Pattern of acquisition of hospital-associated pathogens in the ICU of an academic tertiary care hospital.

BACKGROUND: Among hospitalized patients, a 48-hour window from time of hospitalization defines nosocomial infections and guides empiric antibiotic selection. This time frame may lead to overuse of broad-spectrum antibiotics. Our primary objective was to determine the earliest and median time since hospital admission to acquire antibiotic-resistant pathogens among patients admitted to the intensive care unit (ICU) of an academic, tertiary care hospital. METHODS: Retrospective chart review was conducted for adult patients admitted to the ICU from home or another hospital within the same health authority in 2018, to identify the time to acquisition of hospital-associated pathogens: methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales, non-ESBL ceftriaxone-resistant Enterobacterales, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. Patients transferred from hospitals outside the health authority, admitted to ICU after 14 days of hospitalization, who were solid organ or bone marrow transplant recipients, or who were otherwise immunocompromised were excluded. RESULTS: In 2018, 1,343 patients were admitted to this ICU; 820 met the inclusion criteria. Of these, 121 (14.76%) acquired a hospital-associated pathogen in the ICU. The probability of isolating a hospital-associated pathogen by 48 hours of hospital admission was 3%. The earliest time to isolate any of these pathogens was 29 hours, and the median was 9 days (interquartile range [IQR] 3.8-15.6 days). CONCLUSIONS: Most patients (85.3%) in this ICU never acquired a hospital-associated pathogen. The median time to acquire a hospital-associated pathogen among the remaining patients suggests that initiating empiric broad-spectrum antibiotics on the basis of a 48-hour threshold may be premature.

HISTORIQUE : Chez les patients hospitalisés, une fenêtre de 48 heures après le moment de l'hospitalisation définit les infections nosocomiales et oriente la sélection d'antibiotiques empiriques. Cette période peut favoriser la surutilisation d'antibiotiques à large spectre. L'objectif primaire de l'étude visait à déterminer la période la plus courte et la période médiane à compter de l'admission pour que les patients admis en soins intensifs à partir d'un hôpital universitaire de soins tertiaires contractent des agents pathogènes antibiorésistants. MÉTHODOLOGIE: Les chercheurs ont procédé à un examen rétrospectif des dossiers des patients adultes admis en soins intensifs à partir de la maison ou d'un autre hôpital de la même autorité sanitaire en 2018, afin de déterminer la période avant de contracter des agents pathogènes associés au milieu hospitalier : Staphylococcus aureus résistant à la méthicilline, entérocoque résistant à la vancomycine, Enterobacterales producteurs de bêta-lactamases à spectre élargi (BLSE), Enterobacterales résistant à la ceftriaxine non producteurs de BLSE, Pseudomonas aeruginosa et Stenotrophomonas maltophilia. Ont été exclus les patients transférés d'un hôpital hors de l'autorité sanitaire, admis en soins intensifs plus de 14 jours après l'hospitalisation, receveurs d'un organe plein ou de moelle osseuse ou autrement immunodéprimés. RÉSULTATS: En 2018, 1 343 patients ont été admis en soins intensifs, dont 820 respectaient les critères d'inclusion. De ce nombre, 121 (14,67 %) ont contracté un agent pathogène en soins intensifs. La probabilité d'isoler un tel agent dans les 48 heures suivant l'admission en milieu hospitalier s'élevait à 3 %. Ces agents pathogènes ont été isolés au plus tôt 29 heures après l'hospitalisation, et au bout d'une période médiane de neuf jours (plage interquartile [PIQ] 3,8 à 15,6 jours). CONCLUSIONS: La plupart des patients (85,3%) de cette unité de soins intensifs n'ont jamais contracté d'agent pathogène associé au milieu hospitalier. Selon la période médiane avant d'acquérir un tel agent pathogène chez les autres patients, il serait prématuré d'entreprendre une antibiothérapie à large spectre au seuil de 48 heures.

Adding vitamin C to hydrocortisone lacks benefit in septic shock: a historical cohort study.

PURPOSE: Sepsis has high incidence and mortality rates, particularly in the intensive care unit (ICU). Corticosteroids may improve outcomes, and vitamin C may add benefit. We aimed to assess whether vitamin C and corticosteroids improved outcomes compared with corticosteroids alone. METHODS: This historical cohort study (11 December 2016 to 21 February 2018) was conducted in the ICU of a quaternary referral hospital. Patients with an ICU admission diagnosis of sepsis or septic shock who received vitamin C and hydrocortisone within 72 hr were compared with those who received only hydrocortisone. All patients received standard sepsis care including source control, antibiotics, and fluid resuscitation. Most patients received thiamine as standard ICU care. The primary outcome was hospital mortality. Secondary outcomes included ICU mortality, ventilator-free days, vasopressor-free days, dialysis use, and duration of ICU admission. RESULTS: One hundred and forty-four patients were included in the study. The mean (standard deviation [SD]) age was 64 (15) yr; 39% were female; and the mean (SD) Acute Physiology And Chronic Health Evaluation IV score was 89 (30). Eighty-eight patients did not receive vitamin C and 52 received vitamin C. There was no observed difference in hospital mortality between the non-vitamin C (36%) and vitamin C (39%) groups (adjusted odds ratio for hospital death, 0.52; 95% confidence interval, 0.20 to 1.34; P = 0.18). There were no statistically significant differences in any secondary outcomes. CONCLUSION: In this small observational study of ICU patients with septic shock, the addition of vitamin C to hydrocortisone therapy did significantly affect hospital mortality or other measures of mortality or organ dysfunction.

RéSUMé: OBJECTIF: Le sepsis comporte une incidence et des taux de mortalité élevés, particulièrement à l'unité de soins intensifs (USI). Les corticostéroïdes pourraient améliorer les pronostics, et la vitamine C pourrait être bénéfique. Notre objectif était d'évaluer si la vitamine C et les corticostéroïdes amélioraient les devenirs par rapport à un traitement de corticostéroïdes seulement. MéTHODE: Cette étude de cohorte historique (réalisée entre le 11 décembre 2016 et le 21 février 2018) a été réalisée à l'USI d'un hôpital quaternaire. Les patients ayant un diagnostic de sepsis ou de choc septique lors de leur admission à l'USI et ayant reçu de la vitamine C et de l'hydrocortisone dans les premières 72 heures ont été comparés à ceux n'ayant reçu que de l'hydrocortisone. Tous les patients ont reçu des soins standard pour le sepsis, soit un contrôle de la source de l'infection, un traitement antibiotique et une réanimation liquidienne. La plupart des patients ont reçu de la thiamine, un traitement standard à l'USI. Le critère d'évaluation principal était la mortalité hospitalière. Les critères d'évaluation secondaires comprenaient la mortalité à l'USI, les jours sans respirateur, les jours sans vasopresseurs, le recours à la dialyse et la durée de séjour à l'USI. RéSULTATS: Cent quarante-quatre patients ont été inclus dans notre étude. L'âge moyen (écart type [ÉT]) était de 64 (15) ans; 39 % étaient de sexe féminin; et le score APACHE IV moyen (ÉT) de 89 (30). Quatre-vingt-huit patients n'ont pas reçu de vitamine C et 52 en ont reçu. Aucune différence n'a été observée en matière de mortalité hospitalière entre les groupes sans vitamine C (36 %) ou avec vitamine C (39 %) (rapport de cotes ajusté pour la mortalité hospitalière, 0,52; intervalle de confiance 95 %, 0,20 à 1,34; P = 0,18). Il n'y a eu aucune différence statistiquement significative en ce qui touchait aux critères d'évaluation secondaires. CONCLUSION: Dans cette petite étude observationnelle portant sur des patients de l'USI en choc septique, l'ajout de vitamine C à un traitement d'hydrocortisone n'a pas eu d'impact significatif sur la mortalité hospitalière ou les autres mesures de mortalité ou d'atteintes organiques.

Evaluation of the Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in Hospitalized Patients.

Background: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are estimated to cost $1.5 billion annually in Canada. Previous studies have shown that barely half of all patients receive ideal care in hospitals. Deviations from guideline-defined optimal care lead to longer hospital stays, readmissions, and increased mortality. Objective: To determine the proportion of patients admitted to hospital for AECOPD who received treatment adherent to guidelines. Methods: A retrospective cohort study was conducted with ethics approval from the University of British Columbia Clinical Research Ethics Board. Patients hospitalized for ≥24 hours with an AECOPD at a tertiary care center and a community hospital were assessed. Guideline-adherent treatment was defined as appropriate use of supplemental oxygen, inhaled bronchodilators, systemic corticosteroids, antibiotics, venous thromboembolism prophylaxis, initiation/continuation of nicotine replacement therapy for current smokers, and vaccination optimization, reflecting international standards of care. Outcomes were assessed using descriptive statistics. Results: A random sample of 210 patients were selected of which 99 met inclusion criteria. Only 4% received therapy that met all recommendations. Differences in management were found between sites, specifically the appropriate use of bronchodilators, corticosteroids, antibiotics, and supplemental oxygen. Venous thromboembolism prophylaxis and smoking cessation rates were 97% and 94%, respectively, at the tertiary care center, compared with 73% and 100% at the community hospital. Additionally, less than half of all patients had their immunization history verified. Conclusion: Gaps in the inpatient management of AECOPD continue to exist. Initiatives must be targeted to optimize management and reduce the burden of the disease.

Evaluation of protocol-guided scheduled basal-nutritional-correction insulin over standard care for vascular surgery patients.

BACKGROUND: Practice guidelines have recommended scheduled basal, nutritional and correction insulin to manage hyperglycemia in the hospital setting. For many decades, however, the primary practice has been sliding scale insulin. OBJECTIVE: To evaluate the efficacy and safety of an institution-specific basal-nutritional-correction insulin preprinted order (BNC-PPO). METHODS: A retrospective, single-centre chart review was conducted on patients admitted to a vascular surgery service to compare inpatient glycemia control before and after implementation of the BNC-PPO. Patients were included if they were aged 19 years or more, admitted between June 2009 and December 2010 (for pre-BNC-PPO) or between April 2011 and August 2012 (for post-BNC-PPO), required insulin before admission for their diabetes mellitus (type 1 or 2) and were prescribed insulin during their admission. RESULTS: For the primary outcome, the mean (±SD) daily blood glucose during hospital stay was 9.83±1.74 mmol/L for the pre-BNC-PPO group and 8.79±1.60 mmol/L for the post-BNC-PPO group (p=0.005). Mean (±SD) severe hyperglycemia episodes per patient per day had decreased in the BNC-PPO group: 1.13±0.73 and 0.80±1.02 for the before and after groups, respectively (p=0.008). Hypoglycemia (blood glucose <2.2 mmol/L and <4 mmol/L) and mild and moderate hyperglycemia episodes were no different between groups. CONCLUSIONS: A structured and proactive approach to inpatient hyperglycemia management appears to be more effective (reduced mean daily blood glucose and severe hyperglycemia episodes) and safer (no increase in hypoglycemia episodes) in maintaining glycemia control in insulin-dependent diabetes patients.

Critical appraisal of the SHARP trial: the results may be dull.

PURPOSE: The goal of this commentary was to provide a critical analysis of the SHARP (Study of Heart and Renal Protection) trial. Published in 2011, this study has been used by clinicians to justify the prescribing of statins (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors) ±ezetimibe in patients with chronic kidney disease. METHODS: We conducted a critical appraisal of the SHARP trial and associated documents (ie, US Food and Drug Administration review, SHARP protocol). We also examined background reviews and studies conducted before the SHARP trial to provide additional context and background. FINDINGS: Our analysis provides clinicians with important criticisms of the SHARP trial, which suggest questionable clinical benefit to lipid-lowering therapy in patients with chronic kidney disease. IMPLICATIONS: Our hope is that clinicians limit the broad prescription of statins (±ezetimibe) in all patients with chronic kidney disease (both dialysis and nondialysis) unless there is a valid reason for statin therapy (eg, existing cardiovascular disease).