Administración inmediata versus tardía de antibióticos de amplio espectro antes del ingreso a la unidad de cuidados intensivos para la sepsis severa en adultos

ResumenAntecedentesLa sepsis grave y el shock séptico han surgido recientemente como retos particularmente agudos y letales en los pacientes en estado crítico que se presentan al servicio de urgencias (SU). No hay datos sobre las prácticas actuales para el tratamiento de los pacientes con sepsis grave que comparen la administración inmediata versus tardía de los antibióticos de amplio espectro apropiados como parte del tratamiento precoz dirigido al objetivo, que comienza en las primeras horas de presentación.ObjetivosEvaluar la diferencia de los resultados de la administración inmediata versus tardía de antibióticos en los pacientes con sepsis grave antes del ingreso en la unidad de cuidados intensivos (UCI). Se definió inmediata como la primera hora después de la presentación en el SU.Estrategia de búsquedaSe realizaron búsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) (The Cochrane Library número 1, 2009); MEDLINE (1990 hasta febrero 2010); EMBASE (1990 hasta febrero 2010); e ISI web of Science (febrero 2010). También se hicieron búsquedas de ensayos relevantes en curso en sitios web específicos como www.controlled-trials.com; www.clinicalstudyresults.org; y www.update-software.com. Se hicieron búsquedas en las listas de referencias de artículos. No hubo restricciones basadas en el idioma o en el estado de la publicaciónCriterios de selecciónSe planeó incluir ensayos controlados aleatorios de la administración inmediata versus tardía de antibióticos de amplio espectro en pacientes adultos con sepsis grave en el SU, antes del ingreso a la unidad de cuidados intensivos.Obtención y análisis de los datosDos autores, de forma independiente, evaluaron los artículos para la inclusiónResultados principalesNo se encontraron estudios que cumplieran los criterios de inclusión.Conclusiones de los autoresBasado en esta revisión no se pueden hacer recomendaciones sobre el uso inmediato o tardío de los antibióticos de amplio espectro en los pacientes adultos con sepsis grave en el SU antes del ingreso en la UCI. Es necesario realizar ensayos controlados aleatorios doble ciegos prospectivos amplios sobre la eficacia de la administración inmediata (en una hora) versus tardía de antibióticos de amplio espectro en los pacientes adultos con sepsis grave. Como tiene sentido comenzar los antibióticos tan pronto como sea posible en este grupo de pacientes gravemente enfermos, la administración inmediata de tales antibióticos en contraposición a la administración tardía se basa en pruebas anecdóticas subóptimas.Resumen en términos sencillosEvaluar el momento óptimo de administrar los antibióticos a los pacientes con sepsis en el servicio de urgenciasLa sepsis es un trastorno médico grave caracterizado por una respuesta inflamatoria a una infección que puede afectar todo el cuerpo. El paciente puede desarrollar una respuesta infamatoria a los microbios en su sangre, orina, pulmones, piel u otros tejidos. La sepsis es una enfermedad grave con una tasa de mortalidad muy alta si no se trata. La mayoría de los pacientes con sepsis requieren antibióticos y el ingreso en una unidad de cuidados intensivos (UCI). No puede aún precisarse la rapidez con que los antibióticos de amplio espectro deben ser administrados. El tratamiento con antimicrobianos de amplio espectro se define como una combinación de antibióticos que actúan contra una amplia gama de bacterias que causan la enfermedad, suele reducir las tasas de mortalidad en los pacientes con sepsis, sepsis grave o shock séptico. Se realizó una revisión sistemática de la literatura mediante búsquedas en bases de datos fundamentales de materiales de alta calidad, publicados y no publicados, sobre el momento de administrar los antibióticos en el servicio de urgencias antes del ingreso en la UCI. Estas búsquedas no mostraron ensayos controlados aleatorios (ECA) sobre el momento de administrar tratamiento con antibióticos de amplio espectro en esta población. Se llegó a la conclusión de que es necesario realizar estudios observacionales de cohortes, a falta de ECA, aunque carezcan de la precisión de los ECA. También se concluyó que lo mejor es administrar los antibióticos inmediatamente. Es importante comprender que el reloj comienza a andar cuando el paciente llega al SU y se detiene cuando comienza a administrarse el antibiótico. El período antes de ingresar a la unidad de cuidados intensivos es el tiempo que se pasa en la sala o en el SU antes de ingresar a la UCI, donde se ingresa la mayoría de los pacientes con sepsis grave. La revisión tuvo un propósito definido muy específico, porque se centró sólo en los pacientes con sepsis grave y en encontrar sólo ECA. La ausencia de ECA puede implicar, en sí, la naturaleza complicada de la pregunta de estudio, ya que puede ser éticamente equivocado asignar al azar a tales pacientes a un brazo de tratamiento aparentemente inferior

Acanthamoeba and bacteria produce antimicrobials to target their counterpart

Background In the microbial ecosystem, microbes compete for space and nutrients. Consequently, some have developed the ability to kill or inhibit the growth of other competing microbes by producing antimicrobial substances. As the ‘producer’ species are generally immune to these substances, their compounds act on the competing microbial species and give the producer more space and access to nutrients for growth. Many currently used antibiotics were developed by exploiting this potential of certain microbes. Findings Here, the free-living amoeba, Acanthamoeba castellanii, was investigated for its antibacterial activity against representative Gram positive and Gram negative bacteria, while bacterial isolates were tested for their anti-amoebic properties. Conditioned medium from A. castellanii showed remarkable bactericidal properties against methicillin-resistant Staphylococcus aureus (MRSA) exhibiting almost 100% kill rate, but had limited effect against Acinetobacter sp., Pseudomonas aeruginosa and vancomycin-resistant Enterococcus faecalis (VRE). Similarly, the conditioned medium of E. coli K1 and Enterobacter sp., exhibited potent anti-Acanthamoebic effects in a concentration-dependent manner. Conditioned media of Acanthamoeba, E. coli K1 and Enterobacter sp. showed no cytotoxicity in vitro when tested against human brain microvascular endothelial cells. Active molecule/s in aforementioned amoebic and two bacterial conditioned media were 5 – 10 kDa, and \u3c5 kDa respectively. Conclusions A. castellanii conditioned medium showed potent bactericidal properties against MRSA. The active molecule(s) are heat- and pronase-resistant, and in the 5 to 10 kDa molecular mass range. Contrary to this, E. coli K1 and Enterobacter sp., conditioned medium showed anti-amoebic effects that are \u3c5 kDa in molecular mass, suggestive of active metabolites

Stress management in cyst-forming free-living protists: programmed cell death and/or encystment

In the face of harsh conditions and given a choice, a cell may (i) undergo programmed cell death, (ii) transform into a cancer cell, or (iii) enclose itself into a cyst form. In metazoans, the available evidence suggests that cellular machinery exists only to execute or avoid programmed cell death, while the ability to form a cyst was either lost or never developed. For cyst-forming free-living protists, here we pose the question whether the ability to encyst was gained at the expense of the programmed cell death or both functions coexist to counter unfavorable environmental conditions with mutually exclusive phenotypes

Effects of Economic and Population Factors on Health Expenditures: Special Case of Pakistan

This paper aims to explore the factors affecting the health care expenditures of Pakistan by employing the Multivariate techniques for the annual data series from 1960 to 2010 .The variables we considered are Gross Domestic Product (GDP) as an economic indicator, Population of age 65 and above (P≥65), Population of age 0 to 14 (P(0-14)), Life expectancy at Birth (LE), Crude Birth rate (CBR) and population growth rate (GR) as population indicator and Total Health Expenditure (THE) as an influencing factor. Multiple regression considering Total Health Expenditure (THE) is applied as dependent on the variables mentioned above. Since Variance Inflation Factor (VIF) for all independent variables are very high, the smallest VIF is around 11 goes up to 65. The results obtained by Principal components reveal the effect of population structure and the age factor effect oppositely on Total Health Expenditures (THE). Factor Analysis suggests that the behavior of Health Expenditures is common with Gross Domestic Product (GDP), population of age 65 and above (P≥65) and life expectancy at Birth (LE) in Pakistan while population of age 0 to 14 (P (0-14)), population growth rate (GR) and Crude Birth rate (CBR) are moving in opposite direction i.e. as GDP, P≥65 and LE of Pakistan increases P (0-14), GR and CBR will decreases

How early do antibiotics have to be to impact mortality in severe sepsis? A prospective, observational study from an emergency department

BACKGROUND: The objective of this study was to assess the promptness of antibiotic administration to patients presenting with sepsis and the effects on survival and length of hospitalization. METHODS: Consecutive, adult patients presenting with Systemic Inflammatory Response Syndrome (SIRS) to the emergency department of the Aga Khan University hospital were enrolled in a prospective, observational study over a period of 4 months. Univariate, multivariate regression modeling and one-way ANOVA were used to examine the effects of various variables on survival and for significant differences between timing of antibiotic administration and survival, two-sided p values \u3c 0.05 were considered significant. RESULTS: One hundred and eleven patients were enrolled. Severe sepsis was present in 52% patients; the most frequent organism isolated was Salmonella typhi (18%). Overall mortality was 35.1%. One hundred (90.1%) patients received intravenous antibiotics in the Emergency room; average time from triage to actual administration was 2.48 +/- 1.86 hours. The timing of antibiotic administration was significantly associated with survival (F statistic 2.17, p = 0.003). Using a Cox Regression model, we were able to demonstrate that survival dropped acutely with every hourly delay in antibiotic administration. On multivariate analysis, use of vasopressors (adjusted OR 23.89, 95% CI 2.16,263, p = 0.01) and Escherichia coli sepsis (adjusted OR 6.22, 95% CI 1.21,32, p = 0.03) were adversely related with mortality. CONCLUSIONS: We demonstrated that in the population presenting to our emergency room, each hourly delay in antibiotic administration was associated with an increase in mortality

Peritumoral cystic meningioma

A case of 39 years old male is described who presented with headache, right-sided focal fits and decreased power in the right hand. CT scan brain showed a left fronto-parietal cystic lesion with centrolateral intramural nodule with homogenous enhancement. At surgery, the extra-axial lesion with cyst containing xanthochromic fluid had a well-defined capsule that could easily be separated from the peri-lesional cortical surface. The dural-based nodule with its cyst wall was resected in toto. The histopathology of mural nodule was reported as meningioma while the cyst wall histology revealed meningothelial cells

Factors associated with hydrocarbon ingestion in children

OBJECTIVE: To investigate the types of hydrocarbon ingested by children and identify factors associated with hydrocarbons ingestion. PATIENTS AND METHODS: It was a hospital based case control study in which medical records of sixty seven children with hydrocarbon ingestion, admitted through emergency department between January 2001 to December 2005 of Aga Khan Hospital were reviewed. Variables such as age, sex, types of hydrocarbons, amount ingested, socioeconomic status, family size, number of children, type of containers, trend of ingestion during hot weather, length of stay at hospital along with the outcomes were evaluated. RESULTS: Out of 67 patients, 53 (79%) were male and 14 (21%) were female. Majority of children 36 (54%) were between the ages 2-5 years. Kerosene oil 59 (88%) was the most commonly ingested hydrocarbons. Socioeconomically 48 (71%) children belonged to lower middle class. Children with large family size (\u3e or = 3 siblings/family) were more commonly affected. Hydrocarbon were mostly 41 (61%) stored in beverages and mineral water bottles. The accident occurred in 43 (65%) during summer, whereas 34 (56%) patients had presented with fever and cough. Consolidation of lungs was found in 38 (56%) cases. Majority 53 (79%) of the patients were discharged from the hospital within the first 24 hours of admission. Male, age \u3c 2 years, large family size, poor socioeconomic status, hot weather (afternoon and summer vacations), kerosene oil, unsafe containers were the major factors loading to hydrocarbon ingestion in this study. CONCLUSION: There is a need for strategic planning with parent awareness programs to reduce the hydrocarbon poisoning in our children

How Much Output should be Produced by the Firm? An Analysis

In this study, the main objective of the firm is to determine output and price level; we have taken the time series data of the firm and have applied the ordinary least square technique. We find out the equilibrium point of the firm where marginal revenue is equal to marginal cost and at that point firm earn the maximum profit and we also determine the price level of the firm. The output level that the firm should produce would be of 3922 units, at this point its total cost is 1131611, total revenue is 1115890, marginal revenue is 308.6689, marginal cost is 308.6702 and optimal price is 284.5206. Keywords: Price and Output Determination, Empirical Study, MR = M