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Martin A Croce

Publications and source records attributed to Martin A Croce.

17 recordsLinked to original sources
PubMed2003

Tetracyclines for treating multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia.

OBJECTIVE: To report the use of tetracyclines for the treatment of multidrug-resistant Acinetobacter baumannii ventilator-associated pneumonia (VAP). DESIGN: Observational case series. SETTING: . The Presley Regional Trauma Center located within the Regional Medical Center, Memphis, Tennessee, USA. PATIENTS AND PARTICIPANTS: Seven critically ill trauma patients with VAP caused by A. baumannii isolates that were resistant to all antibiotics tested except for doxycycline or minocycline. INTERVENTIONS: Patients were treated with IV doxycycline or minocycline for an average of 13.5 (range 9-20) days. MEASUREMENTS AND RESULTS: Doxycycline or minocycline was successful in six of seven patients. CONCLUSIONS: Doxycycline or minocycline may be effective for treating multidrug-resistant A. baumannii VAP.

APACHE↗
PubMed2003

Staged management of giant abdominal wall defects: acute and long-term results.

INTRODUCTION: Shock resuscitation leads to visceral edema often precluding abdominal wall closure. We have developed a staged approach encompassing acute management through definitive abdominal wall reconstruction. The purpose of this report is to analyze our experience with this technique applied to the treatment of patients with open abdomen and giant abdominal wall defects. METHODS: Our management scheme for giant abdominal wall defects consists of 3 stages: stage I, absorbable mesh insertion for temporary closure (if edema quickly resolves within 3-5 days, the mesh is gradually pleated, allowing delayed fascial closure); stage II, absorbable mesh removal in patients without edema resolution (2-3 weeks after insertion to allow for granulation and fixation of viscera) and formation of the planned ventral hernia with either split thickness skin graft or full thickness skin closure over the viscera; and stage III, definitive reconstruction after 6-12 months (allowing for inflammation and dense adhesion resolution) by using the modified components separation technique. Consecutive patients from 1993 to 2001 at a single institution were evaluated. Outcomes were analyzed by management stage, with emphasis on wound related morbidity and mortality, and fistula and recurrent hernia rates. RESULTS: Two hundred seventy four patients (35 with sepsis, 239 with hemorrhagic shock) were managed. There were 212 males (77%), and mean age was 37 (range, 12-88). The average size of the defects was 20 x 30 cm. In the stage I group, 108 died (92% of all deaths) because of shock. The remaining 166 had temporary closure with polyglactin 910 woven absorbable mesh. As visceral edema resolved, bedside pleating of the absorbable mesh allowed delayed fascial closure in 37 patients (22%). In the stage II group, 9 died (8% of all deaths) from multiple organ failure associated with their underlying disease process, and 96% of the remaining 120 had split-thickness skin graft placed over the viscera. No wound related mortality occurred. There were a total of 14 fistulae (5% of total, 8% of survivors). In the stage III group, to date, 73 of the 120 have had definitive abdominal wall reconstruction using the modified components separation technique. There were no deaths. Mean follow-up was 24 months, (range 2-60). Recurrent hernias developed in 4 of these patients (5%). CONCLUSIONS: The staged management of patients with giant abdominal wall defects without the use of permanent mesh results in a safe and consistent approach for both initial and definitive management with low morbidity and no technique-related mortality. Absorbable mesh provides effective temporary abdominal wall defect coverage with a low fistula rate. Because of the low recurrent hernia rate and avoidance of permanent mesh, the components separation technique is the procedure of choice for definitive abdominal wall reconstruction.

Abdominal Injuries↗
PubMed2003

Expedited discharge in trauma patients requiring anticoagulation for deep venous thrombosis prophylaxis: the LEAP Program.

OBJECTIVE: With rising health care costs, methods to decrease length of hospital stay without compromising care are necessary. One area that extends length of stay in trauma patients is inpatient anticoagulation to a therapeutic international normalized ratio. The 1998 American College of Chest Physicians guidelines recommend thromboprophylaxis with low-molecular-weight heparin (LMWH) and oral warfarin in this population. The LMWH Expedited Anticoagulation Program (LEAP) was created with the following goals: to decrease the number of inpatient warfarin days and to reduce overall number of hospital days. METHODS: Inpatient anticoagulation was initiated with warfarin and LMWH. LEAP included early multidisciplinary collaboration to ensure third-party approval, outpatient primary care physician follow-up, and LMWH self-injection before discharge. Patients were discharged on LMWH (discontinued by primary care provider when a therapeutic international normalized ratio was attained) and warfarin (continued until resolution of orthopedic injuries). From August 2000 to August 2001, adult patients were included in the prospective study. Primary inclusion criteria were blunt acetabular fracture, bilateral lower extremity fracture, and contralateral upper and lower extremity fractures. Patients with similar injuries receiving warfarin for deep venous thrombosis prophylaxis between June 1999 and June 2000 were the control population. Anticoagulation care was similar for the study and control subjects. RESULTS: There were 182 patients evaluated for LEAP inclusion. After initial evaluation, 108 patients were enrolled in LEAP (Injury Severity Score of 13). There were 69 control subjects (Injury Severity Score of 13). The average number of inpatient warfarin days was decreased from 8.8 days to 5.0 days in the control and study populations, respectively (p < 0.0001). The average length of hospitalization was shortened from 17.3 days in the control group to 12.9 days in the study (LEAP) population (p < 0.002). CONCLUSION: LEAP has successfully decreased the number of inpatient days on warfarin and total hospital days for trauma patients requiring deep venous thrombosis prophylaxis. These results have substantially decreased health care costs and increased available hospital beds in this era of high hospital occupancy.

Adult↗
PubMed2003

A formula for prediction of posttraumatic pneumonia based on early anatomic and physiologic parameters.

BACKGROUND: Identification of risks for development of ventilator-associated pneumonia (VAP), which might be identified early after injury, would allow for prognostic estimates and targeting of high-risk cohorts for clinical trials of preventive strategies. This study was performed to develop an equation that can be applied to estimate the probability of pneumonia based on parameters collected in the early postinjury interval. METHODS: Over a 28-month period, patient admissions were reviewed for mechanism and severity of injury, patterns of injury, shock, and need for emergent intubation. Early deaths (<48 hours) were excluded. VAP diagnosis required > or = 10(5) colony-forming units/mL organisms in the bronchoalveolar lavage effluent. Multiple logistic regression analysis was used to develop the prediction equation and estimate odds ratios. The equation was then tested on consecutive patients admitted over a 2-month period. RESULTS: We reviewed 9,721 admissions (77% blunt, 23% penetrating). VAP incidence was 5.6%. Overall mortality was 2% (21% for patients with VAP vs. 1% for no VAP; p < 0.0001). Multiple logistic regression analysis for all patients produced the following equation: f(x) = -3.08 - 1.56 (MOI) - 0.12 (GCS) + 1.37 (SCI) + 0.30 (chest AIS) + 1.87 (lap) + 0.67 (tx) + 0.05 (ISS) + 0.66 (int), where MOI is mechanism of injury (penetrating = 1, blunt = 0), GCS is Glasgow Coma Scale score, SCI is spinal cord injury (yes = 1, no = 0), lap is emergent laparotomy (yes = 1, no = 0), ISS is Injury Severity Score, tx is units of blood transfused in the resuscitation room, and int is intubation in either the field or the resuscitation room (yes = 1, no = 0). The probability of VAP was calculated as follows: P(VAP) = e(f)(x)/1 + e(f)(x). This formula was concordant in 95% and discordant in 5%. CONCLUSION: It is possible to accurately predict risk for VAP in trauma patients based on data available early after injury. This calculation could be useful for counseling families relative to prognosis and research protocols, and addressing hospitalization issues with third-party payors.

Adult↗
PubMed2003

Multiplicity of solid organ injury: influence on management and outcomes after blunt abdominal trauma.

OBJECTIVE: The current study was undertaken to examine how concomitant injury to liver and spleen after blunt abdominal trauma affects management and outcomes. METHODS: This study was a retrospective chart review of all blunt abdominal trauma patients admitted with a diagnosis of liver or spleen injury at two Level I trauma centers over a 4-year period. Presentation, injury grade, management, and outcomes were analyzed. Patients with single-organ injury (liver or spleen) were compared with patients having injury to both organs (liver and spleen). Significance was set at 95% confidence intervals. RESULTS: Of 1,288 patients who met entry criteria, 1,125 had single (spleen, 573; liver, 552) organ injury (group S) and 163 had injury to both organs (group B). Group B patients had significantly higher Injury Severity Score, higher admission lactate, and lower admission systolic blood pressure and base excess. Eighty-one percent (915 of 1,125) of group S and 69% (112 of 163) of group B patients were managed nonoperatively (p < 0.05). Of the nonoperatively managed patients, 5.8% (53 of 915) in group S and 11.6% (13 of 112) in group B failed this form of therapy (p < 0.05). Higher failure rate in group B was because of bleeding from injured solid organ(s), and not non-solid organ related failures. Mortality, intensive care unit and hospital lengths of stay, and transfusion requirements were all significantly higher in group B. CONCLUSION: Blunt trauma patients with concomitant injury to liver and spleen have higher Injury Severity Score, mortality, lengths of stay, and transfusion requirements. There is a higher failure rate with nonoperative management, and therefore extra vigilance is warranted when choosing this form of therapy in the presence of injury to both organs.

Abdominal Injuries↗
PubMed2003

The predictive value of preliminary bacterial colony counts from bronchoalveolar lavage in critically ill trauma patients.

A common strategy for the diagnosis of ventilator-associated pneumonia (VAP) includes quantitative cultures from bronchoalveolar lavage (BAL). Often, empiric antibiotic therapy is initiated and continued until the final culture report. However, approximately 60 per cent of BAL cultures rule out VAP. Preliminary BAL results, obtained earlier, may identify these patients and allow early discontinuation of empiric antibiotics. This is desirable because unnecessary antibiotic therapy results in increased bacterial resistance, adverse drug events, and increased costs. The purpose of this study was to determine the value of preliminary BAL results for predicting final BAL results. A total of 1579 isolates from 868 BAL cultures over a 3-year period were analyzed. Preliminary and final colony counts for each isolate were categorized as either no growth (NG), insignificant (1-99,999 cfu/mL), or significant (> or = 100,000 cfu/mL). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of preliminary results were calculated based on individual isolates and individual BAL samples. The presence of concurrent antibiotic therapy was collected for all false-negative isolates. On preliminary report, there were 367 isolates with NG, 820 isolates with insignificant growth, and 392 isolates with significant growth. Overall preliminary culture results had a sensitivity of approximately 90 per cent and specificity of >90 per cent for the presence of VAP. Preliminary culture results accurately predicted the presence or absence of VAP in 838 (96.5%) of the BALs performed. Individual isolates and BAL samples with insignificant preliminary growth had greater reliability in predicting the absence of VAP than those with NG. There was no difference in the number of false-negative isolates that were taken while concurrent antibiotic therapy was present between insignificant and NG groups. Preliminary culture results yielding either insignificant or significant growth are highly predictive for final colony counts of similar magnitude. BALs with preliminary results demonstrating no growth are not as reliable. Isolates with significant preliminary growth should be considered clinically important, and antibiotic therapy should be changed, if necessary, to target such organisms. Isolates with insignificant preliminary growth have a low rate of false negatives; therefore, empiric antibiotic therapy specific for such organisms could be discontinued before obtaining final results. Empiric antibiotics should be continued until the final results are available in those patients with NG BALs.

Adult↗
PubMed2002

Risk factors for late-onset nosocomial pneumonia caused by Stenotrophomonas maltophilia in critically ill trauma patients.

Patients with nosocomial pneumonia caused by Stenotrophomonas maltophilia often receive inadequate empiric antibiotic therapy, potentially increasing mortality. Knowledge of the risk factors associated with S. maltophilia pneumonia may better guide the selection of empiric antibiotic therapy. Potential risk factors for S. maltophilia pneumonia were retrospectively analyzed for critically ill trauma patients with late-onset gram-negative pneumonia. The effects of S. maltophilia infection and inadequate empiric antibiotic therapy on patient outcomes were also assessed. By multivariate analysis, S. maltophilia pneumonia was found to be associated with cefepime exposure and tracheostomy in patients with a single pneumonia episode and with higher Injury Severity Score and pulmonary contusion in patients with multiple pneumonia episodes. S. maltophilia pneumonia was associated with increased patient morbidity; only inadequate empiric antibiotic therapy was associated with a higher mortality rate. In critically ill trauma patients with late-onset ventilator-associated pneumonia and these risk factors, empiric antibiotic therapy should include agents active against S. maltophilia.

Adult↗
PubMed2002

Comparison of ampicillin-sulbactam and imipenem-cilastatin for the treatment of acinetobacter ventilator-associated pneumonia.

Acinetobacter organisms, which are a common cause of ventilator-associated pneumonia (VAP) in some health care centers, are becoming more resistant to such first-line agents as imipenem-cilastatin (Imi-Cil). Sulbactam has good in vitro activity against Acinetobacter organisms; thus, ampicillin-sulbactam (Amp-Sulb) may be a viable treatment alternative. The outcomes for critically ill trauma patients with Acinetobacter VAP treated with either Amp-Sulb or Imi-Cil were compared retrospectively. A total of 77 episodes in 75 patients were studied. Fourteen patients were treated with Amp-Sulb, and 63 patients were treated with Imi-Cil. Treatment efficacy was similar in the Amp-Sulb and Imi-Cil groups (93% vs. 83%, respectively; P>.05). No statistically significant differences between groups were noted with regard to associated mortality, duration of mechanical ventilation, or length of stay in the intensive care unit or hospital. However, adjunctive aminoglycoside therapy was used more often in the Amp-Sulb group. Patients generally received Amp-Sulb because of imipenem resistance. Amp-Sulb was effective in treating a small number of patients with Acinetobacter VAP; however, more data are needed.

Acinetobacter↗
PubMed2002

Improving outcomes following penetrating colon wounds: application of a clinical pathway.

INTRODUCTION: During World War II, failure to treat penetrating colon injuries with diversion could result in court martial. Based on this wartime experience, colostomy for civilian colon wounds became the standard of care for the next 4 decades. Previous work from our institution demonstrated that primary repair was the optimal management for nondestructive colon wounds. Optimal management of destructive wounds requiring resection remains controversial. To address this issue, we performed a study that demonstrated risk factors (pre or intraoperative transfusion requirement of more than 6 units of packed red blood cells, significant comorbid diseases) that were associated with a suture line failure rate of 14%, and of whom 33% died. Based on these outcomes, a clinical pathway for management of destructive colon wounds was developed. The results of the implementation of this pathway are the focus of this report. METHODS: Patients with penetrating colon injury were identified from the registry of a level I trauma center over a 5-year period. Records were reviewed for demographics, injury characteristics, and outcome. Patients with nondestructive injuries underwent primary repair. Patients with destructive wounds but no comorbidities or large transfusion requirement underwent resection and anastomosis, while patients with destructive wounds and significant medical illness or transfusion requirements of more than 6 units/blood received end colostomy. The current patients (CP) were compared to the previous study (PS) to determine the impact of the clinical pathway. Outcomes examined included colon related mortality and morbidity (suture line leak and abscess). RESULTS: Over a 5.5-year period, 231 patients had penetrating colon wounds. 209 survived more 24 hours and comprise the study population. Primary repair was performed on 153 (73%) patients, and 56 patients had destructive injuries (27%). Of these, 40 (71%) had resection and anastomosis and 16 (29%) had diversion. More destructive injuries were managed in the CP group (27% vs. 19%). Abscess rate was lower in the CP group (27% vs. 37%), as was suture line leak rate (7% vs. 14%). Colon related mortality in the CP group was 5% as compared with 12% in the PS group. CONCLUSIONS: The clinical pathway for destructive colon wound management has improved outcomes as measured by anastomotic leak rates and colon related mortality. The data demonstrated the need for colostomy in the face of shock and comorbidities. Institution of this pathway results in colostomy for only 7% of all colon wounds.

Abdominal Abscess↗
PubMed2002

Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management.

BACKGROUND: During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or spleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and spleen injuries, and missed injuries were reviewed in patients undergoing NOM. METHODS: Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsuspected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or spleen injury. RESULTS: Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or spleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. CONCLUSION: Damage to the pancreas and bowel is significantly associated with liver as opposed to spleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with spleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We speculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the spleen accounts for the greater rate of associated injuries to the pancreas/small bowel.

Abdominal Injuries↗
PubMed2002

Blunt aortic injury with concomitant intra-abdominal solid organ injury: treatment priorities revisited.

BACKGROUND: Patients with blunt aortic injury (BAI) often have concomitant liver or spleen (L/S) injuries. With increasing use of cardiopulmonary bypass with heparinization in repair of BAI, many advocate operative management of the L/S injury before aortic repair to eliminate risk of hemorrhage. We evaluated the safety of nonoperative management (NOM) of blunt L/S injuries in patients undergoing acute BAI repair with bypass. METHODS: All patients admitted over a 6-year period with BAI were identified from the registry of our Level I trauma center. Patients with isolated L/S injuries without BAI admitted over the same period served as controls. Groups were compared with regard to demographics, injury characteristics, hospital course, and mortality. RESULTS: Eighty-four patients were diagnosed with BAI from 1994 to 2000; 28 (33%) also had blunt abdominal trauma. Three patients with severe brain injury did not undergo BAI repair, and five required laparotomy before BAI repair for other intra-abdominal injuries (two for hemodynamic instability with splenic injury, and three for concomitant bowel injury). Therefore, 20 of 28 (71.4%) BAI patients with grade I or II L/S injury (Aorta L/S group) underwent planned NOM. All BAIs were repaired using partial bypass with full heparinization. These 20 patients are compared with 894 patients with grade I or II L/S injuries with no BAI (L/S group) over the same time period. There was no difference in the nonoperative failure rate of the Aorta L/S group versus the L/S group (0% vs. 1.7%). Both groups had similar complication rates. The Aorta L/S group was also compared with 56 BAIs without solid organ injury (Aorta group). Although the Aorta L/S group was more severely injured than the Aorta group (Injury Severity Score of 35.3 vs. 26.8, < 0.0001), transfusion rates (5.7 U of packed red blood cells vs. 8.0 U of packed red blood cells, p = NS), hospital days (17.9 vs. 19.1, p = NS) and mortality (10% vs. 9%, p = NS) were similar. CONCLUSION: NOM of patients with grade I or II L/S injury who undergo systemic anticoagulation with heparin for repair of BAI is safe and associated with transfusion rates similar to BAI alone. Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass.

Abdominal Injuries↗
PubMed2002

Does gender difference influence outcome?

BACKGROUND: Recent laboratory studies have demonstrated that immune responses differ between male and female rodents, and some clinical studies have suggested gender differences regarding incidence and mortality from sepsis. The differences appear because of both deleterious testosterone and beneficial estrogen effects; clinical trials of testosterone blockage and/or estrogen administration for male subjects have been suggested. We evaluated the effect of gender on various outcomes in trauma patients. METHODS: Trauma patients over a 52-month period were identified from the trauma registry. Early deaths were excluded. Outcomes included mortality, pneumonia (> or = 10 colony-forming units/mL in bronchoalveolar lavage effluent), acute respiratory distress syndrome, bacteremia, ventilator days, and intensive care unit and hospital length of stay. Patients were stratified by injury mechanism, gender, age (assuming women < or = 40 were premenopausal and those > 50 were postmenopausal), and injury severity. RESULTS: There were 18,133 patients identified, and 544 were excluded because of early death. There were 12,756 (73%) men and 4,833 (27%) women. There were no outcome differences after penetrating injury with respect to gender and age group. There was a survival advantage for women < or = 40 in the Injury Severity Score 16 to 24 group, but these patients had statistically less severe injury. Overall, men tended to have more infectious complications, but women had lower survival in the face of infection. Logistic regression did not identify gender as an independent predictor of mortality. CONCLUSION: Although there was a survival advantage for women in subgroup analysis, there was no overall difference in mortality. Women with pneumonia, however, had a higher mortality than men. Further understanding of potential mechanisms is necessary before hormonal manipulation studies.

Adult↗
PubMed2002

Prospective screening for blunt cerebrovascular injuries: analysis of diagnostic modalities and outcomes.

OBJECTIVE: To prospectively examine outcomes associated with an aggressive screening protocol for blunt cerebrovascular injury (BCVI), and to compare the accuracy of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) versus conventional angiography with respect to BCVI diagnosis. SUMMARY BACKGROUND DATA: In the past 5 years, BCVI (carotid and vertebral arteries) has been recognized with increasing frequency. Initial studies described blunt carotid injuries and their associated morbidity, while more recent reports have established the devastating potential of blunt vertebral injuries. It has been suggested that early diagnosis and anticoagulation will improve outcomes and that less-invasive diagnostic techniques than conventional angiography are desirable for screening. However, there are neither established screening criteria nor studies comparing optimal diagnostic modalities. METHODS: The screened population included all patients with cervical spine fractures, LeFort II or III facial fractures, Horner's syndrome, skull base fractures involving the foramen lacerum, neck soft tissue injury, or neurological abnormalities unexplained by intracranial injuries. Patients underwent screening with four-vessel cerebral angiography. During the first half of the study, patients also underwent helical CTA. Selected patients during this same period underwent MRA. At the time of diagnosis, anticoagulant or antiplatelet therapy was instituted unless clinically contraindicated. Results of this screening protocol were compared to a previously published cohort with cerebrovascular injuries (1995-1999) from the authors' institution. RESULTS: Two hundred sixteen patients were screened over a 2-year period (3.5% of all blunt trauma admissions). Angiography identified 24 patients with carotid artery injuries (CAI) and 43 patients with vertebral artery injuries (VAI) for an overall screening yield of 29%. While the incidence of CAI remained similar between the current study and the previous study group, the incidence of VAI diagnosis increased. Stroke rates in those with CAI were also similar between the two periods. The stroke rate in VAI, however, was markedly lower at 0% as compared to 14% in the previous group. Comparison of CTA and MRA with cerebral angiography in 143 patients demonstrated sensitivities of 47% and 50%, respectively, for CAI; sensitivities were 53% (CTA) and 47% (MRA) for VAI. CONCLUSIONS: Aggressive screening of patients with blunt head and neck trauma identified an incidence of BCVI in 1.03% of blunt admissions. Early identification, which led to early treatment, significantly reduced stroke rates in patients with VAI, but provided no outcome improvement with CAI. More encompassing screening may be required to improve outcomes for patients with CAI. However, less-invasive diagnostic techniques (CTA and MRA) are inadequate for screening. Technological advances are necessary before abandonment of conventional angiography, which remains the standard for diagnosis.

Adult↗
PubMed2002

Aerosolized ceftazidime for prevention of ventilator-associated pneumonia and drug effects on the proinflammatory response in critically ill trauma patients.

STUDY OBJECTIVES: To evaluate the safety and efficacy of aerosolized ceftazidime for prevention of ventilator-associated pneumonia (VAP) and to evaluate the effects of the drug on the proinflammatory response. DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. SETTING: University teaching hospital. PATIENTS: Forty critically ill trauma patients at high risk for VAP Intervention. Within 48 hours of admission to the intensive care unit (ICU), patients were randomly assigned to receive aerosolized ceftazidime 250 mg every 12 hours or placebo (normal saline) for up to 7 days. Bronchoalveolar concentrations of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta, IL-6, and IL-8 were determined at baseline and the end of therapy (days 4-7). MEASUREMENTS AND MAIN RESULTS: The frequency of VAP in patients receiving aerosolized ceftazidime was 73% lower than that in patients receiving placebo at ICU day 14 (15% vs 55%, p = 0.021), and 54% lower for the entire ICU stay (30% vs 65%, p = 0.022). No clinically significant changes in bacterial culture and sensitivity patterns were observed. No adverse events from aerosolized ceftazidime were reported. Pulmonary TNF-alpha, IL-beta, and IL-8 concentrations were attenuated in the ceftazidime group compared with those in the placebo group (p < 0.001, p = 0.02, and p = 0.003). The frequency of VAP was related directly to changes in TNF-alpha and IL-beta (p < 0.001, p = 0.02). CONCLUSIONS: Aerosolized ceftazidime decreased the frequency of VAP in critically ill trauma patients, without adversely affecting ICU flora. Aerosolized ceftazidime also may attenuate the proinflammatory response in the lung.

Adult↗
PubMed2002

Lactobacillus species as a cause of ventilator-associated pneumonia in a critically ill trauma patient.

Lactobacillus species are ubiquitous inhabitants of the human gastrointestinal and genitourinary tracts and rarely cause infections. Pneumonia caused by Lactobacillus has been reported only in immunocompromised patients and in one patient with structural lung disease. A 39-year-old, immunocompetent, critically ill woman developed ventilator-associated pneumonia, which was found to be caused by Lactobacillus. To our knowledge, this is the first such report. The infection was treated successfully with 14 days of intravenous vancomycin. Based on this case, Lactobacillus should be considered a possible cause of ventilator-associated pneumonia in immunocompetent, critically ill patients.

Accidents, Traffic↗
PubMed2002

Acute respiratory distress syndrome in blunt trauma: identification of independent risk factors.

Acute respiratory distress syndrome (ARDS) is a major contributor to morbidity and mortality in trauma patients. Although many injuries and conditions are believed to be associated with ARDS independent risk factors in trauma patients and their relative importance in development of the syndrome are undefined. The aim of this project is to identify independent risk factors for the development of ARDS in blunt trauma patients and to examine the contributions of each factor to ARDS development. Patients with ARDS were identified from the registry of a Level I trauma center over a 4.5-year period. Records were reviewed for demographics, injury characteristics, transfusion requirements, and hospital course. Variables examined included age >65 years, Injury Severity Score (ISS) >25, hypotension on admission (systolic blood pressure <90), significant metabolic acidosis (base deficit <-5.0), severe brain injury as shown by a Glasgow Coma Scale score (GCS) <8 on admission, 24-hour transfusion requirement >10 units packed red blood cells, pulmonary contusion (PC), femur fracture, and major infection (pneumonia, empyema, or intra-abdominal abscess). Both univariate and stepwise logistic regression were used to identify independent risk factors, and receiver operating characteristic curve (ROC) analysis was used to determine the relative contribution of each risk factor. A total of 4397 patients having sustained blunt trauma were admitted to the intensive care unit and survived >24 hours between October 1995 and May 2000. Of these patients 200 (4.5%) developed ARDS. All studied variables were significantly associated with ARDS in univariate analyses. Stepwise logistic regression, however, demonstrated age >65 years, ISS >25, hypotension on admission, 24-hour transfusion requirement >10 units, and pulmonary contusion as independent risk factors, whereas admission metabolic acidosis, femur fracture, infection, and severe brain injury were not. Using a model based on the logistic regression equation derived yields better than 80 per cent discrimination in ARDS patients. The risk factors providing the greatest contribution to ARDS development were ISS >25 (ROC area 0.72) and PC (ROC area 0.68) followed by large transfusion requirement (ROC area 0.56), admission hypotension (ROC area 0.57), and age >65 (ROC area 0.54). Independent risk factors for ARDS in blunt trauma include ISS >25, PC, age >65 years, hypotension on admission, and 24-hour transfusion requirement >10 units but not admission metabolic acidosis, femur fracture, infection, or severe brain injury. Assessment of these variables allows accurate estimate of risk in the majority of cases, and the most potent contributors to the predictive value of the model are ISS >25 and PC. Improvement in understanding of which patients are actually at risk may allow for advances in treatment as well as prevention in the future.

Acute Disease↗