impact of onset time on the isolated pathogens and outcomes in ventilator associated pneumonia

Several guidelines base the empirical therapy of ventilator-associated pneumonia [VAP] on the time of onset. However, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. This study evaluated the characteristics and outcomes of VAP with different onset times. All of the mechanically ventilated patients admitted to the ICU of a 900-bed tertiary-care hospital between 01/08/2003 and 31/12/2010 were prospectively followed for VAP development according to the National Healthcare Safety Network criteria. The patients were categorized into four groups: EO if VAP occurred within 4 days of intubation and hospital admission; LO if VAP occurred after 4 days of admission; EL if VAP occurred within 4 days of intubation, but after the fourth hospitalization day; and LL if VAP occurred after the fourth day of intubation and hospitalization. Out of the 394 VAP episodes, 63 [16%] were EO episodes, 331 [84.0%] were LO episodes, 40 [10.1%] were EL episodes and 291 [73.1%] were LL episodes. The isolated microorganisms were comparable among the four groups, with a similar rate of potentially multidrug resistant organisms in the EO-VAP [31.7%], LO-VAP [40.8%], EL-VAP [37.5%] and LL-VAP [43.3%] samples. The hospital mortality was 24% for EO-VAP cases, 28% for LO-VAP cases, 40% for EL-VAP cases and 49% for LL-VAP cases. However, in the adjusted multivariate analysis, neither LO-VAP, EL-VAP nor LL-VAP was associated with an increased risk of hospital mortality compared with EO-VAP [OR, 0.86 95% CI, 0.34-2.19; 1.22; 95% CI, 0.41-3.68, and 0.95; 95% CI, 0.43-2.10, respectively]. In this study, the occurrence of potential multidrug resistant pathogens and the mortality risk were similar regardless of VAP timing from hospital admission and intubation. The bacterial isolates obtained from the VAP cases did not follow an early vs. late-onset pattern, and thus, these terms may not be clinically helpful

Saudi clinical practice guideline for the diagnosis of the first deep venous thrombosis of the lower extremity

The diagnosis of deep venous thrombosis [DVT] may be challenging due to the inaccuracy of clinical assessment and diversity of diagnostic tests. On one hand, missed diagnosis may result in life-threatening conditions. On the other hand, unnecessary treatment may lead to serious complications. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia [KSA], an expert panel led by the Saudi Association for Venous Thrombo-Embolism [SAVTE; a subsidiary of the Saudi Thoracic Society] with the methodological support of the McMaster University Working Group, produced this clinical practice guideline to assist healthcare providers in evidence-based clinical decision-making for the diagnosis of a suspected first DVT of the lower extremity. Twenty-four questions were identified and corresponding recommendations were made following the Grading of Recommendations, Assessment, Development and Evaluation [GRADE] approach. These recommendations included assessing the clinical probability of DVT using Wells criteria before requesting any test and undergoing a sequential diagnostic evaluation, mainly using highly sensitive D-dimer by enzyme-linked immunosorbent assay [ELISA] and compression ultrasound. Although venography is the reference standard test for the diagnosis of DVT, its use was not recommended

Determinants of functional status among survivors of severe sepsis and septic shock: one-year follow-up

Sepsis is a leading cause of intensive care unit [ICU] admissions worldwide and a major cause of morbidity and mortality. Limited data exist regarding the outcomes and functional status among survivors of severe sepsis and septic shock. This study aimed to determine the functional status among survivors of severe sepsis and septic shock a year after hospital discharge. Adult patients admitted between April 2007 and March 2010 to the medical-surgical ICU of a tertiary hospital in Saudi Arabia, were included in this study. The ICU database was investigated for patients with a diagnosis of severe sepsis or septic shock. Survival status was determined based on hospital discharge. Patients who required re-admission, stayed in ICU for less than 24 hours, had incomplete data were all excluded. Survivors were interviewed through phone calls to determine their functional status one-year post-hospital discharge using Karnofsky performance status scale. A total of 209 patients met the eligibility criteria. We found that 38 [18.1%] patients had severe disability before admission, whereas 109 [52.2%] patients were with severe disability or died one-year post-hospital discharge. Only one-third of the survivors had good functional status one-year post-discharge [no/mild disability]. After adjustment of baseline variables, age [adjusted odds ratio [aOR] = 1.03, 95% confidence interval [CI] = 1.01-1.04] and pre-sepsis functional status of severe disability [aOR = 50.9, 95% CI = 6.82-379.3] were found to be independent predictors of functional status of severe disability one-year post-hospital discharge among survivors. We found that only one-third of the survivors of severe sepsis and septic shock had good functional status one-year post-discharge [no/mild disability]. Age and pre-sepsis severe disability were the factors that highly predicted the level of functional status one-year post-hospital discharge

Drug-resistant ventilator associated pneumonia in a tertiary care hospital in Saudi Arabia

There is a wide geographic and temporal variability of bacterial resistance among microbial causes of ventilator-associated pneumonia [VAP]. The contribution of multi-drug resistant [MDR] pathogens to the VAP etiology in Saudi Arabia was never studied. We sought to examine the extent of multiple-drug resistance among common microbial causes of VAP. We conducted a retrospective susceptibility study in the adult intensive care unit [ICU] of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Susceptibility results of isolates from patients diagnosed with VAP between October 2004 and June 2009 were examined. The US National Healthcare Safety Network definition of MDR was adopted. A total of 248 isolates including 9 different pathogens were included. Acinetobacter spp. was highly [60-89%] resistant to all tested antimicrobials, including carbapenems [three- and four-class MDR prevalence were 86% and 69%, respectively]. Pseudomonas aeruginosa was moderately [13-31%] resistant to all tested antimicrobials, including antipseudomonal penicillins [three- and four-class MDR prevalence were 13% and 10%, respectively]. With an exception of ampicillin [fully resistant], Klebsiella spp. had low [0-13%] resistance to other tested antimicrobials with no detected MDR. Staphylococcus aureus was fully susceptible to vancomycin with 42% resistance to oxacillin. There were significant increasing trends of MDR Acinetobacter spp. However not P. aeruginosa during the study. Resistant pathogens were associated with worse profile of ICU patients but not patients' outcomes. Acinetobacter in the current study was an increasingly resistant VAP-associated pathogen more than seen in many parts of the world. The current finding may impact local choice of initial empiric antibiotics.

Knowledge of thromboprophylaxis guidelines pre- and post-didactic lectures during a venous thromboembolism awareness day at a tertiary-care hospital

Didactic lectures are frequently used to improve compliance with practice guidelines. This study assessed the knowledge of health-care providers [HCPs] at a tertiary-care hospital of its evidence-based thromboprophylaxis guidelines and the impact of didactic lectures on their knowledge. The hospital launched a multifaceted approach to improve thromboprophylaxis practices, which included posters, a pocket-size guidelines summary and didactic lectures during the annual thromboprophylaxis awareness days. A self-administered questionnaire was distributed to HCPs before and after lectures on thromboprophylaxis guidelines [June 2010]. The questionnaire, formulated and validated by two physicians, two nurses and a clinical pharmacist, covered various subjects such as risk stratification, anticoagulant dosing and the choice of anticoagulants in specific clinical situations. Seventy-two and 63 HCPs submitted the pre- and post-test, respectively [62% physicians, 28% nurses, from different clinical disciplines]. The mean scores were 7.8 +/- 2.1 [median = 8.0, range = 2-12, maximum possible score = 15] for the pre-test and 8.4 +/- 1.8 for the post-test, P = 0.053. There was no significant difference in the pre-test scores of nurses and physicians [7.9 +/- 1.7 and 8.2 +/- 2.4, respectively, P = 0.67]. For the 35 HCPs who completed the pre- and post-tests, their scores were 7.7 +/- 1.7 and 8.8 +/- 1.6, respectively, P = 0.003. Knowledge of appropriate anticoagulant administration in specific clinical situations was frequently inadequate, with approximately two-thirds of participants failing to adjust low-molecular-weight heparin doses in patients with renal failure. Education via didactic lectures resulted in a modest improvement of HCPs' knowledge of thromboprophylaxis guidelines. This supports the need for a multifaceted approach to improve the awareness and implementation of thromboprophylaxis guidelines