09 May 09

Usefulness of the “Candida score” for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients

Posted in Infection at 0:12 by Laci

By C Leon, S Ruiz-Santana, P Saavedra, B Galvan, A Blanco, C Castro et al on behalf of the Cava Study Group

Crit Care Med 2009;37:1624-1633

To assess the usefulness of the “Candida score” (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point.

Design
Prospective, cohort, observational study.

Setting
Thirty-six medical-surgical intensive care units of Spain, Argentina, and France.

Patients
A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007.

Measurements and main results
Clinical data, surveillance cultures for fungal growth, and serum levels of (1-3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition x1, plus surgery x1, plus multifocal Candida colonization x1, plus severe sepsis x2. A CS >=3 accurately selected patients at high risk for IC. The colonization index was registered if >=0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06-3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p <= 0.001). The area under the receiver operating characteristic curve for CS was 0.774 (95% CI 0.715-0.832) compared with 0.633 (95% CI 0.557-0.709) for CI. (1-3)-Beta-d-glucan was also an independent predictor of IC (odds ratio 1.004, 95% CI 1.0-1.007). The relative risk for developing IC in colonized patients without antifungal treatment was 6.83 (95% CI 3.81-12.45).

Conclusions
In this cohort of colonized patients staying >7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.

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02 May 09

Use of corticosteroids in acute lung injury and acute respiratory distress syndrome

Posted in ALI/ARDS, Steroid at 1:08 by Laci

By B Tang, JC Craig, GD Eslick, I Seppelt, AS McLean

Crit Care Med  2009;37:1594-1603

Controversy remains as to whether low-dose corticosteroids can reduce the mortality and morbidity of acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) without increasing the risk of adverse reactions. We aimed to evaluate all studies investigating prolonged corticosteroids in low-to-moderate dose in ALI or ARDS.

Datasources
MEDLINE, EMBASE, Current Content, and Cochrane Central Register of Controlled Trials, and bibliographies of retrieved articles.

Study selection
Randomized controlled trials (RCTs) and observational studies reported in any language that used 0.5-2.5 mg^.kg^-1.d^-1 of methylprednisolone or equivalent to treat ALI/ARDS.

Data extraction
Data were extracted independently by two reviewers and included study design, patient characteristics, interventions, and mortality and morbidity outcomes.

Data synthesis
Both cohort studies (five studies, n = 307) and RCTs (four trials, n = 341) showed a similar trend toward mortality reduction (RCTs relative risk 0.51, 95% CI 0.24-1.09; p = 0.08; cohort studies relative risk 0.66, 95% CI 0.43-1.02; p = 0.06). The overall relative risk was 0.62 (95% CI 0.43-0.91; p = 0.01). There was also improvement in length of ventilation-free days, length of intensive care unit stay, Multiple Organ Dysfunction Syndrome Score, Lung Injury Scores, and improvement in PaO₂/FiO₂. There was no increase in infection, neuromyopathy, or any major complications. There was significant heterogeneity in the pooled studies. Subgroup and meta-regression analyses showed that heterogeneity had minimal effect on treatment efficacy; however, these findings were limited by the small number of studies used in the analyses.

Conclusion
The use of low-dose corticosteroids was associated with improved mortality and morbidity outcomes without increased adverse reactions. The consistency of results in both study designs and all outcomes suggests that they are an effective treatment for ALI or ARDS. The mortality benefits in early ARDS should be confirmed by an adequately powered randomized trial.

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