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Pancreatitis

    • The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Over the last several decades, mortality related to acute pancreatitis has decreased substantially, which likely reflects improved critical care and better strategies for operative management.
    • Recent guidelines identify the SIRS criteria as the best and most pragmatic predictor of severe acute pancreatitis at admission and at 48 hours. A 1991 consensus committee first coined the term SIRS as the clinical manifestation of the hypermetabolic response to infection or a noninfectious insult. SIRS criteria include (1) temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F); (2) heart rate greater than 90 beats/min; (3) tachypnea with a respiratory rate greater than 20 breaths/min or hyperventilation with arterial carbon dioxide tension (PaCO2) less than 32 mm Hg; and (4) a white blood cell count greater than 12,000/µL or less than 4,000/µL or greater than 10% immature neutrophils (“bands”).
    • The optimal ­strategy for intervention in patients with confirmed infected ­necrotizing pancreatitis is initial image-guided percutaneous retroperitoneal catheter drainage or endoscopic transluminal drainage, followed, when necessary, by minimally invasive endoscopic or surgical necrosectomy. 

Pancreatitis

    • The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Over the last several decades, mortality related to acute pancreatitis has decreased substantially, which likely reflects improved critical care and better strategies for operative management.
    • Recent guidelines identify the SIRS criteria as the best and most pragmatic predictor of severe acute pancreatitis at admission and at 48 hours. A 1991 consensus committee first coined the term SIRS as the clinical manifestation of the hypermetabolic response to infection or a noninfectious insult. SIRS criteria include (1) temperature greater than 38°C (100.4°F) or less than 36°C (96.8°F); (2) heart rate greater than 90 beats/min; (3) tachypnea with a respiratory rate greater than 20 breaths/min or hyperventilation with arterial carbon dioxide tension (PaCO2) less than 32 mm Hg; and (4) a white blood cell count greater than 12,000/µL or less than 4,000/µL or greater than 10% immature neutrophils (“bands”).
    • The optimal ­strategy for intervention in patients with confirmed infected ­necrotizing pancreatitis is initial image-guided percutaneous retroperitoneal catheter drainage or endoscopic transluminal drainage, followed, when necessary, by minimally invasive endoscopic or surgical necrosectomy. 

Central Nervous System Infections

    • Serogroup B meningococcal vaccines. The incidence of community-acquired bacterial meningitis has declined over the past 30 years, in part due to the advancement and implementation of vaccination programs (Haemophilus influenzae type b [1987], Streptococcus pneumoniae or pneumococcal [2000], and Neisseria meningitidis or meningococcal [2005] vaccines) in the United States and western Europe
    • Use of steroids for bacterial meningitis. In patients with bacterial meningitis, dexamethasone delivered prior to (or simultaneously with) the initial empirical antibiotics and continued 4 days thereafter was associated with a significant reduction in the composite end point of death or significant neurologic disability and death at the 2-month follow-up compared with placebo
    • Development of molecular diagnostics (e.g., 16S polymerase chain reaction [PCR]) for identifying pathogens. Broad-range bacterial PCR amplifies species-specific gene coding for 16S ribosomal RNA of common pathogens; the sensitivity depending on the pathogen is 61 to 88% with specificities greater than 95%

Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

    • The resistance by extended-spectrum β-lactamases (ESBLs) is mediated by plasmids that spread microbial resistance across bacterial species and confer additional resistance to fourth-generation cephalosporins.
    • Current guidelines from the IDSA provide a comprehensive approach for the clinician evaluating and managing a bacteremic patient with short-term venous catheters, arterial catheters, long-term central venous catheters, or ports, taking into consideration the patient’s clinical status and the organism recovered. 
    • Vancomycin is the first-line antibiotic for MRSA pneumonia; however, adequate dosing, monitored by drug levels, is required to ensure both efficacy and safety, especially in patients with renal insufficiency. Linezolid, although not superior to vancomycin, may be preferable for patients with renal insufficiency. 

Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

    • The resistance by extended-spectrum β-lactamases (ESBLs) is mediated by plasmids that spread microbial resistance across bacterial species and confer additional resistance to fourth-generation cephalosporins.
    • Current guidelines from the IDSA provide a comprehensive approach for the clinician evaluating and managing a bacteremic patient with short-term venous catheters, arterial catheters, long-term central venous catheters, or ports, taking into consideration the patient’s clinical status and the organism recovered. 
    • Vancomycin is the first-line antibiotic for MRSA pneumonia; however, adequate dosing, monitored by drug levels, is required to ensure both efficacy and safety, especially in patients with renal insufficiency. Linezolid, although not superior to vancomycin, may be preferable for patients with renal insufficiency. 

Hospital Infections

    • Although hospital-acquired pneumonia (HAP) is the second most common HAI in hospitalized patients, the diagnosis is far from straightforward in many cases. More than 80% of HAP is ventilator-associated pneumonia (VAP), defined as pneumonia diagnosed within 24 hours of any duration of mechanical ventilation. Unfortunately, there is no diagnostic gold standard, and other common conditions, such as acute respiratory distress syndrome (ARDS), chest trauma, and even volume overload, share the key features of VAP.
    • Sterile technique is always required for catheter insertion. However, current data support a surgical approach to preparation of the insertion site, with the operator wearing a gown, gloves, a mask, and a hat for the procedure, for all central line.
    • The gold standard for detecting CDAD is to send a stool sample for cytotoxin determination, a procedure that has a sensitivity of 70 to 100%. This labor- intensive cell culture assay has been largely replaced in laboratories for enzyme immunoassays for toxins A and B with same-day results, but at a cost of decreased sensitivity (39 to 73%). At the time of this publication, polymerase chain reaction testing for the presence of toxin B is emerging as a rapid, more sensitive and specific test that will likely become the new standard for clinical screening.

Hospital Infections

    • Although hospital-acquired pneumonia (HAP) is the second most common HAI in hospitalized patients, the diagnosis is far from straightforward in many cases. More than 80% of HAP is ventilator-associated pneumonia (VAP), defined as pneumonia diagnosed within 24 hours of any duration of mechanical ventilation. Unfortunately, there is no diagnostic gold standard, and other common conditions, such as acute respiratory distress syndrome (ARDS), chest trauma, and even volume overload, share the key features of VAP.
    • Sterile technique is always required for catheter insertion. However, current data support a surgical approach to preparation of the insertion site, with the operator wearing a gown, gloves, a mask, and a hat for the procedure, for all central line.
    • The gold standard for detecting CDAD is to send a stool sample for cytotoxin determination, a procedure that has a sensitivity of 70 to 100%. This labor- intensive cell culture assay has been largely replaced in laboratories for enzyme immunoassays for toxins A and B with same-day results, but at a cost of decreased sensitivity (39 to 73%). At the time of this publication, polymerase chain reaction testing for the presence of toxin B is emerging as a rapid, more sensitive and specific test that will likely become the new standard for clinical screening.

Hospital Infections

    • Although hospital-acquired pneumonia (HAP) is the second most common HAI in hospitalized patients, the diagnosis is far from straightforward in many cases. More than 80% of HAP is ventilator-associated pneumonia (VAP), defined as pneumonia diagnosed within 24 hours of any duration of mechanical ventilation. Unfortunately, there is no diagnostic gold standard, and other common conditions, such as acute respiratory distress syndrome (ARDS), chest trauma, and even volume overload, share the key features of VAP.
    • Sterile technique is always required for catheter insertion. However, current data support a surgical approach to preparation of the insertion site, with the operator wearing a gown, gloves, a mask, and a hat for the procedure, for all central line.
    • The gold standard for detecting CDAD is to send a stool sample for cytotoxin determination, a procedure that has a sensitivity of 70 to 100%. This labor- intensive cell culture assay has been largely replaced in laboratories for enzyme immunoassays for toxins A and B with same-day results, but at a cost of decreased sensitivity (39 to 73%). At the time of this publication, polymerase chain reaction testing for the presence of toxin B is emerging as a rapid, more sensitive and specific test that will likely become the new standard for clinical screening.
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