safety.

As resistance to antibiotics is increasing among microbes, rational use of these drugs is important both in the community and in hospitals. Many infections with resistant microorganisms may be fatal. For a long time, carbapenems have been the last resort for treatment of resistant microorganisms. Unfortunately, resistance to these drugs is increasing. It appears that use of higher doses of antibiotics may help in some cases. However, the potential harm caused by higher doses is a problem. In this primary study, higher doses of meropenem, a common carbapenem, were found to be safe.

Clinical features and risk factors associated with acute respiratory distress syndrome in pregnant women diagnosed with COVID-19: a multi-center case-control study.

OBJECTIVES: The aim of this study was to evaluate differences in clinical features and laboratory parameters in critically ill pregnant women with acute respiratory distress syndrome (ARDS) compared to moderate and severe pregnant women with coronavirus disease-2019 (COVID-19) but without ARDS. METHODS: This was a retrospective multicenter study of all pregnant women with COVID-19 diagnosed with ARDS between February 15, and May 1, 2020 in nine level III maternity centers in Iran (ARDS group). The control COVID-19 pregnant women were selected from 3 of 9 level III maternity centers between March 15 and April 20, 2020. Univariate statistics were used to look at differences between groups. Cluster dendrograms were used to look at the correlations between clinical and laboratory findings in the groups. A value of p <.05 was considered statistically significant. RESULTS: Fifteen COVID-19 infected women with ARDS were compared to 29 COVID-19 positive and ARDS negative control (moderate: (n = 26) 89.7% and severe: (n = 3)10.3%). The mean maternal age (35.6 vs. 29.4 years; p = .002) and diagnosis of chronic hypertension (20.0% vs. 0%, p = .034) were significantly higher in the ARDS group. There was no significant difference between the two groups in their presenting symptoms. The ARDS group had a significantly higher prevalence of tachypnea (66.6% vs. 10.3%, p = .042) and blood oxygen saturation (SpO2) <93% (66.6% vs. 10.3%, p = .004) at presentation. Relative lymphopenia (lymphocyte ratio < 10.5%, 66.6% vs. 17.2%, p = .002), lymphocytes to leukocytes ratio (11.3% vs. 17.7%, p = .010), and neutrophils to lymphocytes ratio (NLR) >7.5 were significantly different between the two groups (all p < .05). CONCLUSION: Our data demonstrate that symptom-based strategies for identifying the critically ill pregnant women with SARS-CoV-2 are insufficient; however, vital signs and laboratory data might be helpful to predict ARDS in critically ill COVID-19 pregnant patients.

Ventilator-associated Pneumonia: Multidrug Resistant Acinetobacter vs. Extended Spectrum Beta Lactamase-producing Klebsiella.

INTRODUCTION: Ventilator-associated pneumonia (VAP) has been considered as a healthcare-associated infection with high mortality. Acinetobacter baumannii and Klebsiella pneumoniae are the common causes of VAPs around the world. METHODOLOGY: This research was a retrospective observational study in the intensive care unit (ICU) in a tertiary referral collegiate hospital in Tehran between March 2016 and May 2018. Patients who fulfilled VAP due to documented Multidrug Resistant Acinetobacter baumannii (MDR-AB) or Extended Spectrum Beta Lactamase-producing Klebsiella pneumoniae (ESBL-KP) criteria were enrolled. General demographic features, duration of hospital stay, antimicrobial treatment regimens, duration of ICU admission, the period of mechanical ventilation (MV) and 30-day mortality were documented and compared. RESULTS: 210 patients were found with clinical, microbiological and radiological evidence of VAP. In total, 76 patients with MDR-AB and 76 patients with ESBL-KP infections were matched in the final analysis. Duration of hospitalization in the patients with MDR-AB was significantly more than that of patients infected with ESBL-KP (p-value: 0.045). Patients diagnosed with MDR-AB VAP had a 65.8% mortality rate compared to 42.1% in the ESBL-KP infection group (p = 0.003). CONCLUSIONS: Results of the present study demonstrated that VAPs caused by MDR-AB may be more hazardous than ESBL-KP VAPs because they could be accompanied by a longer hospitalization course and even a higher mortality.

Antibiotic stewardship program in Intensive Care Unit: First report from Iran.

INTRODUCTION: Few data regarding antibiotic stewardship programs in critically ill patients are available. In the present study, the consequence of changing an empirical antibiotic regimen from a carbapenem (meropenem) to a noncarbapenem antibiotic (piperacillin-tazobactam) was evaluated in critically ill patients with a suspicion of sepsis. METHODS: This open-label randomized clinical trial was conducted during May 2015-January 2017 at the general Intensive Care Unit of the Imam Khomeini Hospital Complex, Tehran, Iran. In this study, a carbapenem (meropenem) or a noncarbapenem (piperacillin-tazobactam) antibiotic was considered as an empirical antibiotic regimen in 100 critically ill patients with a suspicion of sepsis. Clinical response and bacterial eradication were defined as primary and secondary outcomes of the study, respectively. Chi-square, Mann-Whitney, and independent sample t-tests were used for comparing variables between the groups. ANOVA was used to compare changes in the mean differences of parameters between the groups. Meaningful difference was indicated as P ≤ 0.05. RESULTS: During the first 72 h of the antibiotic course, the number of patients with clinical response was comparable between piperacillin-tazobactam and meropenem groups (21 [42%] and 25 [50%], respectively, P = 0.31). Also, at this time, microbial eradication occurred in 13 (54.16%) and 9 (40.90%) patients in piperacillin-tazobactam and meropenem groups, respectively (P = 0.67). CONCLUSIONS: Using a carbapenem (meropenem) instead of a noncarbapenem (piperacillin-tazobactam) as an empirical antibiotic regimen did not affect clinical response and bacterial eradication rates in critically ill patients with a suspicion of sepsis.

Comparing efficacy of enteral nutrition plus ranitidine and enteral nutrition alone as stress ulcer prophylaxis.

AIM: Adequacy of enteral nutrition (EN) alone as stress ulcer prophylaxis (SUP) is controversial. The aim of this study was to compare efficacy of EN alone and ranitidine plus EN as SUP. METHOD: Critically ill adults with indications to receive SUP were randomized to ranitidine 50 mg IV every 8 h plus EN (SUP) or EN alone (non-SUP) group for 7 days. Besides, endoscopy was performed at the time of recruitment and on day 7. RESULTS: During the study period, only one patient in each group of SUP and non-SUP experienced gastrointestinal bleeding. At the time of recruitment, gastric erosion and erythema were the most endoscopic findings in the SUP and non-SUP groups. These findings did not significantly change at the end of the study (p = 0.21). CONCLUSION: EN was at least effective as ranitidine plus EN as SUP.

Metoclopramide as intermittent and continuous infusions in critically ill patients: a pilot randomized clinical trial.

AIM: Metoclopramide is commonly used as a prokinetic agent in critically ill patients with enteral feeding intolerance. In this study, noninferiority of metoclopramide as intermittent versus continuous infusion was examined in critically ill patients with enteral feeding intolerance. METHODS: Forty critically ill adults patients were assigned to receive metoclopramide as either intermittent (10 mg every 6 h) or continuous (2 mg/h) infusion. Frequency of feeding intolerance and adverse effects of metoclopramide were assessed during 7 days of study. RESULTS: Number of patients with feeding intolerance during different times of the course was not different between the groups. Although not statistically significant, diarrhea and cardiac rhythm were more common in continuous than intermittent infusion group. CONCLUSION: Continuous and intermittent infusions of metoclopramide showed equivalent effectiveness in critically ill patients.

Effect of high-dose Ascorbic acid on vasopressor's requirement in septic shock.

OBJECTIVE: Effects of ascorbic acid on hemodynamic parameters of septic shock were evaluated in nonsurgical critically ill patients in limited previous studies. In this study, the effect of high-dose ascorbic acid on vasopressor drug requirement was evaluated in surgical critically ill patients with septic shock. METHODS: Patients with septic shock who required a vasopressor drug to maintain mean arterial pressure >65 mmHg were assigned to receive either 25 mg/kg intravenous ascorbic acid every 6 h or matching placebo for 72 h. Vasopressor dose and duration were considered as the primary outcomes. Duration of Intensive Care Unit (ICU) stay and 28-day mortality has been defined as secondary outcomes. FINDINGS: During the study period, 28 patients (14 in each group) completed the trial. Mean dose of norepinephrine during the study period (7.44 ± 3.65 vs. 13.79 ± 6.48 mcg/min, P = 0.004) and duration of norepinephrine administration (49.64 ± 25.67 vs. 71.57 ± 1.60 h, P = 0.007) were significantly lower in the ascorbic acid than the placebo group. No statistically significant difference was detected between the groups regarding the length of ICU stay. However, 28-day mortality was significantly lower in the ascorbic acid than the placebo group (14.28% vs. 64.28%, respectively; P = 0.009). CONCLUSION: High-dose ascorbic acid may be considered as an effective and safe adjuvant therapy in surgical critically ill patients with septic shock. The most effective dose of ascorbic acid and the best time for its administration should be determined in future studies.

Protective and hypoglycemic effects of celery seed on streptozotocin-induced diabetic rats: experimental and histopathological evaluation.

AIMS: Diabetes mellitus is a major manifestation of metabolic disorder which presents with hyperglycemia (high levels of serum blood sugar). In the present study, we aimed to investigate the effects of celery seed extract on different biochemical factors and histopathological changes in normal and streptozotocin (STZ)-induced diabetic rats. METHODS: A total of 35 male Wistar rats were divided into five groups (one normal and four diabetic groups). STZ was injected intraperitoneally to induce diabetes. The effects of hexane extract of celery seed and glibenclamide (as a positive control) were compared. Blood samples were analyzed on days 0, 18, and 33, and histopathological evaluations were performed at the end of the study. RESULTS: Glucose, triglycerides, and cholesterol levels significantly decreased, whereas insulin and high-density lipoprotein (HDL) levels increased in the extract-administered groups, as compared to the negative diabetic control group (P < 0.0001). The concentrations of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in serum of the extract-administered groups were significantly less than the negative control group (P < 0.0001). Histopathological reports revealed significantly less atrophy, necrosis, and inflammation in the rats receiving celery seed extract compared to the negative control group. CONCLUSIONS: The results indicated that celery seed extract can be effective in controlling hyperglycemia and hyperlipidemia in diabetic rats, and demonstrated its protective effects against pancreatic toxicity resulting from STZ-induction.

Evaluation of health related quality of life changes after initial orthodontic treatment.

PURPOSE: To evaluate the changes of Oral Health Related Quality of Life (OHRQoL) in patients after the placement of a fixed orthodontic appliance. MATERIALS AND METHODS: This prospective study consisted of 148 adolescents (97 girls and 51 boys) between the ages of 14 and 17 who were patients of an orthodontic clinic. OHRQoL was assessed by a modified questionnaire that evaluated four domains: oral symptoms, functional limitations as well as emotional and social well-being in three time frames: before bonding and banding (T(0)), two months after initiating orthodontic treatment (T(1)) and six months after initiating orthodontic treatment (T(2)). The repeated measures test was used to compare the relative changes of OHRQoL among the different time frames. RESULTS: There were no significant differences between the levels of OHRQoL and its domains for boys or girls at any time point. The overall level of OHRQoL decreased significantly at T(1) relative to T(0); however, the emotional well-being domain improved at T(1) in comparison to T(0). At T(2), the OHRQoL level increased significantly relative to T(0) in all domains. CONCLUSION: The patients' quality-of-life level decreased by initiating orthodontic treatment; however, during that period, emotional well-being increased. As orthodontic treatment progressed, the quality of life level increased.

Rapidly changing tachyarrhythmia in acute stroke.

INTRODUCTION: We report a 56-year-olds female with supraventricular arrhythmia due acute ischemic stroke without structural heart disease. CASE DESCRIPTION: A patient presented with sudden onset of lethargy, right hemiplegia, and global aphasia. There was previous history of stroke 1 year ago presented with left hemiplegia that recovered completely during 10 days. There was no history of comorbid illness. The brain CT revealed extensive hypodensity in left temporoparietal region suggestive of infarct without midline shift. General examination revealed hypotension and bradycardia that treated with dopamine that gradually recovered during 5 days thus infusion of dopamine discontinued, and muscular power in paretic limbs and aphasia was recovered. In 6th day of admission electrocardiographic monitoring of patient showed a rapidly changing tachyarrhythmia including sinus tachycardia, atrial fibrillation, and atrial flutter that quickly interchanged to another, without hemodynamic instability and alteration in mental status. Laboratory tests and TEE study were normal. During 48 hour arrhythmia relived spontaneously. DISCUSSION: Stroke can cause any type of cardiac arrhythmias that may not be constant.