Current opinion in critical care
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Curr Opin Crit Care · Oct 2018
ReviewAntibiotic treatment of hospital-acquired pneumonia: is it different from ventilator-associated pneumonia?
Hospital-acquired pneumonia (HAP) is a form of nosocomial pneumonia, distinct from ventilator-associated pneumonia (VAP). This review compares HAP and VAP, highlighting differences in natural history, risk factors, and bacteriology that necessitate a different approach to the therapy of HAP, compared with VAP. ⋯ Although more prospective therapy trials of HAP are needed, based on currently available data, it is possible to use an approach that provides appropriate therapy without the overuse of broad-spectrum therapy.
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The burden of critical illness in low-income and middle-income countries (LMICs) is substantial. A better understanding of critical care outcomes is essential for improving critical care delivery in resource-limited settings. In this review, we provide an overview of recent literature reporting on critical care outcomes in LMICs. We discuss several barriers and potential solutions for a better understanding of critical care outcomes in LMICs. ⋯ Outcomes from HICs cannot be reliably extrapolated to LMICs, so it is important to study outcomes for critically ill patients in LMICs. Specific challenges to achieving meaningful outcomes studies in LMICs include defining the critically ill population when few ICU beds exist, the resource-intensiveness of long-term follow-up, and the need for reliable severity of illness scores to interpret outcomes. Although much work remains to be done, examples of studies overcoming these challenges are beginning to emerge.
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Curr Opin Crit Care · Oct 2018
ReviewChoosing outcomes for clinical trials: a pragmatic perspective.
The turn to evidence-based medicine in critical care has lead to a dramatic increase in the number of randomized clinical trials. Yet many of these trials are not showing differences on an appropriately prespecified primary outcome. In light of this, there have been some heated arguments as to what sorts of clinical trials should be conducted. We synthesize pragmatic recommendations from two governing bases: rigorous statistical practice and a commitment to insuring trials provide information that should help guide patient-centered decision-making. ⋯ It may be of value, when proposing a trial, to present preliminary evidence documenting the extent to which a proposed primary outcome actually accords each of these principles.
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Curr Opin Crit Care · Oct 2018
ReviewUnderstanding patient-important outcomes after critical illness: a synthesis of recent qualitative, empirical, and consensus-related studies.
Patients surviving critical illness frequently experience long-lasting morbidities. Consequently, researchers and clinicians are increasingly focused on evaluating and improving survivors' outcomes after hospital discharge. This review synthesizes recent research aimed at understanding the postdischarge outcomes that patients consider important (i.e., patient-important outcomes) for the purpose of advancing future clinical research in the field. ⋯ Recent studies have made major advances in understanding patient-important outcomes to help guide future clinical research aimed at improving ICU survivors' recovery.
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Curr Opin Crit Care · Oct 2018
Review Comparative StudyNew guidelines for hospital-acquired pneumonia/ventilator-associated pneumonia: USA vs. Europe.
The International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia were published in 2017 whilst the American guidelines for Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia were launched in 2016 by the Infectious Diseases Society of America/ATS. Both guidelines made updated recommendations based on the most recent evidence sharing not only some parallelisms but also important conceptual differences. ⋯ American and European guidelines have many areas of common agreement such as limiting antibiotic duration. Both guidelines were in favour of a close clinical assessment. Neither recommended a regular use of biomarkers but only in specific circumstances such as dealing with MDR and treatment failure. Risk factor prediction for MDR differed and whilst American guidelines focus on organ failure, the European ones did it in local ecology and septic shock.