Showing papers by "Michael Klompas published in 2016"

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

Abstract: It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

A Framework for the Development and Interpretation of Different Sepsis Definitions and Clinical Criteria.

Abstract: Although sepsis was described more than 2,000 years ago, and clinicians still struggle to define it, there is no "gold standard," and multiple competing approaches and terms exist. Challenges include the ever-changing knowledge base that informs our understanding of sepsis, competing views on which aspects of any potential definition are most important, and the tendency of most potential criteria to be distributed in at-risk populations in such a way as to hinder separation into discrete sets of patients. We propose that the development and evaluation of any definition or diagnostic criteria should follow four steps: 1) define the epistemologic underpinning, 2) agree on all relevant terms used to frame the exercise, 3) state the intended purpose for any proposed set of criteria, and 4) adopt a scientific approach to inform on their usefulness with regard to the intended purpose. Usefulness can be measured across six domains: 1) reliability (stability of criteria during retesting, between raters, over time, and across settings), 2) content validity (similar to face validity), 3) construct validity (whether criteria measure what they purport to measure), 4) criterion validity (how new criteria fare compared to standards), 5) measurement burden (cost, safety, and complexity), and 6) timeliness (whether criteria are available concurrent with care decisions). The relative importance of these domains of usefulness depends on the intended purpose, of which there are four broad categories: 1) clinical care, 2) research, 3) surveillance, and 4) quality improvement and audit. This proposed methodologic framework is intended to aid understanding of the strengths and weaknesses of different approaches, provide a mechanism for explaining differences in epidemiologic estimates generated by different approaches, and guide the development of future definitions and diagnostic criteria.

Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes

Abstract: Sepsis is the focus of national quality improvement programs and a recent public reporting measure from the Centers for Medicare and Medicaid Services. However, diagnosing sepsis requires interpreting nonspecific signs and can therefore be subjective. We sought to quantify interobserver variability in diagnosing sepsis. We distributed five case vignettes of patients with suspected or confirmed infection and organ dysfunction to a sample of practicing intensivists. Respondents classified cases as systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, or none of the above. Interobserver variability was calculated using Fleiss’ κ for the five-level classification, and for answers dichotomized as severe sepsis/septic shock versus not-severe sepsis/septic shock and any sepsis category (sepsis, severe sepsis, or septic shock) versus not-sepsis. Ninety-four physicians completed the survey. Most respondents (88 %) identified as critical care specialists; other specialties included pulmonology (39 %), anesthesia (19 %), surgery (9 %), and emergency medicine (9 %). Respondents had been in practice for a median of 8 years, and 90 % practiced at academic hospitals. Almost all respondents (83 %) felt strongly or somewhat confident in their ability to apply the traditional consensus sepsis definitions. However, overall interrater agreement in sepsis diagnoses was poor (Fleiss’ κ 0.29). When responses were dichotomized into severe sepsis/septic shock versus not-severe sepsis/septic shock or any sepsis category versus not-sepsis, agreement was still poor (Fleiss’ κ 0.23 and 0.18, respectively). Seventeen percent of respondents classified one of the five cases as severe sepsis/septic shock, 27.7 % rated two cases, 33.0 % respondents rated three cases, 19.2 % rated four cases, and 3.2 % rated all five cases as severe sepsis/septic shock. Among respondents who felt strongly confident in their ability to use sepsis definitions (n = 45), agreement was no better (Fleiss’ κ 0.28 for the five-category classification, and Fleiss’ κ 0.21 for the dichotomized severe sepsis/septic shock classification). Cases were felt to be extremely or very realistic in 74 % of responses; only 3 % were deemed unrealistic. Diagnosing sepsis is extremely subjective and variable. Objective criteria and standardized methodology are needed to enhance consistency and comparability in sepsis research, surveillance, benchmarking, and reporting.

Trend in Ventilator-Associated Pneumonia Rates Between 2005 and 2013

Abstract: Trend in Ventilator-Associated Pneumonia Rates Between 2005 and 2013 From 2006 to 2012, the incidence of ventilator-associated pneumonia (VAP) reported to the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN) decreased.1,2 In medical and surgical intensive care units, between 2006 and 2012, the reported incidence of VAP per 1000 ventilator-days decreased from 3.1 to 0.9 (71% decline) and 5.2 to 2.0 (62% decline), respectively. Whether the decrease was attributable to better care or stricter application of subjective surveillance criteria is unclear.3 The Medicare Patient Safety Monitoring System (MPSMS)4 has independently measured VAP rates since 2005, using a stable definition of VAP. Trends in MPSMS VAP rates from 2005 through 2013 were analyzed.

Associations Between Ventilator Bundle Components and Outcomes

Abstract: Importance Ventilator bundles, including head-of-bed elevation, sedative infusion interruptions, spontaneous breathing trials, thromboprophylaxis, stress ulcer prophylaxis, and oral care with chlorhexidine gluconate, are ubiquitous, but the absolute and relative value of each bundle component is unclear. Objective To evaluate associations between individual and collective ventilator bundle components and ventilator-associated events, time to extubation, ventilator mortality, time to hospital discharge, and hospital death. Design, Setting, and Participants This retrospective cohort study included all 5539 consecutive patients who underwent mechanical ventilation for at least 3 days from January 1, 2009, to December 31, 2013, at Brigham and Women’s Hospital. Exposures Head-of-bed elevation, sedative infusion interruptions, spontaneous breathing trials, thromboprophylaxis, stress ulcer prophylaxis, and oral care with chlorhexidine. Main Outcomes and Measures Hazard ratios (HRs) for ventilator-associated events, extubation alive vs ventilator mortality, and hospital discharge vs hospital death. Effects were modeled using Cox proportional hazards regression and Fine-Gray competing risk models adjusted for patients’ demographic characteristics, comorbidities, unit type, severity of illness, recent procedures, process measure contraindications, day-to-day markers of clinical status, and calendar year. Results Of 5539 consecutive patients undergoing mechanical ventilation, 3208 were male (57.9%), 2331 female (42.1%), and the mean (SD) age was 61.2 (16.1) years. Sedative infusion interruptions were associated with less time to extubation (HR, 1.81; 95% CI, 1.54-2.12; P P P P = .001). Spontaneous breathing trials were also associated with lower hazards for ventilator-associated events (HR, 0.55; 95% CI, 0.40-0.76; P P = .001) and thromboembolism prophylaxis (HR, 2.57; 95% CI, 1.80-3.66; P P = .006), and stress ulcer prophylaxis was associated with an increased risk for ventilator-associated pneumonia (HR, 7.69; 95% CI, 1.44-41.10; P = .02). Conclusions and Relevance Standard ventilator bundle components vary in their associations with patient-centered outcomes. Head-of-bed elevation, sedative infusion interruptions, spontaneous breathing trials, and thromboembolism prophylaxis appear beneficial, whereas daily oral care with chlorhexidine and stress ulcer prophylaxis may be harmful in some patients.

Application of a Framework to Assess the Usefulness of Alternative Sepsis Criteria.

Abstract: The current definition of sepsis is life-threatening, acute organ dysfunction secondary to a dysregulated host response to infection. Criteria to operationalize this definition can be judged by six domains of usefulness (reliability, content, construct and criterion validity, measurement burden, and timeliness). The relative importance of these six domains depends on the intended purpose for the criteria (clinical care, basic and clinical research, surveillance, or quality improvement [QI] and audit). For example, criteria for clinical care should have high content and construct validity, timeliness, and low measurement burden to facilitate prompt care. Criteria for surveillance or QI/audit place greater emphasis on reliability across individuals and sites and lower emphasis on timeliness. Criteria for clinical trials require timeliness to ensure prompt enrollment and reasonable reliability but can tolerate high measurement burden. Basic research also tolerates high measurement burden and may not need stability over time. In an illustrative case study, we compared examples of criteria designed for clinical care, surveillance and QI/audit among 396,241 patients admitted to 12 academic and community hospitals in an integrated health system. Case rates differed four-fold and mortality three-fold. Predictably, clinical care criteria, which emphasized timeliness and low burden and therefore used vital signs and routine laboratory tests, had the greater case identification with lowest mortality. QI/audit criteria, which emphasized reliability and criterion validity, used discharge information and had the lowest case identification with highest mortality. Using this framework to identify the purpose and apply domains of usefulness can help with the evaluation of existing sepsis diagnostic criteria and provide a roadmap for future work.

Objective Sepsis Surveillance Using Electronic Clinical Data

Abstract: Multiple studies have reported a 2- to 3-fold rise in severe sepsis incidence over the past several decades, accompanied by substantial decreases in case fatality rates.1–6 Almost all of these estimates are based upon claims data, however, and may therefore be biased by increasingly vigilant diagnosis and coding practices.7–9 Indeed, we previously demonstrated that the sensitivity of sepsis codes for capturing the most overt form of sepsis, bacteremia with concurrent vasopressors or lactic acidosis, has increased significantly over time, and that improving documentation of acute organ dysfunction is also likely biasing estimates of changing sepsis severity and burden.10,11 Given the questionable reliability of administrative claims to track severe sepsis incidence and outcomes, we developed a surveillance definition that uses clinical data instead of diagnosis codes and is potentially applicable using electronic health record (EHR) data. Our aim was to characterize the accuracy and stability of this definition over time and compare it with claims-based definitions, using manual medical chart reviews with the international consensus definition as the reference standard. We then estimated and compared changes in severe sepsis incidence and mortality rates using the clinical vs claims-based surveillance definitions.

The CMS Sepsis Mandate: Right Disease, Wrong Measure.

Abstract: In 2015, the Centers for Medicare & Medicaid Services began requiring hospitals to report their adherence to treatment bundles for patients with sepsis. The reporting rules are rigid and onerous an...

Ventilator-Associated Events in Neonates and Children--A New Paradigm.

Abstract: Objectives:To identify a pediatric ventilator-associated condition definition for use in neonates and children by exploring whether potential ventilator-associated condition definitions identify patients with worse outcomes.Design:Retrospective cohort study and a matched cohort analysis.Setting:Pedi

Ultra-Short-Course Antibiotics for Patients With Suspected Ventilator-Associated Pneumonia but Minimal and Stable Ventilator Settings

Abstract: Background Many patients started on antibiotics for possible ventilator-associated pneumonia (VAP) do not have pneumonia. Patients with minimal and stable ventilator settings may be suitable candidates for early antibiotic discontinuation. We compared outcomes among patients with suspected VAP but minimal and stable ventilator settings treated with 1-3 days vs >3 days of antibiotics. Methods We identified consecutive adult patients started on antibiotics for possible VAP with daily minimum positive end-expiratory pressure of ≤5 cm H2O and fraction of inspired oxygen ≤40% for at least 3 days within a large tertiary care hospital between 2006 and 2014. We compared time to extubation alive vs ventilator death and time to hospital discharge alive vs hospital death using competing risks models among patients prescribed 1-3 days vs >3 days of antibiotics. All models were adjusted for patient demographics, comorbidities, severity of illness, clinical signs of infection, and pathogens. Results There were 1290 eligible patients, 259 treated for 1-3 days and 1031 treated for >3 days. The 2 groups had similar demographics, comorbidities, and clinical signs. There were no significant differences between groups in time to extubation alive (hazard ratio [HR], 1.16 for short- vs long-course treatment; 95% confidence interval [CI], .98-1.36), ventilator death (HR, 0.82 [95% CI, .55-1.22]), time to hospital discharge alive (HR, 1.07 [95% CI, .91-1.26]), or hospital death (HR, 0.99 [95% CI, .75-1.31]). Conclusions Very short antibiotic courses (1-3 days) were associated with outcomes similar to longer courses (>3 days) in patients with suspected VAP but minimal and stable ventilator settings. Assessing serial ventilator settings may help clinicians identify candidates for early antibiotic discontinuation.

Should Ventilator-Associated Events become a Quality Indicator for ICUs?

Abstract: The United States Centers for Disease Control and Prevention replaced their longstanding ventilator-associated pneumonia (VAP) definitions with ventilator-associated event (VAE) definitions in 2013. Controversy abounds as to whether VAE definitions are potentially suitable to serve as quality indicators for ICUs. On the pro side, VAE definitions overcome many of the weaknesses of traditional VAP surveillance. VAE definitions are objective, reproducible, electronically computable, and strongly predict poor outcomes for patients. There is an increasing amount of data on clinical correlates, risk factors, and approaches to prevent VAEs. Potential strategies to prevent VAEs are highly aligned with accepted best practices in critical care. VAE surveillance therefore has the potential to catalyze better care and to help hospitals track outcomes in ventilated patients more rigorously and more efficiently. On the con side, the complete VAE definition set with subtiers is complicated, neither sensitive nor specific for VAP, non-physiological compared with other ICU metrics, susceptible to gaming, and may bring about changes in clinician behavior that could paradoxically end up harming patients.

Hospital-Acquired Pneumonia in Nonventilated Patients: The Next Frontier

Abstract: (See the article by See et al, on pages 818–824.) Landmark studies from the 1970s and 1980s established surgical-site infections as the most common nosocomial infections and devices as the most common risk factors for nonsurgical-site nosocomial infections. Infection prevention and control programs have consequently dedicated the majority of their efforts for the past 30 years tomonitoring and preventing surgical-site and device-associated infections. For pneumonia, most hospitals only conduct surveillance and prevention programs for ventilator-associated pneumonia (VAP). Little or nothing is done to track and prevent nonventilator-associated hospital-acquired pneumonia (NV-HAP). The original decision to focus on VAP is understandable. The disease has a high mortality rate and afflicts a vulnerable, well-defined segment of the hospital population. National quality improvement initiatives implicitly encouraged hospitals to focus on VAP in particular by repeatedly proposing public reporting and pay-for-performance programs for VAP but not NV-HAP. Groups like the Institute for Healthcare Improvement promulgated well-defined prevention bundles for VAP but not NV-HAP. The National Healthcare Safety Network reported device-associated pneumonia but not NV-HAP rates. The landscape of nosocomial infection epidemiology has significantly changed, however, since the landmark studies of the 1970s and 1980s. A recent multistate point-prevalence survey organized by the Centers for Disease Control and Prevention (CDC) found that pneumonia is now tied with surgical-site infections as the most common healthcare-associated infection and that the majority of pneumonias now occur in nonventilated patients. The CDC estimates that more than two-thirds of the 157,500 hospital-acquired pneumonias in the United States each year occur in nonventilated patients. These observations suggest the possibility that there is a major gap in current surveillance and prevention programs. Most hospitals do not routinely track NV-HAP, and almost everything we know about nosocomial pneumonia comes from studies in ventilated patients. Key questions, such as the incidence, risk factors, attributable mortality, and preventability of NV-HAP, have barely been studied. As with any infection control problem, the first step toward tackling NV-HAP is to define it. The CDC does have a longstanding surveillance definition for hospital-acquired pneumonia that is intended to apply to both ventilated and nonventilated patients (PNEU). Ample data are available on the performance of PNEU in ventilated patients, but very little data are available on its performance in nonventilated patients. This gap is important because the studies in ventilated patients found surveillance for PNEU to be time-consuming, subjective, and nonspecific. Do the same concerns also apply to nonventilated patients? The limitations of PNEU in ventilated patients helped catalyze the development of ventilator-associated event definitions as objective surveillance alternatives for this population. Is something similar required for nonventilated patients? This month’s issue of Infection Control and Hospital Epidemiology includes a valuable report on the performance of PNEU in nonventilated patients. Dr. See et al from the CDC conducted a retrospective analysis of 250 adults and children with either PNEU or lower respiratory tract infection (LRI) as detected by infection preventionists in 8 Pennsylvania hospitals. Expert personnel from the CDC and the Pennsylvania Department of Health reviewed the charts of these patients to confirm PNEU and LRI classifications. The reviewers also looked for clinical diagnoses assigned at the time of PNEU or LRI to gather insights into the clinical significance of these surveillance events. The report includes data on the performance of PNEU in nonventilated adults, PNEU in ventilated and nonventilated children, and the relative value of LRI subcategories for bronchitis and other infections of the lower respiratory tract among adults and children. The current discussion, however, is focused on PNEU in adults. A total of 96 PNEU events were reported in nonventilated adults. The review team revoked 15 cases (16%) for failure to fulfill PNEU criteria, typically because of differences between observers in the interpretation of radiographic reports. Thus, PNEU may be susceptible to some of the same sources of disagreement in nonventilated patients as it is in ventilated patients. Of the remaining 81 cases, frontline clinicians documented a clinical diagnosis of pneumonia in 69 patients.

Risk Factors for Surgical Site Infections Following Anterior Cruciate Ligament Reconstruction.

Abstract: OBJECTIVE To determine the effect of graft choice (allograft, bone-patellar tendon-bone autograft, or hamstring autograft) on deep tissue infections following anterior cruciate ligament (ACL) reconstructions. DESIGN Retrospective cohort study. SETTING AND POPULATION Patients from 6 US health plans who underwent ACL reconstruction from January 1, 2000, through December 31, 2008. METHODS We identified ACL reconstructions and potential postoperative infections using claims data. A hierarchical stratified sampling strategy was used to identify patients for medical record review to confirm ACL reconstructions and to determine allograft vs autograft tissue implanted, clinical characteristics, and infection status. We estimated infection rates overall and by graft type. We used logistic regression to assess the association between infections and patients' demographic characteristics, comorbidities, and choice of graft. RESULTS On review of 1,452 medical records, we found 55 deep wound infections. With correction for sampling weights, infection rates varied by graft type: 0.5% (95% CI, 0.3%-0.8%) with allografts, 0.6% (0.1%-1.5%) with bone-patellar tendon-bone autografts, and 2.5% (1.9%-3.1%) with hamstring autograft. After adjusting for potential confounders, we found an increased infection risk with hamstring autografts compared with allografts (odds ratio, 5.9; 95% CI, 2.8-12.8). However, there was no difference in infection risk among bone-patellar tendon-bone autografts vs allografts (odds ratio, 1.2; 95% CI, 0.3-4.8). CONCLUSIONS The overall risk for deep wound infections following ACL reconstruction is low but it does vary by graft type. Infection risk was highest in hamstring autograft recipients compared with allograft recipients and bone-patellar tendon-bone autograft recipients. Infect Control Hosp Epidemiol 2016;37:827-833.

The Relationship Between Sedatives, Sedative Strategy, and Healthcare-Associated Infection: A Systematic Review.

Abstract: BACKGROUND Healthcare-associated infections (HAIs) cause significant morbidity in critically ill patients. An underappreciated but potentially modifiable risk factor for infection is sedation strategy. Recent trials suggest that choice of sedative agent, depth of sedation, and sedative management can influence HAI risk in mechanically ventilated patients. OBJECTIVE To better characterize the relationships between sedation strategies and infection. METHODS Systematic literature review. RESULTS We found 500 articles and accepted 70 for review. The 3 most common sedatives for mechanically ventilated patients (benzodiazepines, propofol, and dexmedetomidine) have different pharmacologic and immunomodulatory effects that may impact infection risk. Clinical data are limited but retrospective observational series have found associations between sedative use and pneumonia whereas prospective studies of sedative interruptions have reported possible decreases in bloodstream infections, pneumonia, and ventilator-associated events. CONCLUSION Infection rates appear to be highest with benzodiazepines, intermediate with propofol, and lowest with dexmedetomidine. More data are needed but studies thus far suggest that a better understanding of sedation practices and infection risk may help hospital epidemiologists and critical care practitioners find new ways to mitigate infection risk in critically ill patients. Infect Control Hosp Epidemiol 2016;1-9.

Sepsis and the theory of relativity: measuring a moving target with a moving measuring stick.

Abstract: Sepsis is the subject of intense interest for clinicians, policy makers, patients, and researchers. Stakeholders around the world are striving to improve sepsis awareness and quality of care. The Surviving Sepsis Campaign, World Sepsis Day, and mandatory reporting rules are but a few examples of ongoing initiatives. All sepsis stakeholders need accurate data on sepsis incidence, characteristics, outcomes, and whether these are changing over time. Without these it is almost impossible to plan appropriately or to know whether our efforts to prevent sepsis and improve care are bearing fruit. The most common source for sepsis surveillance is hospital discharge codes. Their advantages include widespread availability and low cost. At first blush they also appear relatively straightforward to analyze. On closer inspection, however, they are fraught with subtleties and uncertainties. There are two prevailing strategies to identify sepsis using diagnosis codes: 1) identify patients with explicit codes for severe sepsis and septic shock, or 2) seek patients with concurrent discharge codes for infection and organ dysfunction, the so-called “implicit” method. The second strategy has obvious limitations. Investigators have proposed at least 5 different sets of infection and diagnosis codes to identify sepsis. Not surprisingly, different methods suggest very different sepsis rates [1]. Moreover, simultaneous infection and organ dysfunction codes at discharge do not reliably imply that organ dysfunction was due to infection. Explicit sepsis codes also have their limitations. They were only added to the International Classification of Disease (ICD9-CM) lexicon in 2002. Despite the passage of almost 15 years since their release, clinicians and coders are still becoming familiar with them and only gradually introducing them into practice. A recent study in Critical Care by Bouza et al. elucidated the uptake rate of explicit diagnosis codes using data from the Spanish national hospital discharge database for the years 2006-2011 [2]. They queried the database for sepsis using the explicit and one implicit strategy in a mutually exclusive fashion. The fraction of total cases assigned explicit codes rose from 51 % in 2006 to 64 % in 2011. Patients assigned explicit codes were sicker than patients with implicit codes alone: almost twice as many had mechanical ventilation codes and ten times as many had cardiovascular dysfunction codes. The in-hospital mortality rate for patients with explicit codes was almost double that of patients with implicit codes alone (55 % vs 29 %). This study has important implications for stakeholders trying to understand sepsis epidemiology through codebased analyses. It is clear that one cannot consider cases identified using explicit codes interchangeably with those identified through implicit codes. It is also clear that tracking sepsis using explicit codes alone provides an incomplete and changing picture of the septic population. One might wonder, however, whether it’s feasible to track sepsis adequately using the combined population of patients with either explicit or implicit codes? To answer this question we need to understand more about the reliability of explicit and implicit codes. Do all * Correspondence: mklompas@partners.org Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Street, Suite 401, Boston, MA 02215, USA Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA

The Cost of Responding to an Acinetobacter Outbreak in Critically Ill Surgical Patients.

Abstract: Background: Our institution had an outbreak of multi-drug-resistant Acinetobacter (MDRA) in 2011. We analyzed the costs of responding to this outbreak from the hospital's perspective. Methods: We estimated retrospectively the excess costs associated with an MDRA outbreak response at a major academic medical center, including the costs of staffing, supplies, administrative time, deep cleaning, and environmental testing. Differences in mean costs before and during the 2011 MDRA outbreak were analyzed using the Student t-test. Results: The overall excess cost incurred during the outbreak response was $371,079 in 2011 U.S. dollars. The largest contributors were the extra resources needed to staff and clean the two intensive care units (ICUs) (78%). In the general surgery ICU, the mean weekly cost of nursing during the outbreak was $13,276 more for regular hours (+15%; p < 0.01) than in the pre-outbreak period and $2,682 more for overtime hours (+86%; p = 0.02). In the trauma ICU, the cost was $20,746...

24: impact of penalties for central line-associated bloodstream infections on blood culture ordering.

Abstract: Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) injury only), and Group 4 (no cardiac injury or AKI). Outcomes including inhospital, 28-day and one-year mortality were compared across the four groups. A two-tailed p<0.05 was considered statistically significant. Results: A total of 494 patients with sepsis and septic shock met our inclusion criteria. Groups 1–4 included 214 (43%), 59 (12%), 161 (33%), and 60 (12%) patients respectively. Groups 1–4 had significant differences in Sequential Organ Failure Assessment score [11 (8–13), 10 (8–13), 7 (4–10), 7 (5–9); p<0.001) and serum lactate levels [2.4 (2–4), 3 (2–5), 2 (1–3), 2 (1–3) mmol/L; p<0.001]. In-hospital mortality was significantly different across groups 1–4 (37%, 39%, 18%, 20%; p<0.001). Follow-up at 28 days and 1 year was available for 449 (91%) patients. Mortality at 28 days (42%, 40%, 26%, 27%; p=0.01) and one-year (63%, 55%, 44%, 43%; p=0.002) showed significant differences between groups 1–4 respectively. In a multivariate logistic regression analysis, in-hospital [odds ratio (OR) 1.3 (0.8–2.3); p=0.33], 28-day [OR 1.2 (0.7–2.2); p=0.47] or 1-year mortality [OR 1.4 (0.7–2.4); p=0.29] in group 1 was not different from groups 2–4. Conclusions: In sepsis and septic shock patients, CRS is common and associated with differences in unadjusted mortality outcomes across different cohorts with variable cardiac and renal dysfunction.

Should Aerosolized Antibiotics Be Used to Treat Ventilator-Associated Pneumonia?

Abstract: In patients with ventilator-associated pneumonia, systemic use of antibiotics is the cornerstone of medical management Supplemental use of aerosolized antibiotics with intravenous antibiotics in both experimental and clinical studies has been shown to have the following pharmacologic benefits: (1) aerosolized antibiotics reach the infected lung parenchyma without crossing the pulmonary alveolar capillary barrier; (2) aerosolized antibiotics increase anti-bacterial efficacy through increased local antibiotic concentration; and (3) aerosolized antibiotics decrease systemic toxicity These benefits may be particularly beneficial to treat pneumonia caused by multidrug-resistant pathogens Clinical data on the benefits of aerosolized antibiotics are more limited Studies to date have not clearly shown improvements in time to extubation, mortality, or other patient-centered outcomes At present, amikacin, colistin, and ceftazidime are the most frequently used and studied aerosolized antibiotics This review summarizes the characteristics of aerosolized antibiotics, reviews the advantages and disadvantages of using aerosolized antibiotics, and calls for future investigations based on animal study data

Evaluating the Accuracy of Sampling Strategies for Estimation of Compliance Rate for Ventilator-Associated Pneumonia Process Measures.

Abstract: BACKGROUND Measuring processes of care performance rates is an invaluable tool for quality improvement; however, collecting daily process measure data is time-consuming and burdensome. OBJECTIVE To evaluate the accuracy of sampling strategies to estimate monthly compliance rates with ventilator-associated pneumonia prevention measures. SETTING AND PARTICIPANTS A total of 37 intensive care units affiliated with 29 hospitals participating in a 2-state 35-month ventilator-associated pneumonia prevention collaborative. Analysis was limited to 325 unit-months with complete data entry rates. METHODS We calculated unit-month level actual and sample monthly compliance rates for 6 ventilator-associated pneumonia prevention measures, using 4 sampling strategies: sample 1 day per month, sample 1 day per week, sample 7 consecutive days per month, and sample 7 consecutive days per month plus additional consecutive days as necessary to obtain at least 30 ventilator-days for that month whenever possible. We compared sample versus actual rates using paired t test and χ2 test. RESULTS Mean sampling accuracy ranged 84%-97% for 1 day per month, 91%-98% for 1 day per week, 92%-98% for 7 consecutive days per month, and 96%-99% for 7 consecutive days with at least 30 days per month if possible. The most accurate sampling strategy was to sample 7 consecutive days with at least 30 ventilator-days per month if possible. With this strategy, sample rates were within 10% of actual rates in 88%-99% of unit-months and within 5% of actual rates in 74%-97% of unit-months. CONCLUSION Sampling process measures intermittently rather than continually can yield accurate estimates of process measure performance rates. Infect Control Hosp Epidemiol 2016;37:1037-1043.

717: ultrashort-course antibiotics for suspected vap with minimal and stable ventilator settings

Abstract: Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) demonstrated successfully in multiple studies (up to 12 mg/kg/day), however there is sparse literature demonstrating the effects of dosing on clinical outcomes such as clinical cure rate, safety, and mortality. Methods: A single-center, retrospective, observational study of patients with positive VRE cultures and concurrent daptomycin was conducted at a Veterans Affairs Medical Center from September 1, 2003 to December 31, 2015. Multivariate regression models were used to estimate the association between weight-based dosing (total body weight) and mortality, ICU admission, hospital readmission, reinfection, length of stay, and ICU length of stay. Results: 135 patients received daptomycin over the study period, of which 77 patients met inclusion criteria. Study population demographics included: 95% male; mean age 65.5 (SD±9.3) years, BMI 27, Charlson comorbidity 6; E. faecium 61.1%. Microbiologic failure 18.2%. Average dose 6 mg/kg (±1.3mg/kg) and duration 18 (±15) days. Observed 30-day and 90-day mortalities were 25.9% and 35.1%. Average dose in survivors was 6.1 mg/kg vs. 5.7 mg/kg in the non-survivors. In a logistic regression model the odds of 90-day mortality was lower in patients with higher dosing regimens versus those with lower dosages (OR 0.67; 95% CI 0.449–0.999, p<0.05). When dosing was increased by 1 unit (mg/kg), a 33% reduction in likelihood to experience 90-day mortality was noted. Thirty day mortality (p=0.39), length of stay (p=0.16), ICU admission (p=0.74), and ICU length of stay (p=0.62) were not significantly different. Conclusions: Increased daptomycin dosing exhibited a significant impact on 90-day mortality in VRE infections. This study highlights the need for careful selection of appropriate doses when treating VRE. Further studies on dosing impact are needed.