Effect of a restrictive transfusion strategy on transfusion-attributable severe acute complications and costs in the US ICUs: a model simulation

<p>Abstract</p> <p>Background</p> <p>Nearly half of all patients in the Intensive Care Unit (ICU) receive red blood cell (pRBC) transfusions (TFs), despite their associated complications. Restrictive transfusion strategy (Hemoglobin [Hb] < 7 g/dL) has been shown to reduce TF exposure. We estimated the potential annual reduction in transfusion-attributable severe acute complications (TSACs) and costs across the US ICUs with the adoption of restrictive strategy.</p> <p>Methods</p> <p>A model, utilizing inputs from published studies, was constructed. Step 1 calculated potential number of patients appropriate for this strategy. In step 2, total number of pRBC units avoided with the restrictive trigger was extrapolated to the annual TFs in the US ICUs. Step 3 quantified excess acute complications and the number of pRBC units TF/1 TSAC in the TRICC trial. Step 4 transformed restrictive strategy-related avoidance of pRBC units to a reduction in TSACs, and step 5 quantified the associated cost savings.</p> <p>Results</p> <p>Of the 4.4 million annual ICU admissions, 1,020,800 comprised the at-risk population. The total of 1,295,126 units of pRBC ($643/unit) could be saved with the restrictive strategy. Based on the data from the TRICC trial, dividing the 49 excess complications in the liberal group into the calculated excess of pRBCs transfused (1,624 units) yielded the rate of 33 pRBC units per one complication. Thus, dividing 1,295,126 units saved by 33 units/1 TSAC, the base-case analysis showed that 39,246 TSACs could potentially be avoided annually in the US ICUs, with the cost savings of$821,109,826.</p> <p>Conclusion</p> <p>This model demonstrates that a restrictive transfusion strategy in appropriate at risk ICU patients is dominant and could result in improved quality of care and cost savings. Given the potential savings of 40,000 TSACs and nearly $1 billion, it is incumbent upon the intensivist community to promote more ubiquitous adoption of a clinically appropriate restrictive transfusion strategy in the ICU.</p

Outcomes associated with bacteremia in the setting of methicillin-resistant Staphylococcus aureus pneumonia: A retrospective cohort study

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in pneumonia. Bacteremia may secondarily complicate MRSA pneumonia. The epidemiology and outcomes associated with bacteremia in the setting of MRSA pneumonia are unknown. We sought to describe the prevalence of bacteremia in MRSA pneumonia and its impact on hospital mortality and length of stay (LOS). METHODS: We conducted a single-center retrospective cohort study (2008–2013) including adult patients hospitalized with pneumonia caused by MRSA. We defined pneumonia based on clinical criteria and all cases were culture confirmed. MRSA bacteremia was identified based on positive blood cultures. Pneumonia was categorized as either community-onset (CO, occurring at presentation or within 2 days of admission) or hospital-onset (HO, occurring > 2 days after admission). We compared bacteremic and non-bacteremic groups with respect to their demographic and clinical characteristics and outcomes. A logistic regression and a generalized linear model (GLM) were constructed to examine the impact of bacteremia on hospital mortality and post-pneumonia onset LOS, respectively. RESULTS: Among the 765 patients with MRSA pneumonia (33.1 % CO), 93 (12.2 %) had concurrent bacteremia (37.6 % CO). Patients with bacteremia were similar to non-bacteremic subjects based on demographic and clinical characteristics with the exception of frequency of a hospitalization within prior 180 days (48.4 % bacteremic and 37.7 % non-bacteremic, p = 0.047), prevalence of chronic liver disease (17.2 % vs. 9.5 %, p = 0.030), and the mean APACHE II score at the onset of pneumonia (17.5 ± 6.0 vs. 16.1 ± 6.0, p = 0.045). Both unadjusted mortality (33.7 % vs. 23.8 %, p = 0.067) and median post-pneumonia LOS (18.2 vs. 12.2 days, p < 0.001) were greater in the bacteremic than the non-bacteremic group. In a logistic regression, bacteremia showed a trend toward an association with increased mortality (odds ratio 1.56, 95 % confidence interval 0.93 to 2.61). Concomitant bacteremia was independently associated with a 10.3-day increase in the post-pneumonia hospital LOS (95 % confidence interval 6.7 to 13.9 days). CONCLUSIONS: Concurrent bacteremia occurred with moderate frequency in the setting of hospitalization with MRSA pneumonia. Although bacteremia did not appear to independently impact mortality, this was likely due to our study’s limited sample size. However, bacteremia complicating MRSA pneumonia added between 1 and 2 weeks to the hospital LOS

Development and validation of a bedside instrument to predict carbapenem resistance among gram-negative pathogens in complicated urinary tract infections

We developed a bedside instrument to predict carbapenem resistance in complicated urinary tract infections. A model assigning weighted points for admission from an extended care facility (1), history of weight loss (1), early mechanical ventilation (1), age \u3c50 years (2), male gender (3), catheter-associated urinary tract infection (4), prior antibiotics treatment (4), and prior carbapenem-resistant infection (8) exhibited good discrimination (C statistic, 0.721)

Inappropriate empiric antifungal therapy for candidemia in the ICU and hospital resource utilization: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>Candida represents the most common cause of invasive fungal disease, and candidal blood stream infections (CBSI) are prevalent in the ICU. Inappropriate antifungal therapy (IAT) is known to increase a patient's risk for death. We hypothesized that in an ICU cohort it would also adversely affect resource utilization.</p> <p>Methods</p> <p>We retrospectively identified all patients with candidemia on or before hospital day 14 and requiring an ICU stay at Barnes-Jewish Hospital between 2004 and 2007. Hospital length of stay following culture-proven onset of CBSI (post-CBSI HLOS) was primary and hospital costs secondary endpoints. IAT was defined as treatment delay of ≥24 hours from candidemia onset or inadequate dose of antifungal agent active against the pathogen. We developed generalized linear models (GLM) to assess independent impact of inappropriate therapy on LOS and costs.</p> <p>Results</p> <p>Ninety patients met inclusion criteria. IAT was frequent (88.9%). In the IAT group antifungal delay ≥24 hours occurred in 95.0% and inappropriate dosage in 26.3%. Unadjusted hospital mortality was greater among IAT (28.8%) than non-IAT (0%) patients, p = 0.059. Both crude post-CBSI HLOS (18.4 ± 17.0 vs. 10.7 ± 9.4, p = 0.062) and total costs ($66,584 ±$49,120 vs. $33,526 ±$27,244, p = 0.006) were higher in IAT than in non-IAT. In GLMs adjusting for confounders IAT-attributable excess post-CBSI HLOS was 7.7 days (95% CI 0.6-13.5) and attributable total costs were $13,398 (95$1,060-$26,736).</p> <p>Conclusions</p> <p>IAT of CBSI, such as delays and incorrect dosing, occurs commonly. In addition to its adverse impact on clinical outcomes, IAT results in substantial prolongation of hospital LOS and increase in hospital costs. Efforts to enhance rates of appropriate therapy for candidemia may improve resource use.</p

The protein C pathway: implications for the design of the RESPOND study

The predictive value of plasma protein C level in sepsis has been demonstrated in a number of studies in which depressed protein C levels were associated with increased likelihood of negative outcome. Data from the PROWESS (Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis) trial indicate that administration of drotrecogin alfa (activated; DrotAA) leads to an increase in endogenous protein C levels in severe sepsis patients. In a group as heterogeneous as sepsis patients, the currently approved dose and duration of administration (24 μg/kg per hour for 96 hours) might not be optimal in some individuals. The RESPOND (Research Evaluating Serial Protein C levels in severe sepsis patients ON Drotrecogin alfa [activated]) trial is a phase II study being conducted to explore the use of endogenous protein C level as both a biomarker and a steering parameter for administration of DrotAA. Eligible patients will receive DrotAA either at the normal, currently approved dose and duration of administration ('standard therapy') or at a higher dose with variable infusion duration or variable infusion duration only ('alternative therapy'). The duration of DrotAA infusion in the alternative therapy arm depends on the individual response in terms of sustained increase in endogenous protein C. The ultimate aims of this and potential following studies are as follows: to establish serial plasma protein C measurement as a biomarker that will aid in the identification of severe sepsis patients who are most likely to benefit from DrotAA therapy, to enable adjustment of DrotAA therapy in individual patients (specifically, the possibility to use a higher dose and to adjust the infusion duration), and to provide guidance to the clinician regarding whether the patient is responding to DrotAA