Long-term admission to the intensive care unit: a cost-benefit analysis

A retrospective case-control study to evaluate the use of beta-lactam desensitization in the management of penicillin-allergic patients: a potential strategy for Antimicrobial Stewardship Programs

Introduction: Penicillin allergy labels (PAL) are common in the hospital setting and are associated with worse clinical outcomes. Desensitization can be a useful strategy for allergic patients when alternative options are suboptimal or not available. The aim was to compare clinical outcomes of patients with PAL managed with antibiotic desensitization vs. those who received alternative non-beta-lactam antibiotic treatments. Methods: A retrospective 3:1 case-control study was performed between 2015-2022. Cases were adult PAL patients with infection who required antibiotic desensitization; controls were PAL patients with infection managed with an alternative antibiotic treatment. Cases and controls were adjusted for age, sex, infection source, and critical or non-critical medical services. Results: Fifty-six patients were included: 14 in the desensitization group, 42 in the control group. Compared to the control group, desensitized PAL patients had more comorbidities, with a higher Charlson index (7.4 vs. 5; p = 0.00) and more infections caused by multidrug-resistant (MDR) pathogens (57.1% vs. 28.6%; p = 0.05). Thirty-day mortality was 14.3% in the desensitized group, 28.6% in the control group (p = 0.24). Clinical cure occurred in 71.4% cases and 54.8% controls (p = 0.22). Four control patients selected for MDR strains after alternative treatment; selection of MDR strains did not occur in desensitized patients. Five controls had antibiotic-related adverse events, including Clostridioides difficile or nephrotoxicity. No antibiotic-related adverse events were found in the study group. In multivariate analysis, no differences between groups were observed for main variables. Conclusion: Desensitization was not associated with worse clinical outcomes, despite more severe patients in this group. Our study suggests that antibiotic desensitization may be a useful Antimicrobial Stewardship tool for the management of selected PAL patients.

Epidemiology and Predictors of Long-Stays in Medical ICU: A Retrospective Cohort Study

INTRODUCTION

Prolonged stays in ICU have been associated with overconsumption of resources but little is known about their epidemiology. We aimed to identify predictors and prognostic factors of extended stays, studying a long-stay population.

METHODS

We present a retrospective cohort study between July 2000 and December 2013 comparing patients hospitalized in a medical ICU for ≥30 days (long-stay patients-LSP) with patients hospitalized for <30 days (short-stay patients-SSP). Admission characteristics were collected from the local database for every patient and evolution during the ICU stay was retrieved from LSP files.

RESULTS

Among 8906 patients hospitalized in the ICU, 417 (4.7%) were LSP. At admission, male sex (adjusted odds-ratio (aOR) 1.4 [1.1; 1.7]), inpatient (aOR 2.0 [1.6; 2.4]) and in-ICU hospitalizations for respiratory (aOR 2.9 [1.6; 3.5]) or infectious diseases (aOR 1.6 [1.1; 2.5]) were all independently associated with a long stay in the ICU, while hospitalizations for metabolic (aOR 0.2 [0.1; 0.5]) or cardiovascular diseases (aOR 0.3 [0.2; 0.5]) were in favor of a short stay. In-ICU and in-hospital LSP mortality were 38.8% and 48.2%. Age (aOR 1.02 [1.00-1.04]), catecholamines (aOR 3.9 [1.9; 8.5]), renal replacement therapy (aOR 2.4 [1.3; 4.3]), primary disease-related complications (aOR 2.5 [1.4; 4.6]) and nosocomial infections (aOR 4.1 [1.8; 10.1]) were independently associated with mortality in LSP.

CONCLUSION

LSP were highly comorbid patients mainly hospitalized for respiratory diseases. Their mortality was mostly related to nosocomial infections but the majority were discharged alive from the hospital.

ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE) II SCORE - THE CLINICAL PREDICTOR IN NEUROSURGICAL INTENSIVE CARE UNIT

The APACHE II scoring system is approved for its benchmarking and mortality predictions, but there are only a few articles published to demonstrate it in neurosurgical patients. Therefore, this study was performed to acknowledge this score and its predictive performance to hospital mortality in a tertiary referral neurosurgical intensive care unit (ICU). All patients admitted to the Neurosurgical ICU from February 1 to July 31, 2011 were recruited. The parameters indicated in APACHE II score were collected. The adjusted predicted risk of death was calculated and compared with the death rate observed. Descriptive statistics including the receiver operating characteristic curve (ROC) was performed. The results showed that 276 patients were admitted during the mentioned period. The APACHE II score was 16.56 (95% CI, 15.84-17.29) and 19.08 (95% CI, 15.40-22.76) in survivors and non-survivors, while the adjusted predicted death rates were 13.39% (95% CI, 11.83-14.95) and 17.49% (95% CI, 9.81-25.17), respectively. The observed mortality was only 4.35%. The area under the ROC of APACHE II score to the hospital mortality was 0.62 (95% CI, 0.44-0.79). In conclusion, not only the APACHE II score in neurosurgical patients indicated low severity, but its performance to predict hospital mortality was also inferior. Additional studies of predicting mortality among these critical patients should be undertaken.