Online Letters to the Editor

The authors have disclosed that they do not have any potential conflicts of interest.

The authors have disclosed that they do not have any potential conflicts of interest.

Märit Amanda Halmin, MD, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden, and Department of Anesthesiology and Intensive Care, Danderyds Hospital, Stockholm, Sweden; Gustaf Edgren, MD, PhD, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden, and Division of Hematology, Department of Medicine, Karolinska University Hospital, Stockholm, Sweden

Chia-Chang Kuo, MD, Department of Emergency Medicine, Tainan Municipal Hospital, Tainan, Taiwan; Hsin-Lan Lin, RN, Department of Nursing, Chi-Mei Medical Center, Liouying, Tainan, Taiwan; Chien-Ming Chao, MD, Department of Intensive Care Medicine, Chi-Mei Medical Center, Liouying, Tainan, Taiwan

REFERENCES

1. Tourtier J-P, Galinou N, Rivet C, et al: Rationale of Plasma-to-RBC Ratios. Crit Care Med 2014; 42:e245 2. Halmin M, Boström F, Brattström O, et al: Effect of plasma-to-RBC ratios in trauma patients: A cohort study with time-dependent data. Crit Care Med 2013; 41:1905–1914 3. Holcomb JB, del Junco DJ, Fox EE, et al; PROMMTT Study Group: The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: Comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg 2013; 148:127–136 DOI: 10.1097/CCM.0000000000000068

How Multidrug-Resistant Pathogens Affect Outcomes? To the Editor:

W

e read with great interest the article by Di Pasquale et al (1) who investigated the association between the severity of ICU-acquired pneumonia and multidrug-resistant (MDR) pathogens. They found that the severity of illness was not different between patients with and without an MDR pathogen. In addition, no significant differences were found in mortality or survival between patients with and without an MDR pathogen. Although we did agree about the point that the presence of MDR pathogens did not affect the outcome, we believe that something needs to be clarified before making the conclusion. The key point should be the appropriate use of initial antibiotics for patients with MDR pathogens. As we know, the difficulty in treating MDR pathogen–associated infections resulted from the choice of initial empirical antibiotic. Thus, the risk of initial inadequate antibiotic should be higher in patients with MDR pathogens than in patients without MDR pathogens. Furthermore, the initial inadequate antibiotic would be associated with poor outcome (1). In summary, it suggests that the patients with MDR pathogens should receive less initial appropriate antibiotic, which had negative impact on clinical outcome. However, there were more than 70% of patients with MDR pathogens who had received initial adequate treatment in this study. Therefore, the possible poor outcome associated with MDR pathogens may be eliminated by appropriate empirical antibiotics. Finally, we can find that MDR pathogens did not affect the clinical outcome.

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REFERENCES

1. Di Pasquale M, Ferrer M, Esperatti M, et al: Assessment of Severity of ICU-Acquired Pneumonia and Association With Etiology. Crit Care Med 2013 Oct 7. [Epub ahead of print] DOI: 10.1097/CCM.0000000000000071

Prophylactic Intra-Aortic Balloon Counterpulsation in Cardiac Surgery: Challenges in Planning the “Right” Trial To the Editor:

I

n a recent issue of Critical Care Medicine, we read with great interest the article by Ranucci et al (1) evaluating the impact of prophylactic intra-aortic balloon counterpulsation (IABC) on the postoperative outcome of patients with reduced left-ventricular ejection fraction (LVEF) undergoing elective coronary artery bypass grafting surgery (CABG). The authors report in this single-center randomized controlled trial that prophylactic IABC has no positive effects on postoperative major morbidity as defined by the Society of Thoracic Surgeons. However, the present trial raises some concerns that we would like to address in this letter. As the authors state in their discussion, the inclusion criteria were mostly based on the poor LVEF. However, in all previous trials concerning prophylactic IABC, including the trials of Christenson et al (2–4) in the late 1990s, heterogeneous inclusion criteria with questionable implication on perioperative risk have been a major drawback. Inclusion criteria based on a modern and valid risk estimation instrument (e.g., European System for Cardiac Operative Risk Evaluation II) to really include high-risk patients would have been advantageous. The single-center trial was powered to detect a 50% relative risk reduction of the composite endpoint “major morbidity” (absolute risk reduction 40% to 20%). In our opinion, some of its components do not relate to IABC (e.g., sternal wound infection, need of reoperation, which is mostly due to bleeding). Prolonged mechanical ventilation and acute renal failure are perioperative surrogate variables. Their persistence after a certain time after operation (e.g., 30 d, 6 mo) would have been of interest. Operative mortality is the most relevant component of the primary endpoint. A primary endpoint that is more focused on patient-relevant criteria (30-d mortality, survival, and New York Heart Association stadium at 6 mo, 1 yr) would have been preferable. March 2014 • Volume 42 • Number 3

How multidrug-resistant pathogens affect outcomes?

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