Reviews of Research on Health-Care Acquired Infections, Glucocorticoid Therapy in COPD, and Blood-Pressure Lowering in Intracerebral Hemorrhages

The Hospitalist. 2013 September;2013(09):

September 1, 2013|Breast Cancer ICYMI

Sameem Abedin, MD;Sarah Anand, MD;Julieann Grant, MD;Andrea Kim, MD;Mark McQuillan, MD;University Of Michigan Health System

Synopsis: All adult ICUs in a given hospital were randomized to one of three infection prevention strategies: Group 1 continued MRSA screening and isolation; Group 2 performed screening, isolation, and decolonization of MRSA carriers; and Group 3 implemented universal decolonization with intranasal mupirocin and daily bathing with chlorhexidine-impregnated cloths but no screening.

Forty-three hospitals, including 74 ICUs and 74,256 patients, underwent randomization. Significant reductions in the primary outcome of ICU-attributable MRSA clinical isolates (excluding MRSA screening tests) and the secondary outcome of bloodstream infection due to any pathogen were demonstrated across the three groups. One bloodstream infection was prevented for every 54 patients who underwent decolonization. Formal cost-effectiveness analysis was not performed.

Bottom line: In the ICU, universal decolonization was more effective than screening and isolation or targeted decolonization in the reduction of clinical MRSA isolates and bloodstream infection due to any pathogen, although monitoring for emerging resistance is necessary.

Citation: Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368(24):2255-2265.

Intensive Blood-Pressure Lowering in Intracerebral Hemorrhage Did Not Reduce Death or Severe Disability

Clinical question: What is the efficacy and safety of early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage?

Background: After intracerebral hemorrhage, blood pressure often becomes elevated and is a predictor of outcome. It is not known whether rapid lowering of blood pressure would improve outcome.

Study design: International, multicenter, prospective, randomized, open-treatment, blinded end-point trial.

Setting: One hundred forty-four hospitals in 21 countries.

Synopsis: Researchers randomly assigned 2,839 patients with intracerebral hemorrhage in the previous six hours to intensive blood-pressure lowering with target systolic blood pressure of <140 mmHg within one hour, or guideline-recommended treatment with target systolic blood pressure of <180 mmHg. The mean systolic blood pressure achieved was 150 mmHg in the intensive-treatment group and 164 mmHg in the standard-treatment group.

There was no significant difference between the two groups in the primary outcome of death or major disability. A pre-specified ordinal analysis of modified Rankin score (score of 0 indicates no symptoms; a score of 5 indicates severe disability) did show significantly lower modified Rankin scores with intensive treatment. There was no difference between the two groups in the rate of serious adverse events.

Bottom line: Early intensive blood-pressure lowering in patients with acute intracerebral hemorrhage did not reduce death or major disability, although there may be improved functional outcomes with intensive blood-pressure lowering.

Citation: Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365.

Clinical Shorts

INCREASED RISK OF DVT WITH PICCS COMPARED WITH CVCS

Systematic review of peripherally inserted central catheter (PICC)-related DVT showed increased risk of thrombosis with PICCs compared with central venous catheters (CVC).

Citation: Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382(9889):311-25. doi: 10.1016/S0140-6736(13)60592-9. Epub 2013 May 20.

EARLY TRACHEOSTOMY HAS NO EFFECT ON SURVIVAL IN MECHANICALLY VENTILATED PATIENTS

Multicenter randomized clinical trial of early tracheostomy (within four days) versus late tracheostomy (after 10 days) did not show any difference in mortality at 30 days or two years.

Citation: Young D, Harrison DA, Cuthbertson BH, Rowan K. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation. JAMA. 2013;309(20):2121-2129.

FDA APPROVES KCENTRA, AN ATTRACTIVE ALTERNATIVE FOR RAPID WARFARIN REVERSAL

Kcentra (human prothrombin complex concentrate) is an alternative to plasma that can be available more rapidly as blood typing and thawing is unnecessary, and it is administered in significantly less volume.

Citation: U.S. Food and Drug Administration. FDA approves Kcentra for the urgent reversal of anticoagulation in adults with major bleeding. U.S. Food and Drug Administration website. Available at: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm350026.htm. Accessed June 19, 2013.

MUSIC THERAPY REDUCED ANXIETY AND SEDATIVE EXPOSURE IN MECHANICALLY VENTILATED PATIENTS

In a randomized trial of critically ill patients requiring ventilatory support, patient-directed music therapy reduced anxiety and sedation intensity compared with usual care but not compared with noise-canceling headphones.

Citation: Chlan LL, Weinert CR, Heiderscheit A, et al. Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: a randomized clinical trial. JAMA. 2013;309(22):2335-2344.