Evaluation of the performance of a modified Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system for critically ill patients in emergency departments in Hong Kong

High-Dose Tigecycline in Elderly Patients with Pneumonia Due to Multidrug-Resistant Acinetobacter baumannii in Intensive Care Unit

Purpose

The association between clinical and microbiological outcomes and high-dose tigecycline (TGC) was assessed in elderly (≥60 years old) patients with hospital-acquired and ventilator-associated pneumonia due to multidrug-resistant Acinetobacterbaumannii(A. baumannii). This study also assessed tigecycline combination with different antibiotics and its influence on the outcome.

Patients and Methods

An observational retrospective cohort study was conducted. Patients over 60 years old were treated with standard-dose (SD) TGC (100-mg intravenous TGC initially, followed by 50-mg doses administered intravenously twice daily) and high-dose (HD) TGC (200-mg intravenous TGC initially, followed by 100-mg doses administered intravenously twice daily) for a microbially confirmed infection. The outcome was 30-day crude mortality, co-administered antimicrobial agent and the microbial eradication percentage in both groups.

Results

A total of 48 multidrug-resistant A. baumannii respiratory patients were identified. Tigecycline was administered to 85% of ventilation-associated pneumonia (VAP) patients (28/33) in the SD group and 80% of VAP patients (12/15) in the HD group. Combined therapy was the major treatment option in both groups, accounting for 85% and 87%, respectively. Median treatment duration in both groups was 7.36 vs 8.6 days, respectively. Survival days were 13.61 vs 12.4 days (P=0.357), respectively. The 30-day crude mortality was 39.4% (13/33) for the SD group and 14% (2/15) for the HD group (P=0.098). The microbial eradication rate of respiratory specimens in the SD group was higher than that in the HD group (P=0.02). The variables associated with 30-day crude mortality were chronic obstructive pulmonary disease (hazard ratio [HR] 11.63, 95% CI 1.094–123.058; P=0.042), tigecycline treatment duration (HR 0.690, 95% CI 0.515–0.926; P=0.013), and surgery before infection (HR 79.276, 95% CI 6.983–899.979; P=0.000). High-dose tigecycline was not associated with 30-day crude mortality (adjusted HR 0.329, 95% CI 0.074–1.460; P=0.145). Combined antibiotics was also not different between the two groups.

Conclusions

High-dose tigecycline was not associated with 30-day crude mortality in elderly patients with pneumonia due to multidrug-resistant A. baumannii, although the microbial eradication rate was high.

Clinical study on the safety and efficacy of high-dose tigecycline in the elderly patients with multidrug-resistant bacterial infections: A retrospective analysis

Multidrug-resistant bacterial (MDRB) infections have been difficult to treat clinically. Tigecycline (TIG) has several advantages, especially in the treatment of severe infections. Many clinicians have considered increasing the TIG dose to improve the efficacy of this molecule. The safety and efficacy of high-dose TIG in elderly patients with MDRB infections were investigated in this study.We conducted a retrospective analysis of the elderly patients with MDRB infections who were treated at the First Affiliated Hospital. A total of 106 patients received a conventional dose (CD-TIG group: 50 mg every 12 hours) of TIG and 51 received a high dose (HD-TIG group: 100 mg every 12 hours). The data from all patients were collected for examining the clinical features and performing the microbiological analysis. The safety profile and efficacy of the HD regimen were investigated.The clinical efficacy and microbiological eradication in the patients with MDRB infection were higher in the HD-TIG group than the CD-TIG group. The independent predictors of clinical cure were the use of TIG at HD (odd ratio [OR], 5.129; 95% confidence interval [CI] [1.890, 13.921]; P = .001) and microbiological eradication (OR, 3.049; 95% CI, [1.251, 7.430]; P = .014). In the ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) subgroups, the sole independent predictor of clinical cure was the HD of TIG, and no significant adverse events were observed. The occurrence of multidrug-resistant Acinetobacter baumannii infection and an MIC value of 1 to 2 g/mL for TIG were independently associated with clinical failure in the VAP subgroup.HDs of TIG was found to associate with better clinical efficacy and microbiological eradication than its CDs in the elderly patients with MDRB infections. In the VAP and BSIs subgroups, administration of HDs of TIG was associated with better outcomes.

Predictors of mortality in cases of thermal burns admitted to Burn Unit, Ain Shams University Hospitals, Cairo

In cases of death due to burn injury, it may be of great medico-legal importance to determine if the death is caused by fatal burn injury or due to other factors related to treatment. Therefore, this study aimed to investigate early predictors of mortality in patients with thermal burns admitted to Burn Unit, Ain Shams University Hospitals during a period of one year (2011). The study included 152 cases, mortalities represented 20.4% of the included cases (31 cases). Binary logistic regression analysis showed that, total body surface area (TBSA) of the burns and APACHE III score were significant predictors of mortality. This model resulted in accurate classification of 95.9% of the cases. Further multi-centric studies on larger sample sizes are recommended to validate the results of this study. Also, it is important to study the effect of co-morbidities as confounding factors on the prediction of mortality in patients with thermal burns.

Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study

BACKGROUND

Delirium increases the risk of mortality during an acute hospital admission. Full syndromal delirium (FSD) is associated with greatest risk and subsyndromal delirium (SSD) is associated with intermediate risk, compared to patients with no delirium - suggesting a dose-response relationship. It is not clear how individual diagnostic symptoms of delirium influence the association with mortality. Our objectives were to measure the prevalence of FSD and SSD, and assess the effect that FSD, SSD and individual symptoms of delirium (from the Confusion Assessment Method-short version (s-CAM)) have on mortality rates.

METHODS

Exploratory analysis of a prospective cohort (aged ≥70 years) with acute (unplanned) medical admission (4/6/2007-4/11/2007). The outcome was mortality (data censored 6/10/2011). The principal exposures were FSD and SSD compared to no delirium (as measured by the CAM), along with individual delirium symptoms on the CAM. Cox regression was used to estimate the impact FSD and SSD and individual CAM items had on mortality.

RESULTS

The cohort (n = 610) mean age was 83 (SD 7); 59% were female. On admission, 11% had FSD and 33% had SSD. Of the key diagnostic symptoms for delirium, 17% acute onset, 19% inattention, 17% disorganised thinking and 17% altered level of consciousness. Unadjusted analysis found FSD had an increased hazard ratio (HR) of 2.31 (95% CI 1.71, 3.12), for SSD the HR was 1.26 (1.00, 1.59). Adjusted analysis remained significant for FSD (1.55 95% CI 1.10, 2.18) but nonsignificant for SSD (HR = 0.92 95% CI 0.70, 1.19). Two CAM items were significantly associated with mortality following adjustment: acute onset and disorganised thinking.

CONCLUSION

We observed a dose-response relationship between mortality and delirium, FSD had the greatest risk and SSD having intermediate risk. The CAM items "acute-onset" and "disorganised thinking" drove the associations observed. Clinically, this highlights the necessity of identifying individual symptoms of delirium.

Evaluation of the Modified Acute Physiology and Chronic Health Evaluation Scoring System for Prediction of Mortality in Patients Admitted to an Emergency Department

Objective

To evaluate the ability of the Modified Acute Physiology and Chronic Health Evaluation (M-APACHE II) scoring system for the prediction of mortality in patients admitted to a tertiary emergency department in Iran.

Methods

During the study period, all patients aged >12 years who had been admitted to the emergency department of a tertiary hospital in Tehran, Iran were enrolled in the study. Traumatic and poisoned patients and those who died immediately after arriving at the emergency room were excluded. Using the M-APACHE II, risk of mortality was calculated for each patient. Finally, expected and observed mortalities were compared and the accuracy of M-APACHE II for prediction of mortality was determined using receiver operating characteristics (ROC) analysis.

Results

During the study period, 389 cases including 236 males (60.7%) were enrolled into the study. The mean age of the patients was 60.6±19.4 years (range 14 to 98 years). 117 patients died (30%) while the M-APACHE II predicted 129 deaths. The greatest discrepancy between observed and expected deaths occurred at M-APACHE II scores ≥21. The constructed area under the ROC curve basng on predicted and observed death was 0.938 (95% confidence interval 0.915-0.961).

Conclusion

M-APACHE II is an accurate scoring system for predicting mortality in patients admitted to the emergency department. However, further studies are needed to confirm our findings.

A combination of clinical parameters and blood-gas analysis identifies patients at risk of transfer to intensive care upon arrival to the Emergency Department

OBJECTIVES

Identifying patients at risk of transfer to the ICU upon arrival to the Emergency Department (ED) might direct early therapy and optimize transfers. However, among the many ED patients, it is difficult to pinpoint the few who insidiously deteriorate to an ICU-requiring level. The aim of this study was to identify predictors in background information, vital values and blood-gas analysis for transfer to ICU 3-36 h after arrival among nontrauma ED patients.

METHODS

A case-control study of 10 007 acute adult patients admitted to ED within 1 year was carried out. The case group consisted of all ICU transfers 3-36 h after arrival who underwent blood-gas analysis and a similar control group not transferred to the ICU. Blood pressure, respiratory frequency, pulse rate, peripheral oxygen saturation and temperature, triage, height, weight, Glasgow Coma Score, drugs, alcohol, tobacco, age, sex, Charlson score and blood-gas results were analysed.

RESULTS

A total of 49 medical and 33 surgical patients were transferred to the ICU. For medical cases, 2.3 and surgical cases 3.7 controls were included. For medical patients, low systolic blood pressure [odds ratio (OR) 14.4], elevated heart rate (OR 3.9), severe acidosis (OR 5.1) and hypercapnia (OR 8.4) and for surgical patients age 60-79 years (OR 6.3), low diastolic blood pressure (OR 2.7) and severe acidosis (OR 15.3) were associated significantly with later transfer to the ICU.

CONCLUSION

The predictors identified could be used as part of ED triage to identify high-risk patients for ICU. These findings should be examined in a well-designed prospective cohort study.

Sulbactam treatment for pneumonia involving multidrug-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii complex

BACKGROUND

Multidrug-resistant (MDR) Acinetobacter calcoaceticus-Acinetobacter baumannii (Acb) complex has become an important cause of nosocomial pneumonia. Sulbactam is a β-lactamase inhibitor with antimicrobial activity against MDR Acb complex.

METHODS

To investigate outcomes of pneumonia involving MDR Acb complex treated with sulbactam or ampicillin/sulbactam for at least 7 days, we conducted a retrospective study of 173 adult patients over a 34 month period.

RESULTS

Of 173 patients, 138 (79.8%) received combination therapy, mainly with carbapenems (119/138, 86.2%). The clinical response rate was 67.6% and the 30 day mortality rate was 31.2%. The independent predictors of clinical failure were malignancy, bilateral pneumonia and shorter duration of treatment. In patients with sulbactam-susceptible strains, there was no difference in clinical and microbiological outcome between combination therapy and monotherapy. Compared to the sulbactam-susceptible group, the sulbactam-resistant group had a lower rate of airway eradication, a longer duration of treatment and a higher rate of combination therapy with predominantly carbapenems (p < 0.05). There was no significant difference between the two groups in clinical resolution and 30 day mortality rates.

CONCLUSIONS

Sulbactam could be a treatment option for pneumonia involving MDR Acb complex, and combination therapy with carbapenems could be considered for sulbactam-resistant cases.

[Validation of APACHE II and SOFA scores in 2 cohorts of patients with suspected infection and sepsis, not admitted to critical care units]

OBJECTIVE

To validate the APACHE II and SOFA scores in patients with suspected infection in clinical settings other than intensive care units.

MATERIALS AND METHODS

A secondary analysis was performed on 2,530 adult patients participating in 2 cohort studies, with suspected infection as admission diagnosis within the first 24 h of hospitalization. The performance of both scoring systems was studied in order to set calibration and discrimination, respectively, on the outcomes such as mortality, admission to Intensive Care Unit, development of septic shock, or multiple organ dysfunctions.

RESULTS

The AUC-ROC values for mortality at discharge and on day 28 in the first cohort were around 0.50 for the SOFA and APACHE II scores; whereas for the second cohort the discrimination value was around 0.70. Calibration of both scoring systems for primary outcomes, according to Hosmer-Lemeshow test, showed p>.05 in the first cohort; while in the second cohort calibration it only showed a p>.05 in the case of the SOFA for mortality at hospital discharge.

CONCLUSION

This validation study of SOFA and APACHE II scores in patients with suspected infection in-hospital units other than the Intensive Care Unit, showed no consistent performance for calibration and discrimination. Its application in emergency and in-hospital patients is limited.

Association between hospital volume and outcomes of elderly and non-elderly patients with acute biliary diseases: a national administrative database analysis

AIM

This study aimed to investigate the relationship between hospital volume and clinical outcomes of elderly and non-elderly patients with acute biliary diseases using data from a national administrative database.

METHODS

Overall, 26720 elderly and 33774 non-elderly patients with acute biliary diseases were referred to 820 hospitals in Japan. Hospital volume was categorized into three groups based on the case numbers during the study period: low-volume, medium-volume and high-volume. We compared the risk-adjusted length of stay (LOS) and in-hospital mortality in relation to hospital volume. These analyses were stratified according to the presence of invasive treatments for acute biliary diseases.

RESULTS

Multiple linear regression analyses showed that increased hospital volume was significantly associated with shorter LOS in both elderly and non-elderly patients with and without invasive treatments. Increased hospital volume was significantly associated with decreased relative risk of in-hospital mortality in elderly patients. The odds ratio for high-volume hospitals was 0.672 in elderly patients without invasive treatments (95% confidence interval [CI] 0.533-0.847, P=0.001) and 0.715 in those with invasive treatments (95% C, 0.566-0.904, P=0.005). However, no significant differences for in-hospital mortality were seen in non-elderly patients with and without invasive treatments.

CONCLUSION

  This study has highlighted that higher volume hospitals significantly reduced LOS and in-hospital mortality for elderly patients with acute biliary diseases, but not non-elderly patients. The current results are of value for elderly healthcare policy decision-making, and highlight the need for further studies into the quality of care for elderly patients.

Effect of hospital volume on clinical outcome in patients with acute pancreatitis, based on a national administrative database

OBJECTIVE

This study aimed to investigate the relationship between hospital volume and clinical outcome in patients with acute pancreatitis, using a Japanese national administrative database.

METHODS

A total of 7007 patients with acute pancreatitis were referred to776 hospitals in Japan. Patient data were corrected according to the severity of acute pancreatitis to allow the comparison of risk-adjusted in-hospital mortality and length of stay in relation to hospital volume. Hospital volume was categorized based on the number of cases during the study period into low-volume (<10 cases), medium-volume (10-16 cases), and high-volume hospitals (HVHs, >16 cases).

RESULTS

Increased hospital volume was significantly associated with decreased relative risk of in-hospital mortality in both patients with mild and those with severe acute pancreatitis. The odds ratios for HVHs were 0.424 (95% confidence interval [CI], 0.228-0.787; P = 0.007) and 0.338 (95% CI, 0.138-0.826; P = 0.017), respectively. Hospital volume was also significantly associated with shorter length of stay in patients with mild acute pancreatitis. The unstandardized coefficient for HVHs was -0.978 days (95% CI, -1.909 to -0.048; P = 0.039).

CONCLUSIONS

This study demonstrated that hospital volume influences the clinical outcome in both patients with mild and those with severe acute pancreatitis.

Effect of attachment styles of individuals discharged from an intensive care unit on intensive care experience

INTRODUCTION

The present study was conducted as a cross-sectional type to examine the effect of attachment styles of individuals discharged from an intensive care unit (ICU) on intensive care experience and health status.

METHODS

The population of the study included patients discharged from the ICU in a university hospital. The sample included 108 patients who were selected via simple random sampling method. Data were collected using a Demographic Information Questionnaire, Intensive Care Experience Questionnaire, the Relationship Scales Questionnaire, and Acute Physiology and Chronic Health Evaluation II system. In the analysis of data, frequency, percentage, mean, standard deviation, minimum and maximum values, and Mann-Whitney U, Kruskal-Wallis, Bonferroni-adjusted Mann-Whitney, and Spearman ρ correlation tests were used.

RESULTS

A significant difference in the awareness of surroundings subscale for attachment styles was noted (χ(2) = 10.820, P ≤ .01). Moreover, participants' attachment styles (fearful, preoccupied, and dismissing) and intensive care experience were significantly correlated. A significant correlation was found between participants' secure attachment style points and Acute Physiology and Chronic Health Evaluation II score during discharge from the ICU (r = 0.322, P = .001).

CONCLUSION

Individuals' attachment styles should be taken into consideration when planning and implementing the nursing care and treatment of individuals hospitalized in an ICU.

The usefulness of the semiquantitative procalcitonin test kit as a guideline for starting antibiotic administration

OBJECTIVES

The Surviving Sepsis Campaign has recommended that antibiotic therapy should be started within the first hour of recognizing severe sepsis. Procalcitonin has recently been proposed as a biomarker of bacterial infection, although the quantitative procalcitonin assay is often time consuming, and it is not always available in many emergency departments (EDs). Our aim is to evaluate usefulness of the semiquantitative procalcitonin fast kit as a guideline for starting antibiotic administration for patients with severe sepsis or septic shock that requires prompt antibiotic therapy in the ED.

METHODS

We include those patients who were admitted to the ED and who were suspected of having infection. The procalcitonin concentration was determined by semiquantitative PCT-Q strips, and the points of the severity scoring system were calculated. The receiver operating characteristic curve was used to assess the diagnostic value of the PCT-Q strips to predict severe sepsis or septic shock.

RESULTS

Of the 80 recruited patients, 33 patients were categorized as having severe sepsis or septic shock according to the definition. At a procalcitonin cutoff level of 2 ng/mL or greater, the sensitivity of the PCT-Q for detecting severe sepsis or septic shock was 93.94% and the specificity was 87.23. The receiver operating characteristic curve for PCT-Q to predict severe sepsis or septic shock had an area under the curve of 0.916.

CONCLUSION

PCT-Q is probably a fast, useful method for detecting severe sepsis in the ED, and it can be used as a guideline for antibiotic treatment.

[Age as predictive factor of mortality in an intensive and intermediate care unit]

INTRODUCTION

Age by itself is not a criterion of biological prognosis. Scores for physiological variables on admission and multiorgan failure are better predictors of mortality.

PATIENTS AND METHODS

We performed a retrospective/ prospective observational study from September, 2005 to May, 2007. The following variables were analyzed: age, sex, Acute Physiology and Chronic Health Classification System (APACHE) II, modified APACHE II score (without the variable of age), Sequential Organ Failure Assessment (SOFA) score, length of hospital stay, type of disease and mortality, limitation of therapeutic effort (LTE), Katz index on admission, intensive and intermediate care unit (IICU) mortality and in-hospital mortality. Student's t-test was used to analyze continuous variables.

RESULTS

Of the 572 patients admitted to the IICU, we excluded 75 due to transfer to other hospitals, 142 due to direct admission to intermediate care, and 89 due to acute coronary syndrome. Of the 266 remaining patients with medical disease, mortality was higher when the APACHE II score was > 20 (OR = 9.4) and/or the SOFA score was >4 (OR = 15.41) but not when age was 3 76 years (OR = 2.04). Multivariate analysis of these parameters revealed higher mortality in the IICU (P=.01) in patients with a SOFA score > 4 and modified APACHE II score >16, independently of age or the Katz index. In addition to the SOFA and the APACHE II scores, in-hospital mortality was significantly influenced by the Katz index (P=.05). LTE was significantly greater in patients with a Katz index E-G.

CONCLUSIONS

Higher SOFA and APACHE II scores predicted higher IICU mortality, regardless of age. LTE was more frequent in patients with a greater degree of dependence.