Dangerfield B.,Maricopa Medical Center |
Webb B.,University of Utah
Antimicrobial Agents and Chemotherapy | Year: 2014
Pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA) is associated with poor outcomes and frequently merits empirical antibiotic consideration despite its relatively low incidence. Nasal colonization with MRSA is associated with clinical MRSA infection and can be reliably detected using the nasal swab PCR assay. In this study, we evaluated the performance of the nasal swab MRSA PCR in predicting MRSA pneumonia. A retrospective cohort study was performed in a tertiary care center from January 2009 to July 2011. All patients with confirmed pneumonia who had both a nasal swab MRSA PCR test and a bacterial culture within predefined time intervals were included in the study. These data were used to calculate sensitivity, specificity, positive predictive value, and negative predictive value for clinically confirmed MRSA pneumonia. Four hundred thirty-five patients met inclusion criteria. The majority of cases were classified as either health care-associated (HCAP) (54.7%) or community- acquired (CAP) (34%) pneumonia. MRSA nasal PCR was positive in 62 (14.3%) cases. MRSA pneumonia was confirmed by culture in 25 (5.7%) cases. The MRSA PCR assay demonstrated 88.0% sensitivity and 90.1% specificity, with a positive predictive value of 35.4% and a negative predictive value of 99.2%. In patients with pneumonia, the MRSA PCR nasal swab has a poor positive predictive value but an excellent negative predictive value for MRSA pneumonia in populations with low MRSA pneumonia incidence. In cases of culture-negative pneumonia where initial empirical antibiotics include an MRSA-active agent, a negative MRSA PCR swab can be reasonably used to guide antibiotic de-escalation. Copyright © 2014, American Society for Microbiology. All Rights Reserved.
Nadir A.,Maricopa Medical Center
Journal of Ayub Medical College, Abbottabad : JAMC | Year: 2010
Ascites is a common clinical manifestation of advanced liver disease which can be managed with repeated large volume paracentesis. We sought to determine if continuous paracentesis via placement of an indwelling catheter for the management of ascites is safe and effective. We placed 38 peritoneal drainage catheters in 30 patients for durations ranging from 1-10 days. Patients underwent ascites fluid culture and cell count determinations immediately before and after the completion of paracentesis. Serum WBC count, BUN and creatinine levels were available on all patients before and after paracentesis. The descriptive data were analysed to assess the rate of peritoneal infections, change in renal function and ultimate clinical outcome of patients. A mean 12.73 litres of peritoneal fluid was removed via continuous peritoneal drainage accomplished with the use of an indwelling abdominal catheter. Eight peritoneal cultures obtained after paracentesis grew out. The mean peritoneal cell count before and after paracentesis in each subject did not show evidence for spontaneous bacterial peritonitis. Five patients underwent successful liver transplantation (OLTX) and did not develop any peritoneal infections post OLTX. Continuous large volume paracentesis using an indwelling abdominal catheter for several days is effective in removing large volumes of peritoneal fluid in patients with endstage-liver-disease (ESLD). The peritoneal fluid can grow out bacteria if it is left in the abdomen for > or = 3 days.
Yealy D.M.,University of Pittsburgh |
Kellum J.A.,University of Pittsburgh |
Huang D.T.,University of Pittsburgh |
Barnato A.E.,University of Pittsburgh |
And 9 more authors.
New England Journal of Medicine | Year: 2014
BACKGROUND: In a single-center study published more than a decade ago involving patients presenting to the emergency department with severe sepsis and septic shock, mortality was markedly lower among those who were treated according to a 6-hour protocol of early goal-directed therapy (EGDT), in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets, than among those receiving usual care. We conducted a trial to determine whether these findings were generalizable and whether all aspects of the protocol were necessary. METHODS: In 31 emergency departments in the United States, we randomly assigned patients with septic shock to one of three groups for 6 hours of resuscitation: protocol-based EGDT; protocol-based standard therapy that did not require the placement of a central venous catheter, administration of inotropes, or blood transfusions; or usual care. The primary end point was 60-day in-hospital mortality. We tested sequentially whether protocol-based care (EGDT and standard-therapy groups combined) was superior to usual care and whether protocol-based EGDT was superior to pro-tocol- based standard therapy. Secondary outcomes included longer-term mortality and the need for organ support. RESULTS: We enrolled 1341 patients, of whom 439 were randomly assigned to protocol-based EGDT, 446 to protocol-based standard therapy, and 456 to usual care. Resuscitation strategies differed significantly with respect to the monitoring of central venous pressure and oxygen and the use of intravenous fluids, vasopressors, inotropes, and blood transfusions. By 60 days, there were 92 deaths in the protocol-based EGDT group (21.0%), 81 in the protocol-based standard-therapy group (18.2%), and 86 in the usual-care group (18.9%) (relative risk with protocol-based therapy vs. usual care, 1.04; 95% confidence interval [CI], 0.82 to 1.31; P = 0.83; relative risk with protocol-based EGDT vs. protocol-based standard therapy, 1.15; 95% CI, 0.88 to 1.51; P = 0.31). There were no significant differences in 90-day mortality, 1-year mortality, or the need for organ support. CONCLUSIONS: In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes. (Funded by the National Institute of General Medical Sciences; ProCESS ClinicalTrials.gov number, NCT00510835.) Copyright © 2014 Massachusetts Medical Society.
Donohue J.F.,University of North Carolina at Chapel Hill |
Jain N.,Maricopa Medical Center
Respiratory Medicine | Year: 2013
Until recently, no point-of-care tool was available for assessing the underlying airway inflammation associated with asthma. Fractional exhaled nitric oxide (FeNO) emerged in the last decade as an important biomarker for asthma assessment and management. Evidence also indicates that FeNO is most accurately classified as a marker of T-helper cell type 2 (Th2)-mediated airway inflammation with a high positive and negative predictive value for identifying corticosteroid-responsive airway inflammation. This manuscript evaluates the evidence for FeNO as a predictor of Th2-mediated corticosteroid-responsive airway inflammation and presents the results of a meta-analysis of three adult studies comparing asthma exacerbation rates with FeNO-based versus clinically-based asthma management algorithms, one of which was not included in a 2012 Cochrane meta-analysis. The primary purpose of the updated meta-analysis was to evaluate asthma exacerbation rates. The results demonstrate that the rate of exacerbations was significantly reduced in favor of FeNO-based asthma management (mean treatment difference = -0.27; 95% CI [-0.42, -0.12] as was the relative rate of asthma exacerbations (relative rate = 0.57; 95% CI [0.41, 0.80]). In summary, FeNO has value for identifying patients with airway inflammation who will and will not respond to corticosteroids. Importantly, the use of FeNO in conjunction with clinical parameters is associated with significantly lower asthma exacerbation rates compared with asthma managed using clinical parameters alone. Together these data indicate that FeNO testing has an important role in the assessment and management of adult asthma. Further studies will continue to define the exact role of FeNO testing in adult asthma. © 2013 Elsevier Ltd. All rights reserved.
Enriquez J.L.,Maricopa Medical Center |
Wu T.S.,University of Arizona
Critical Care Clinics | Year: 2014
The use of ultrasonography in medical practice has evolved dramatically over the last few decades and will continue to improve as technological advances are incorporated into daily medical practice. Although ultrasound machine size and equipment have evolved, the basic principles and fundamental functions have remained essentially the same. This article reviews the general ultrasound apparatus design, the most common probe types available, and the system controls used to manipulate the images obtained. Becoming familiar with the machine and the controls used for image generation optimizes the scans being performed and enhances the use of ultrasound in patient care. © 2014 Elsevier Inc.