Editorials 8. Aimog Y, Shefer A, Novack V, et al: Prior statin therapy is associated with a decreased rate of severe sepsis. Circulation 2004; 110:880-885 9. Lador A, Nasir H, Mansur N, et al: Antibiotic prophylaxis in cardiac surgery: Systematic review and meta-analysis. J Antimicrob Chemother 2012; 67:541-550
10. Kappeler R, Gillham M, Brown NM: Antibiotic prophylaxis for cardiac surgery. J Antimicrob Chemother 201 2; 67:521-522 11. Lazar HL, Chipkin SR, Fitzgerald CA, et al: Tight glyeemie control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischémie events. Circulation 2004; 109:1497-1502
Old Soldiers Never Die, They Just... Are Transferred* RikTh. Gerritsen, MD, FCCM Intensive Care Medical Centre Leeuwarden Leeuwarden, The Netherlands
the unit. A problem I come across with external, that is none ICU experts, is that end of life care in ICU patients is quite different from end of life care for patients in a normal ward. Even more from care for people a hospice environment. The difference is even greater in patients on a ventilator, which in my unit is the fast majority of dying patients. In my ICU, more very now and then you are more than just scientifically than 90% of patients are ventilated. Let alone in a hospice enviengaged when you are asked to review an article. This ronment. The duration of the dying process, the predictability, happened to me when I read the article by Binney et al and the means of communication with the patient makes it (1), in a recent issue of Critical Care Medicine, about a dedi- challenging for none ICU-based palliative care teams to give cated hospice unit for terminally ill ICU patients. usable advice. I agree with Binney et al (1) that it is almost I practice intensive care medicine for years. And the longer impossible to find a suitable hospice environment where they I practice, the more I realize that end-of-life care is not only an are able to combine the hospice knowledge and type of care integral part of my job but also a very important one. Dying is with forms of ICU care. part of intensive care as is ventilation or inotropes (2). The solution provided in this article, creating an in In the first place for the dying patient him or herself To be hospital-dedicated hospice inpatient unit, is original and able to die in the way concordant with his wishes, free of treatable seems feasible. It is always good to try to find new ways, if old symptoms is a right. But also for the family and loved ones of this ones do not work. But if you do not have a problem, please do patient, a dignified death is paramount. It is the duty of the inten- not come up with a solution. sivist to do anything in his power to provide this type of care. He or The article reports a number of absolute data which she must be trained and have the tools to do so (3). Every intensiv- show that a palliative consult is leading to a transfer. The ist caring for dying patients, and that is almost everybody, should cost-effectiveness is hard to follow because the length of ICU realize that you can provide end-of-life care to that patient and stay of the patients that were not transferred is shorter. It could their loved ones only once. If you provide inadequate symptom be that when a patient stays in the unit removal of life support relief or do not care enough for other needs of your patient or their leads to a shorter length than the 3.5 days, the referred patients families, you can cause enormous extra suffering and lasting damspend in the dedicated hospice inpatient units. So we should age (4). On the other hand, if you provide good care, the patient not use the economic argument but only improvement of care dies in a dignified way and the relatives can cope better. Remember, for patients and relatives. you do not get a second chance to provide good end-of-life care. The major question that remains open is if this approach Now coming back to the article by Binney et al (1) that brings to patients and relatives what it is supposed to bring, describes a way to provide end-of-life care. They acknowledge namely quality end-of-life care. It is shown in the literature that end-of-life care is an integral part of ICU care but also that quality end-of-life care can be provided within the unit and of course that good palliative care can be provided in point out that this care is not always adequate (5). One of the hospices (6). The next step should be to find out if this inimentioned solutions is to bring palliative care expertise into tiative brings together the best of both worlds. There are numerous instruments to measure quality of dying and 'Seealso p. 1074. death, so I challenge the authors to prove the added value of Key Words: critical care; end-of-life care; hospice care; palliative care; their initiative (7). Quality of Dying and Death questionnaire In conclusion I find the study very interesting way to The author has disclosed that he does not have any potential conflicts of improve end-of-life care, but I think that the solution provided interest. should stay a second best option for specific settings after proCopyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins viding top-quality end-of-life care in the ICU by trained intenDOI: 10.1097/CCM.0000000000000175 sivist and nurses.
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May 2014 • Volume 42 • Number 5
Editorials
REFERENCES 1, Binney ZO, Quest TE, Feingold PL, et al: Feasibility and Economic Impact of Dedicated Hospioe Inpatient Units for Terminally III ICU Patients. Crit Care Med 2014; 42:1074-1080 2, Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group: Use of intensive care at the end of life in the United States: An epidemiologic study, Crit Care Med 2004; 32:638-643 3, Curtis JR, Wenrioh MD, Carline JD, et al: Understanding physicians' skills at providing end-of-life care perspectives of patients, families, and health oare workers, J Gen Intern Med 2001; 16: 41-49
4, Poohard F, Azoulay E, Chevret S, et al; French FAMIREA Group: Symptoms of anxiety and depression in family members of intensive care unit patients: Ethical hypothesis regarding deoision-making capacity, Crit Care Med 2001 ; 29:1893-1897 5, DeCato TW, Engelberg RA, Downey L, et al: Hospital variation and temporal trends in palliative and end-of-life care in the ICU, Crit Care Wed 2013; 41:1405-1411 6, Gerritsen RT, Hofhuis JG, Koopmans M, et al: Perception by family members and ICU staff of the quality of dying and death in the ICU: A prospective multicenter study in The Netherlands, Chest 2013; 143:357-363 7, Patrick DL, Engelberg RA, Curtis JR: Evaluating the quality of dying and death, J Pain Symptom Manage 2001 ; 22:717-726
The Deadly Impact of Extreme Drug Resistance in Acinetobacter baumannii* Brad Spellberg, MD Division of General Internal Medicine Los Angeles Biomédical Research Institute at Harbor-UCLA Medical Center Torrance, CA; and Division of General Internal Medicine David Geffen School of Medicine at UCLA Los Angeles, CA Robert A. Bonomo, MD Department of Medicine; Department of Pharmacology; and Department of Molecular Biology and Microbiology Louis Stokes Cleveland Department of Veterans Affairs Medical Center Case Western Reserve University Cleveland, OH
I
nfections caused by Acinetobacter species, and by Acinetobacter baumannii in particular, began to emerge in the 1960s and 1970s, driven by the development of modern intensive care medicine, including mechanical ventilation, central venous and urinary catheterization, and intensive antibacterial therapy (1-4). Antibacterial therapy wipes out normal flora, enabling resistant Acinetobacter to thrive, while insertion of foreign bodies enables the organism to bypass anatomical barriers it would not normally be able to penetrate. Even as
'See also p. 1081. Key Words: Acinetobacter baumannii; carbapenem resistance; extreme drug resistance Dr, Spellberg received support for article research from the National Institutes of Health (NIH), His institution consulted for GlaxoSmithKlein, Adenium, Cardeas, Meiji, and aRigen, Dr, Bonomo received support for article research from the NIH, Copyright (© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI:10.1097/CCM.0000000000000181
Critical Care Medicine
these infections continued to increase in frequency through the 1980s and 1990s, Acinetobacter was often considered to be of low virulence potential, and mortality was often attributed to patients' underlying disease, rather than to the infection itself. However, as far back as 1977, mortality rates of nosocomial pneumonia caused by A. baumannii were described to be very high for patients who received inadequate therapy compared with those who were treated adequately ( 1 ). These results hinted that the true virulence of the pathogen might have been obscured by the availability of adequate therapy. Similarly, for many years, the impact of ventilator-associated pneumonia (VAP) on mortality generally was underappreciated, with a common expression being that patients "die with VAP, rather than of VAR" Patients with adequately treated VAP often die of their underlying diseases (5); however, recent analyses comparing the mortality rate of VAP treated with initially effective versus ineffective therapy have determined that initially eftective therapy reduces mortality of VAP by at least 30% (6-8). These results underscore a critically important concept: effective antibiotic therapy can mask the virulence of microbes by greatly improving outcomes of infection irrespective of pathogenic potential of the organisms. Such virulence is unmasked in settings where inadequate therapy is not administered in a timely manner. It is in this context that the dramatic rise in the prevalence of carbapenem-resistant Acinetobacter is of substantial concern. Recent data from a national surveillance of hospitals in the United States revealed that more than 50% oí A. baumannii isolates from ICUs are now carbapenem-resistant (9). Internationally, carbapenem-resistance rates among A. baumannii are described that are even higher (10, 11). This rise in extreme drug-resistant strains, which tend to be treatable only with polymyxins or tigecycline, has been accompanied by an alarming rise in the mortality of resulting infections (12-16). In this issue of Critical Care Medicine, Lee et al ( 17) now add important new data that underscore the deadly impact of carbapenem resistance in the context of bacteremia and help explain why it contributes to excess mortality. www,ccmjournal,org
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Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
10. Kappeler R, Gillham M, Brown NM: Antibiotic prophylaxis for cardiac surgery. J Antimicrob Chemother 201 2; 67:521-522 11. Lazar HL, Chipkin SR, Fitzgerald CA, et al: Tight glyeemie control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischémie events. Circulation 2004; 109:1497-1502
Old Soldiers Never Die, They Just... Are Transferred* RikTh. Gerritsen, MD, FCCM Intensive Care Medical Centre Leeuwarden Leeuwarden, The Netherlands
the unit. A problem I come across with external, that is none ICU experts, is that end of life care in ICU patients is quite different from end of life care for patients in a normal ward. Even more from care for people a hospice environment. The difference is even greater in patients on a ventilator, which in my unit is the fast majority of dying patients. In my ICU, more very now and then you are more than just scientifically than 90% of patients are ventilated. Let alone in a hospice enviengaged when you are asked to review an article. This ronment. The duration of the dying process, the predictability, happened to me when I read the article by Binney et al and the means of communication with the patient makes it (1), in a recent issue of Critical Care Medicine, about a dedi- challenging for none ICU-based palliative care teams to give cated hospice unit for terminally ill ICU patients. usable advice. I agree with Binney et al (1) that it is almost I practice intensive care medicine for years. And the longer impossible to find a suitable hospice environment where they I practice, the more I realize that end-of-life care is not only an are able to combine the hospice knowledge and type of care integral part of my job but also a very important one. Dying is with forms of ICU care. part of intensive care as is ventilation or inotropes (2). The solution provided in this article, creating an in In the first place for the dying patient him or herself To be hospital-dedicated hospice inpatient unit, is original and able to die in the way concordant with his wishes, free of treatable seems feasible. It is always good to try to find new ways, if old symptoms is a right. But also for the family and loved ones of this ones do not work. But if you do not have a problem, please do patient, a dignified death is paramount. It is the duty of the inten- not come up with a solution. sivist to do anything in his power to provide this type of care. He or The article reports a number of absolute data which she must be trained and have the tools to do so (3). Every intensiv- show that a palliative consult is leading to a transfer. The ist caring for dying patients, and that is almost everybody, should cost-effectiveness is hard to follow because the length of ICU realize that you can provide end-of-life care to that patient and stay of the patients that were not transferred is shorter. It could their loved ones only once. If you provide inadequate symptom be that when a patient stays in the unit removal of life support relief or do not care enough for other needs of your patient or their leads to a shorter length than the 3.5 days, the referred patients families, you can cause enormous extra suffering and lasting damspend in the dedicated hospice inpatient units. So we should age (4). On the other hand, if you provide good care, the patient not use the economic argument but only improvement of care dies in a dignified way and the relatives can cope better. Remember, for patients and relatives. you do not get a second chance to provide good end-of-life care. The major question that remains open is if this approach Now coming back to the article by Binney et al (1) that brings to patients and relatives what it is supposed to bring, describes a way to provide end-of-life care. They acknowledge namely quality end-of-life care. It is shown in the literature that end-of-life care is an integral part of ICU care but also that quality end-of-life care can be provided within the unit and of course that good palliative care can be provided in point out that this care is not always adequate (5). One of the hospices (6). The next step should be to find out if this inimentioned solutions is to bring palliative care expertise into tiative brings together the best of both worlds. There are numerous instruments to measure quality of dying and 'Seealso p. 1074. death, so I challenge the authors to prove the added value of Key Words: critical care; end-of-life care; hospice care; palliative care; their initiative (7). Quality of Dying and Death questionnaire In conclusion I find the study very interesting way to The author has disclosed that he does not have any potential conflicts of improve end-of-life care, but I think that the solution provided interest. should stay a second best option for specific settings after proCopyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins viding top-quality end-of-life care in the ICU by trained intenDOI: 10.1097/CCM.0000000000000175 sivist and nurses.
E
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www.ccmjournal.org
May 2014 • Volume 42 • Number 5
Editorials
REFERENCES 1, Binney ZO, Quest TE, Feingold PL, et al: Feasibility and Economic Impact of Dedicated Hospioe Inpatient Units for Terminally III ICU Patients. Crit Care Med 2014; 42:1074-1080 2, Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group: Use of intensive care at the end of life in the United States: An epidemiologic study, Crit Care Med 2004; 32:638-643 3, Curtis JR, Wenrioh MD, Carline JD, et al: Understanding physicians' skills at providing end-of-life care perspectives of patients, families, and health oare workers, J Gen Intern Med 2001; 16: 41-49
4, Poohard F, Azoulay E, Chevret S, et al; French FAMIREA Group: Symptoms of anxiety and depression in family members of intensive care unit patients: Ethical hypothesis regarding deoision-making capacity, Crit Care Med 2001 ; 29:1893-1897 5, DeCato TW, Engelberg RA, Downey L, et al: Hospital variation and temporal trends in palliative and end-of-life care in the ICU, Crit Care Wed 2013; 41:1405-1411 6, Gerritsen RT, Hofhuis JG, Koopmans M, et al: Perception by family members and ICU staff of the quality of dying and death in the ICU: A prospective multicenter study in The Netherlands, Chest 2013; 143:357-363 7, Patrick DL, Engelberg RA, Curtis JR: Evaluating the quality of dying and death, J Pain Symptom Manage 2001 ; 22:717-726
The Deadly Impact of Extreme Drug Resistance in Acinetobacter baumannii* Brad Spellberg, MD Division of General Internal Medicine Los Angeles Biomédical Research Institute at Harbor-UCLA Medical Center Torrance, CA; and Division of General Internal Medicine David Geffen School of Medicine at UCLA Los Angeles, CA Robert A. Bonomo, MD Department of Medicine; Department of Pharmacology; and Department of Molecular Biology and Microbiology Louis Stokes Cleveland Department of Veterans Affairs Medical Center Case Western Reserve University Cleveland, OH
I
nfections caused by Acinetobacter species, and by Acinetobacter baumannii in particular, began to emerge in the 1960s and 1970s, driven by the development of modern intensive care medicine, including mechanical ventilation, central venous and urinary catheterization, and intensive antibacterial therapy (1-4). Antibacterial therapy wipes out normal flora, enabling resistant Acinetobacter to thrive, while insertion of foreign bodies enables the organism to bypass anatomical barriers it would not normally be able to penetrate. Even as
'See also p. 1081. Key Words: Acinetobacter baumannii; carbapenem resistance; extreme drug resistance Dr, Spellberg received support for article research from the National Institutes of Health (NIH), His institution consulted for GlaxoSmithKlein, Adenium, Cardeas, Meiji, and aRigen, Dr, Bonomo received support for article research from the NIH, Copyright (© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI:10.1097/CCM.0000000000000181
Critical Care Medicine
these infections continued to increase in frequency through the 1980s and 1990s, Acinetobacter was often considered to be of low virulence potential, and mortality was often attributed to patients' underlying disease, rather than to the infection itself. However, as far back as 1977, mortality rates of nosocomial pneumonia caused by A. baumannii were described to be very high for patients who received inadequate therapy compared with those who were treated adequately ( 1 ). These results hinted that the true virulence of the pathogen might have been obscured by the availability of adequate therapy. Similarly, for many years, the impact of ventilator-associated pneumonia (VAP) on mortality generally was underappreciated, with a common expression being that patients "die with VAP, rather than of VAR" Patients with adequately treated VAP often die of their underlying diseases (5); however, recent analyses comparing the mortality rate of VAP treated with initially effective versus ineffective therapy have determined that initially eftective therapy reduces mortality of VAP by at least 30% (6-8). These results underscore a critically important concept: effective antibiotic therapy can mask the virulence of microbes by greatly improving outcomes of infection irrespective of pathogenic potential of the organisms. Such virulence is unmasked in settings where inadequate therapy is not administered in a timely manner. It is in this context that the dramatic rise in the prevalence of carbapenem-resistant Acinetobacter is of substantial concern. Recent data from a national surveillance of hospitals in the United States revealed that more than 50% oí A. baumannii isolates from ICUs are now carbapenem-resistant (9). Internationally, carbapenem-resistance rates among A. baumannii are described that are even higher (10, 11). This rise in extreme drug-resistant strains, which tend to be treatable only with polymyxins or tigecycline, has been accompanied by an alarming rise in the mortality of resulting infections (12-16). In this issue of Critical Care Medicine, Lee et al ( 17) now add important new data that underscore the deadly impact of carbapenem resistance in the context of bacteremia and help explain why it contributes to excess mortality. www,ccmjournal,org
1289
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
