Current opinion in critical care
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In this review, we focus on the dual face of antibiotic therapy in the critically ill that must harmonize the need for early, appropriate and adequate antibiotic therapy in the individual-infected patient with the obligation to limit antibiotic selection pressure as much as possible to preserve its future potential. ⋯ Reconciling antibiotic efficacy with the limitations of their use is feasible but requires a dedicated and sustained effort throughout the whole process of clinical decision-making, from initial suspicion of sepsis to its definitive treatment.
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To provide an update on implementation efforts in the care of critically ill patients, with a focus on work published in the last 2 years. ⋯ Clinical research in intensive care has moved beyond simple discovery and dissemination. Best practices must be applied to effect change in ICU care, requiring the application of principles from implementation science. Future work should move beyond simple before-after evaluations to provide a stronger case for causal inference following implementation efforts.
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Curr Opin Crit Care · Oct 2019
ReviewIntravenous immunoglobulin for adjunctive treatment of severe infections in ICUs.
This review focuses on the emerging literature regarding the use of intravenous immunoglobulins (IVIg) in critically ill patients with severe infections. The aim is to provide an accessible summary of the most recent evidence of IVIg use in sepsis and septic shock and to help clinicians to understand why there is still equipoise regarding the potential benefit of this adjunctive therapy in this setting. ⋯ Insufficient evidence is available to support IVIg use in sepsis and septic shock, apart from the specific case of streptococcal toxic shock syndrome. Current literature suggests that IVIg efficacy in sepsis or septic shock could depend on the IVIg preparation (IgM-enriched or minimal IgM), time of administration (<24 h), dose, and the inflammatory/immunomodulation profile of the patients. Investigator-initiated research, incorporating these parameters, is warranted to determine whether IVIg benefits critically ill patients with severe infection.
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Overview of influenza infection, focusing on outcome and complications in critically ill patients. We also discuss relevant elements in immunopathogenesis and their role as predictors of severity. ⋯ The present review summarizes current knowledge on pathogenesis and clinical manifestations of severe influenza. Immunological dysfunction during viral infection correlates with severity and mortality among ICU patients. A theranostics strategy should be implemented to improve outcomes.
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Curr Opin Crit Care · Oct 2019
ReviewDefining standard of practice: pros and cons of the usual care arm.
The aim of this review is to describe the use of usual care arms in randomized trials. ⋯ Usual care control arms may enhance generalizability while introducing significant limitations. Potential solutions include the use of pretrial surveys to evaluate the extent to which a protocolized control arm reflects the current standard of care and the implementation of adaptive trials.