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Year in review 2011: Critical Care - infection

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ABSTRACT

There is an ever-growing importance for critical assessment of benefits and harms of various strategies with regards to antibiotic stewardship, infection control, molecular detection of pathogens and adequate treatment of multidrug-resistant organisms in ICUs. Ongoing financial constraints globally, changing demographics with an increasing and aging population and the slow introduction of new antibiotics make the utilisation of the best available evidence and goal-directed strategies essential in the ICU setting. This review will summarise findings from some of the recent major publications in the area of infectious diseases with emphasis on the role of behaviour change strategies for infection control purposes, the role of biomarkers such as C-reactive protein and procalcitonin, and the impact of molecular diagnostics in clinical decision-making. Furthermore, we will update readers on some recent findings in relation to invasive fungal infections, community-acquired pneumonia and ventilator-associated pneumonia in ICU patients.

No MeSH data available.


Related in: MedlinePlus

Updated meta-analysis of linezolid versus glycopeptide antibiotics for methicillin-resistant Staphylococcus aureus nosocomial pneumonia. Updated meta-analysis of (a) mortality, (b) clinical success and (c) microbiological success. CI, confidence interval; M-H, Mantel-Haenszel test.
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Figure 2: Updated meta-analysis of linezolid versus glycopeptide antibiotics for methicillin-resistant Staphylococcus aureus nosocomial pneumonia. Updated meta-analysis of (a) mortality, (b) clinical success and (c) microbiological success. CI, confidence interval; M-H, Mantel-Haenszel test.

Mentions: In a double-blind multicentre RCT, Wunderink and colleagues assessed the efficacy and safety of linezolid compared with a dose-optimised vancomycin strategy against MRSA nosocomial pneumonia in 448 adult participants [37]. Patients were randomised to either intravenous linezolid (600 mg every 12 hours) or vancomycin (15 mg/kg every 12 hours) for 7 to 14 days with continuous dose adjustment of vancomycin. Clinical success was achieved at the end of the study in 57.6% of the linezolid group versus 46.6% of the vancomycin group (95% CI for difference, 0.5 to 21.6%; P = 0.042). There was similar all-cause mortality at 60 days (linezolid, 15.7% vs. vancomycin, 17.0%) while renal toxicity occurred more frequently with vancomycin (18.2% vs. linezolid, 8.4%). There was a similar rate of adverse events in both groups and there was no difference with regards to mortality from MRSA pneumonia. However, patients were allowed up to 48 hours of vancomycin treatment prior to randomisation, which could favour the linezolid group. Furthermore, one could argue that it would be hard to carry out adequate blinding when vancomycin should be given over 90 to 120 minutes whereas linezolid can be administered in 15 to 30 minutes. Finally, one should also consider the impact of conflict of interest and funding bias in this industry-designed and sponsored trial. The findings of this study contradict the conclusions of a recently published systematic review by Walkey and colleagues in which the authors found no superiority of linezolid over glycopeptide antibiotics [38]. By including the results of Wunderink and colleagues in various relevant meta-analyses, despite trends towards improved microbiological and clinical success and improved survival, these findings are still statistically nonsignificant and therefore more studies are needed (Figure 2).


Year in review 2011: Critical Care - infection
Updated meta-analysis of linezolid versus glycopeptide antibiotics for methicillin-resistant Staphylococcus aureus nosocomial pneumonia. Updated meta-analysis of (a) mortality, (b) clinical success and (c) microbiological success. CI, confidence interval; M-H, Mantel-Haenszel test.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3672546&req=5

Figure 2: Updated meta-analysis of linezolid versus glycopeptide antibiotics for methicillin-resistant Staphylococcus aureus nosocomial pneumonia. Updated meta-analysis of (a) mortality, (b) clinical success and (c) microbiological success. CI, confidence interval; M-H, Mantel-Haenszel test.
Mentions: In a double-blind multicentre RCT, Wunderink and colleagues assessed the efficacy and safety of linezolid compared with a dose-optimised vancomycin strategy against MRSA nosocomial pneumonia in 448 adult participants [37]. Patients were randomised to either intravenous linezolid (600 mg every 12 hours) or vancomycin (15 mg/kg every 12 hours) for 7 to 14 days with continuous dose adjustment of vancomycin. Clinical success was achieved at the end of the study in 57.6% of the linezolid group versus 46.6% of the vancomycin group (95% CI for difference, 0.5 to 21.6%; P = 0.042). There was similar all-cause mortality at 60 days (linezolid, 15.7% vs. vancomycin, 17.0%) while renal toxicity occurred more frequently with vancomycin (18.2% vs. linezolid, 8.4%). There was a similar rate of adverse events in both groups and there was no difference with regards to mortality from MRSA pneumonia. However, patients were allowed up to 48 hours of vancomycin treatment prior to randomisation, which could favour the linezolid group. Furthermore, one could argue that it would be hard to carry out adequate blinding when vancomycin should be given over 90 to 120 minutes whereas linezolid can be administered in 15 to 30 minutes. Finally, one should also consider the impact of conflict of interest and funding bias in this industry-designed and sponsored trial. The findings of this study contradict the conclusions of a recently published systematic review by Walkey and colleagues in which the authors found no superiority of linezolid over glycopeptide antibiotics [38]. By including the results of Wunderink and colleagues in various relevant meta-analyses, despite trends towards improved microbiological and clinical success and improved survival, these findings are still statistically nonsignificant and therefore more studies are needed (Figure 2).

View Article: PubMed Central - HTML

ABSTRACT

There is an ever-growing importance for critical assessment of benefits and harms of various strategies with regards to antibiotic stewardship, infection control, molecular detection of pathogens and adequate treatment of multidrug-resistant organisms in ICUs. Ongoing financial constraints globally, changing demographics with an increasing and aging population and the slow introduction of new antibiotics make the utilisation of the best available evidence and goal-directed strategies essential in the ICU setting. This review will summarise findings from some of the recent major publications in the area of infectious diseases with emphasis on the role of behaviour change strategies for infection control purposes, the role of biomarkers such as C-reactive protein and procalcitonin, and the impact of molecular diagnostics in clinical decision-making. Furthermore, we will update readers on some recent findings in relation to invasive fungal infections, community-acquired pneumonia and ventilator-associated pneumonia in ICU patients.

No MeSH data available.


Related in: MedlinePlus