[Effects of plasma substitutes on hemostasis]

Evaluation of early antibiotic use in patients with non-severe COVID-19 without bacterial infection

OBJECTIVES

The use of antibiotics was common in some countries during the early phase of the coronavirus disease 2019 (COVID-19) pandemic, but adequate evaluation remains lacking. This study aimed to evaluate the effect of early antibiotic use in patients with non-severe COVID-19 admitted without bacterial infection.

METHODS

This multi-centre retrospective cohort study included 1,373 inpatients with non-severe COVID-19 admitted without bacterial infection. Patients were divided into two groups according to their exposure to antibiotics within 48 h of admission. The outcomes were progression to severe COVID-19, length of stay >15 days and mortality rate. A mixed-effect Cox model and random effect logistic regression were used to explore the association between early antibiotic use and outcomes.

RESULTS

During the 30-day follow-up period, the proportion of patients who progressed to severe COVID-19 in the early antibiotic use group was almost 1.4 times that of the comparison group. In the mixed-effect model, the early use of antibiotics was associated with higher probability of developing severe COVID-19 and staying in hospital for >15 days. However, there was no significant association between early use of antibiotics and mortality. Analysis with propensity-score-matched cohorts displayed similar results. In subgroup analysis, patients receiving any class of antibiotic were at increased risk of adverse health outcomes. Azithromycin did not improve disease progression and length of stay in patients with COVID-19.

CONCLUSIONS

It is suggested that antibiotic use should be avoided unless absolutely necessary in patients with non-severe COVID-19, particularly in the early stages.

Non-oncotic properties of albumin. A multidisciplinary vision about the implications for critically ill patients

INTRODUCTION

Effective resuscitation with human albumin solutions is achieved with less fluid than with crystalloid solutions. However, the role of albumin in today's critical care unit is also linked to its multiple pharmacological effects. Areas covered: The potential clinical benefits of albumin in select populations of critically ill patients like sepsis seem related to immunomodulatory and anti-inflammatory effects, antibiotic transportation and endothelial stabilization. Albumin transports many drugs used in critically ill patients. Such binding to albumin is frequently lessened in critically ill patients with hypoalbuminemia. These changes could result in sub-optimal treatment. Albumin has immunomodulatory capacity by binding several bacterial products. Albumin also influences vascular integrity, contributing to the maintenance of the normal capillary permeability. Moreover, the albumin molecule encompasses several antioxidant properties, thereby significantly reducing re-oxygenation injury, which is especially important in sepsis. In fact, most studies of albumin administration are a combination of a degree of resuscitation with a degree of maintenance or supplementation of albumin. Expert commentary: The potential clinical benefits of the use of albumin in selected critically ill patients such as sepsis seem related to its immunomodulatory and anti-inflammatory effects, antioxidant properties, antibiotic transportation and endothelial stabilization. Additional studies are warranted to further elucidate the underlying physiologic and molecular rationale.

Are renal adverse effects of hydroxyethyl starches merely a consequence of their incorrect use?

BACKGROUND

Clinical studies such as VISEP-study, which show a negative outcome after the administration of hydroxyethyl starch (HES), are often criticized for an "incorrect" use of HES. It is argued that HES used in these studies differed from usual practice and that recommendations for maximal dosage, duration, and creatinine values were ignored, not enough "free water" was provided and more modern HES solutions should have been used. These comments imply that renal adverse events in clinical studies are the consequence of an inappropriate use of HES. We therefore searched for evidence whether these suggested measures are beneficial.

METHODS

Narrative review; post hoc statistical analysis of epidemiologic data from a representative nationwide survey.

RESULTS

It is evident from published clinical studies that the renal risk of HES increases with cumulative dose and rising serum creatinine values, but no safe upper dose limit or creatinine threshold is known. Suggested safety measures were not able to prevent HES-induced renal failure in clinical studies. Published clinical trials with modern HES solutions are not suited to prove its assumed increased safety because of small sample sizes, low cumulative doses, short observation periods, and inadequate control fluids. Use of HES in a clinical study with negative outcomes conformed to clinical practice, indicating the generalizability of study results.

CONCLUSION

There is no evidence for the assumption that HES-associated renal impairment may be avoided by accompanying measures. Because HES use does not improve clinical outcome, the question arises whether it should be used at all in patients at risk.

[Hydroxyethyl starch]

OBJECTIVE

The purpose of this review is to draw up a statement on current knowledge available on the more recent hydroxyethyl starch (HES).

DATA SOURCES

References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files.

STUDY SELECTION

All categories of articles on this topic have been selected.

DATA EXTRACTION

Articles have been analysed for biophysics, pharmacology, toxicity, side effects, clinical effects and using prospect of HES.

DATA SYNTHESIS

The first HES was made available in the United States in 1970. The development of a new generation of HES restarted the discussion on clinical interest and the limits in the use of these macromolecules. This interest is also strengthened today by the recent data attached to plasma substitution in intensive care or perioperative resuscitation. The interest for crystalloids and colloids is still widely debated, and among the latter, the relative interest of the HES last generation compared to older ones. Recent HES development is in line with a decrease molecular weight, change rate molar substitution and to amend the glucose to hydroxyethyl report. The ultimate goal is to reduce the side effects of these molecules preventing their use. Side effects are dominated by haemostasis and renal dysfunction. The latest developments are the so-called HES "balanced" solutions.