Bleeding risk of ticagrelor compared to clopidogrel in intensive care unit patients with acute coronary syndrome: A propensity-score matching analysis.

BACKGROUND: Intensive care unit (ICU) patients with the most severe forms of acute coronary syndrome (ACS) require invasive therapies such as extracorporeal life support. The risk of bleeding in ICU patients with ACS treated with a dual antiplatelet therapy of aspirin and ticagrelor is unknown. The primary objective of this study was to compare the bleeding risk of ticagrelor and clopidogrel in ICU patients with ACS. METHODS AND FINDINGS: We conducted a retrospective study based on a propensity score and a proportional hazards model. All patients with ACS hospitalized in the ICU of a French university hospital between January 2013 and January 2017 were included in the study. Bleeding during ICU stay was defined as all Thrombolysis in myocardial infarction (TIMI) major or minor events. A total of 155 patients were included in the study. According to propensity score matching, 57 patients treated with aspirin and ticagrelor were matched with 57 patients treated with aspirin and clopidogrel. Median (first-third quartile) Simplified Acute Physiology Score II was 61.5 (41.0-85.0). Bleeding during ICU stay occurred in 12 patients (21.1%) treated with clopidogrel and in 35 patients (61.4%) treated with ticagrelor (p<0.0001). This significant association was found for both TIMI major bleeding (12.3% vs. 35.1%, p = 0.004) and TIMI minor bleeding (8.8% vs. 26.3%, p = 0.01). The relative risk of bleeding occurrence during ICU stay was 2.60 (confidence interval 95%: 1.55-4.35) for ticagrelor compared to clopidogrel. No significant difference in ICU mortality was found between the two groups (45.6% in the clopidogrel group vs. 29.8% in the ticagrelor group, p = 0.08). CONCLUSIONS: Bleeding complications are frequent and serious in ICU patients with ACS. A dual antiplatelet therapy of aspirin and ticagrelor is associated with a higher risk of bleeding compared to a dual antiplatelet therapy of aspirin and clopidogrel.

Derivation and validation of a simple score to predict the presence of bacteria requiring carbapenem treatment in ICU-acquired bloodstream infection and pneumonia: CarbaSCORE.

Background: The recommendations of learned societies mention risk factors for the presence of multidrug resistant bacteria in hospital-acquired infections, but they do not propose a scoring system to guide empiric antibiotic therapy. Our study was aimed at developing a simple score for predicting "the presence of bacteria requiring carbapenem treatment" in ICU-acquired bloodstream infection and pneumonia. Methods: Between December 2011 and January 2015, we conducted a retrospective study using a prospectively collected French database of nosocomial infections in the polyvalent intensive care unit of a French university hospital. All patients with ICU-acquired bloodstream infection or pneumonia were included in the study. Bivariate and multivariate analyses were performed to develop the CarbaSCORE, and this score was internally validated. Results: In total, 338 patients were analyzed, including 27 patients requiring carbapenem treatment. The CarbaSCORE was composed of four criteria: "presence of bloodstream infection" (as opposed to pneumonia) scored 2 points, "chronic hemodialysis" scored 4 points, "travel abroad in the last 6 months" scored 5 points, and "MDR-colonization or prior use of a ß-lactam of class ≥ 3" scored 6 points. Internal validation by bootstrapping showed an area under the receiver operating characteristic curve of 0.81 [0.73-0.89]. Sensitivity was 96% at the 6-point threshold and specificity was 91% at the 9-point threshold. Conclusions: The CarbaSCORE is a simple and efficient score for predicting the presence of bacteria requiring carbapenem treatment. Further studies are needed to test this score before it can be used in practice.