Desirability of Outcome Ranking and Response Adjusted for Antibiotic Risk (DOOR/RADAR) Post Hoc Analysis Supports Equipoise for Antibiotic Initiation Strategies in Intensive Care Unit-Acquired Pneumonia.

Background: Pneumonia is the most common intensive care unit (ICU)-acquired infection and source of potential sepsis in ICU populations but can be difficult to diagnose in real-time. Despite limited data, rapid initiation of antibiotic agents is endorsed by society guidelines. We hypothesized that a post hoc analysis of a recent randomized pilot study would show no difference between two antibiotic initiation strategies. Patients and Methods: The recent Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP) was a pragmatic cluster-randomized pilot of antibiotic initiation strategies for patients with suspected ICU-acquired pneumonia. Participating ICUs were cluster-randomized to either an immediate initiation protocol or a specimen-initiated protocol where a gram stain was required for initiation of antibiotics. Patients in the study were divided into one of seven mutually exclusive outcome rankings (desirability of outcome ranking; DOOR): (1) Survival, No Pneumonia, No adverse events; (2) Survival, Pneumonia, No adverse events; (3) Survival, No Pneumonia, ventilator-free-alive days ≤14; (4) Survival, Pneumonia, ventilator-free-alive days ≤14; (5) Survival, No Pneumonia, Subsequent episode of suspected pneumonia; (6) Survival, Pneumonia, Subsequent episode of suspected pneumonia; and (7) Death. These rankings were further refined using the duration of antibiotics prescribed for pneumonia (response adjusted for antibiotic risk; RADAR). Results: There were 186 patients enrolled in the study. After applying the DOOR analysis, a randomly selected patient was equally likely to have a better outcome in specimen-initiated arm as in the immediate initiation arm (DOOR probability: 50.8%; 95% confidence interval [CI], 42.7%-58.9%). Outcome probabilities were similar after applying the RADAR analysis (52.5%; 95% CI, 44.2%-60.6%; p = 0.31). Conclusions: We found that patients for whom antibiotic agents were withheld until there was objective evidence (specimen-initiated group) had similar outcome rankings to patients for whom antibiotic agents were started immediately. This supports the findings of the TARPP pilot trial and provides further evidence for equipoise between these two treatment strategies.

Provider Perceptions of Antibiotic Initiation Strategies for Hospital-Acquired Pneumonia.

Background: The practice of rapidly initiating antibiotic therapy for patients with suspected infection has recently been criticized yet remains commonplace. Provider comfort level has been an understudied aspect of this practice. Hypothesis: We hypothesized that there would be no significant differences in provider comfort level between the two treatment groups. Methods: We prospectively surveyed critical care intensivists who provided care for patients enrolled in the Trial of Antibiotic Restraint in Presumed Pneumonia (TARPP), which was a multicenter cluster-randomized crossover trial that evaluated an immediate antibiotic initiation protocol compared with a protocol of specimen-initiated antibiotic initiation in ventilated patients with suspected new-onset pneumonia. At the end of each enrollment arm, physicians at each center were surveyed regarding their overall comfort level with the recently completed treatment arm, and perception of adherence. Both a paired and unpaired analysis was performed. Results: We collected 51 survey responses from 31 unique participants. Providers perceived a higher rate of adherence to the immediate initiation arm than the specimen-initiated arm (Always Adherent: 37.5% vs. 11.1%; p = 0.045). Providers were less comfortable waiting for objective evidence of infection in the specimen-initiated arm than with starting antibiotic agents immediately (Very Comfortable: 83.3% vs. 40.7%; p = 0.004). For the smaller paired analysis, there was no longer a difference in comfort level. Conclusions: There may be differences in provider comfort levels and perceptions of adherence when considering two different antibiotic initiation strategies for suspected pneumonia in ventilated patients. These findings should be considered when planning future studies.

Trial of antibiotic restraint in presumed pneumonia: A Surgical Infection Society multicenter pilot.

BACKGROUND: Pneumonia is the most common intensive care unit-acquired infection in the trauma and emergency general surgery population. Despite guidelines urging rapid antibiotic use, data supporting immediate antibiotic initiation in cases of suspected infection are limited. Our hypothesis was that a protocol of specimen-initiated antibiotic initiation would have similar compliance and outcomes to an immediate initiation protocol. METHODS: We devised a pragmatic cluster-randomized crossover pilot trial. Four surgical and trauma intensive care units were randomized to either an immediate initiation or specimen-initiated antibiotic protocol for intubated patients with suspected pneumonia and bronchoscopically obtained cultures who did not require vasopressors. In the immediate initiation arm, antibiotics were started immediately after the culture regardless of patient status. In the specimen-initiated arm, antibiotics were delayed until objective Gram stain or culture results suggested infection. Each site participated in both arms after a washout period and crossover. Outcomes were protocol compliance, all-cause 30-day mortality, and ventilator-free alive days at 30 days. Standard statistical techniques were applied. RESULTS: A total of 186 patients had 244 total cultures, of which only the first was analyzed. Ninety-three patients (50%) were enrolled in each arm, and 94.6% were trauma patients (84.4% blunt trauma). The median age was 50.5 years, and 21% of the cohort was female. There were no differences in demographics, comorbidities, sequential organ failure assessment, Acute Physiology and Chronic Health Evaluation II, or Injury Severity Scores. Antibiotics were started significantly later in the specimen-initiated arm (0 vs. 9.3 hours; p < 0.0001) with 19.4% avoiding antibiotics completely for that episode. There were no differences in the rate of protocol adherence, 30-day mortality, or ventilator-free alive days at 30 days. CONCLUSION: In this cluster-randomized crossover trial, we found similar compliance rates between immediate and specimen-initiated antibiotic strategies. Specimen-initiated antibiotic protocol in patients with a suspected hospital-acquired pneumonia did not result in worse clinical outcomes compared with immediate initiation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Antibiotic Initiation Timing and Mortality in Trauma Patients With Ventilator-Associated Pneumonia.

BACKGROUND: Early antibiotic initiation is considered a cornerstone in the management of ventilator-associated pneumonia (VAP). However, recent data suggests that early antibiotic initiation may not be necessary in all cases. Additionally, the benefits of early antibiotic administration for infection have not been studied in a dedicated trauma population. This study's aim was to evaluate the impact of antibiotic administration timing on in-hospital mortality in trauma patients with VAP. METHODS: This retrospective case-control study identified all trauma patients at a single level 1 academic trauma center from 2016 to 2020. Patients with a TQIP-defined VAP were included and stratified into 2 subgroups by in-hospital mortality. Time interval between airway culture and antibiotic initiation was gathered. Baseline measures of injury and illness severity were collected. Univariate analysis of the data was performed. RESULTS: Forty-five patients met inclusion criteria. Overall, 80% of patients survived admission (n = 36) and 20% of patients did not survive admission (n = 9). There were no significant differences in baseline characteristics or cultured organism between survivors and non-survivors. The median time interval between airway culture and antibiotic initiation was 2 hours (IQR 0-4.5) for survivors, and 0 hours (IQR 0-0) for non-survivors (P = .07). Antibiotics were administered within 1 hour of airway culture for 33.3% of survivors, and 77.8% of non-survivors (P = .02). CONCLUSIONS: In a population of trauma patients with VAP, survivors had antibiotics initiated in more delayed fashion than non-survivors. These findings question the primacy of early antibiotic administration for suspected infection.

Acute stress disorder in trauma patients discharged in 72 h or less.

INTRODUCTION: Acute Stress Disorder (ASD) is a psychiatric condition affecting individuals exposed to trauma and requires the presence of symptoms 72 h following trauma. Patients evaluated for trauma related injury are often discharged prior to 72 h, but the risk of ASD remains. The aim of this study was to quantify the rate of acute stress disorder in trauma patients admitted for fewer than 72 h. MATERIALS AND METHODS: We performed a prospective, observational study of trauma patients discharged prior to 72 h at our ACS Level I Trauma Center between June 2020 and December 2020. Participants were administered an institutional screening tool following hospital discharge. Positive screens were then administered the diagnostic Acute Stress Disorder Scale (ASDS) tool. The rate of ASD was calculated and bivariate comparisons between participants who met diagnostic criteria and those who did not were performed to identify risk factors for the development of acute stress disorder. RESULTS: 116 patients participated (median age 54, 66% male, median injury severity score (ISS) 9). Forty patients (34%) screened positive via the institutional screening tool, with 14 (12%) ultimately demonstrating ASD by ASDS. Participants who developed ASD were more likely to be female (71 vs. 30%, p = 0.005), African American (43 vs. 12% White, p = 0.016), spend less time in the hospital overall (1-2 vs. 2-3 days. p = 0.045), and have a lower ISS (6 vs. 9, p = 0.041). CONCLUSIONS: Our study found 12% of trauma patients discharged prior to 72 h developed ASD. These data point to possible benefit in reassessment of injured patients following hospital discharge and the importance of developing pathways for trauma patients to access mental health resources.

Availability of Multiple Organ Failure Score Components in Surgical Patients.

Background: Scoring systems are often used describe the degree of multi-system organ failure (MOF), however, the data used to calculate these scores are often missing. Studies utilizing these scoring systems often underreport the frequency of missing data. No study has examined the availability of clinical data needed to calculate Sequential Organ Failure Assessment (SOFA), and other organ failure scores. The primary objective of this study is to observe how often emergency general surgery and trauma patients have missing data needed to calculate MOF scores. Patients and Methods: Patients admitted between June 2017 and September 2019 were evaluated. Data to calculate SOFA, quick SOFA (qSOFA), Marshall Multiple Organ Dysfunction Score (MODS), Denver Post-Injury Multiple Organ Failure, and systemic inflammatory response syndrome (SIRS) criteria, as well as demographic and general admission and discharge data, were collected. Results: Of the 238 patients included in this study, 66.4% were emergency general surgery and 33.6% were trauma patients. For all patients, the median intensive care unit (ICU) length of stay (LOS) was seven days (range, 4-12), the median hospital LOS was 14 days (range, 10-21), and 28 patients (11.8%) did not survive to hospital discharge. Sequential Organ Failure Assessment was calculable in 21.4%-18.1%, whereas MODS was calculable in 6.3%-5.0% on days three and five, respectively. The Denver score was calculable in 32.5%-28.8% of trauma patients on these days. Of the data points needed to calculate these scores, the partial pressure of oxygen (Pao2)/fraction of inspired oxygen (FIo2) ratio, central venous pressure (CVP), and bilirubin were the least available components. Conclusions: Data needed to fully calculate SOFA and other common MOF scores are often not readily available highlighting the degree of imputation required to calculate these scores. We recommend better reporting of the degree of missing data in the literature.

Empowering the affected: Informing community-based solutions through interviews with survivors of interpersonal firearm violence-Perspectives of survivors of firearm injuries.

BACKGROUND: Firearm violence remains epidemic in the United States, with interpersonal gun violence leading to significant morbidity and mortality. Interpersonal violence has strong associations with social determinants of health, and community-specific solutions are needed to address root causes. We hypothesized that open-ended interviews with survivors of interpersonal firearm violence would identify themes in individual and community-level factors that contribute to ongoing violence. METHODS: Between July 2017 and November 2019, we performed a mixed-methods study in which qualitative and quantitative data were obtained from survivors of interpersonal firearm violence admitted to our urban level I trauma center. Qualitative data were obtained through semistructured, open-ended interviews with survivors. Quantitative data were obtained via survey responses provided to these same individuals. Qualitative and quantitative data were then used to triangulate and strengthen results. RESULTS: During the study period, 51 survivors were enrolled in the study. The most common cause of firearm violence reported by survivors was increased gang and drug activity (n = 40, 78%). The most common solution expressed was to reduce drug and gang lifestyle by offering jobs and educational opportunities to afflicted communities to improve opportunities (n = 35, 69%). Nearly half of the survivors (n = 23, 45%) believe that firearm violence should be dealt with by the affected community itself, and another group of survivors believe that it should be through partnership between the community and trauma centers (n = 19, 37%). CONCLUSION: Interviews with survivors of firearm violence at our urban level I trauma center suggest that drug and gang lifestyle perpetuate ongoing violence and that this would best be overcome by improving access to quality education and job opportunities. To address endemic firearm violence in their communities, trauma centers should identify opportunities to partner in developing programs that provide improved education, job access, and conflict mediation. LEVEL OF EVIDENCE: Prognostic and epidemiological, level I.