Journal Watch

Recent studies about sepsis treatment, UTI prevention efforts, and other topics.

New research sheds light on treatment for sepsis

Hydrocortisone does not reverse shock or improve survival in patients with septic shock, and intensive insulin therapy may lead to greater risk of hypoglycemic events in sepsis, two studies in the Jan. 10 New England Journal of Medicine reported.

In the first study, the CORTICUS Study Group randomly assigned patients to receive 50 mg of hydrocortisone or placebo every six hours for five days. The primary outcome was death at 28 days in patients without a response to a corticotropin test.

Approximately 47% of all patients, 125 of 251 in the hydrocortisone group and 108 of 248 in the placebo group, had no response to corticotropin. Mortality rates at 28 days did not differ significantly between the hydrocortisone and placebo groups among those who did not respond to corticotropin (39.2% vs. 36.1%, respectively; P = 0.69) or among those who did (28.8% vs. 28.7%; P = 1.00). Overall, 86 of 251 (34.3%) of patients in the hydrocortisone group and 78 of 248 patients in the placebo group (31.5%) had died at 28 days. Although septic shock reversed more quickly in the hydrocortisone group, these patients were also at higher risk for superinfection.

The authors concluded that low-dose hydrocortisone had no effect on 28-day mortality rates in patients with septic shock. Although their study had limitations, including a lack of adequate power, the authors wrote that their findings do not support the use of hydrocortisone as general adjuvant therapy for vasopressor-responsive septic shock or corticotropin testing to determine the appropriateness of hydrocortisone therapy. However, the authors noted that hydrocortisone may be useful in early treatment of patients with septic shock who do not respond to high-dose vasopressors.

In the second study, researchers for the German Competence Network Sepsis studied the efficacy and safety of intensive insulin therapy in patients with severe sepsis. They also assessed whether low-molecular-weight hydroxyethyl starch (HES) or modified Ringer's lactate was more effective for fluid resuscitation. The primary end points were 28-day mortality rate and mean organ failure score.

Intensive insulin therapy was stopped at the first safety analysis. Patients in the intensive therapy group had higher rates of hypoglycemia (30 of 247 patients, or 12.1%, vs. 5 of 241 patients, or 2.1%; P < 0.001), higher rates of severe hypoglycemia (17.0% vs. 4.1%; P < 0.001) and higher rates of serious adverse events (10.9% vs. 5.2%; P = 0.01). The intensive insulin therapy group was switched to conventional therapy, and fluid resuscitation methods continued to be compared until the planned interim analysis. At that time, researchers found that patients receiving HES had a greater incidence of renal failure and a trend toward higher 90-day mortality rates compared with those receiving Ringer's lactate. The data safety and monitoring board suspended the study.

The authors concluded that intensive insulin therapy is not advisable in critically ill patients with sepsis, and that using 10% HES 200/0.5 for fluid resuscitation in this population leads to renal impairment and, at higher doses, decreases long-term survival rates.

U.S. hospitals inconsistent in UTI prevention efforts, survey finds

U.S. hospitals may not be doing enough to prevent urinary tract infections (UTIs), according to a survey.

Researchers in Michigan surveyed 2,790 randomly sampled hospitals (119 of which were part of the Veterans Administration system) to determine what methods they used to prevent UTIs. Hospitals were mailed a study questionnaire asking how often they used specific prevention methods for catheter-related UTIs and how UTIs and urinary catheters were monitored. The study appeared in the Jan. 15 Clinical Infectious Diseases.

The survey response rate was 72% (80% for VA hospitals and 70% for non-VA hospitals). More than half of the hospitals (56%) had no system for monitoring which patients had catheters, and almost two-thirds (74%) didn't monitor the duration of catheter placement. Portable bladder scanners and antimicrobial urinary catheters were used by 30% of hospitals, while 14% reported using condom catheters and 9% reported using catheter reminders.

The study yielded several significant findings, the authors wrote:

  • Few hospitals reported monitoring urinary catheter use;
  • No single strategy was widely used to prevent UTI;
  • VA hospitals were more likely to use portable bladder scanners, condom catheters and suprapubic catheters than were non-VA hospitals but were less likely to use antimicrobial catheters; and
  • Fewer than 10% of hospitals used urinary catheter reminders despite evidence of their effectiveness.

The authors noted several study limitations, including reliance on self-reported data and possible lack of generalizability. However, they concluded that their results provide a “snapshot” of UTI prevention methods in U.S. hospitals and could have important policy implications, given Medicare's new policies on reimbursement for hospital-acquired infections.

Endovascular repair mostly safer for abdominal aortic aneurysms

Endovascular repair of abdominal aortic aneurysms results in better short-term survival than open surgery and similar rates of later complications, according to a large study.

The observational study compared matched cohorts of Medicare beneficiaries who underwent repair between 2001 and 2004 and were followed until 2005. The researchers recorded perioperative rates of death and complications, long-term survival, rupture and reinterventions. The study included 22,830 patients, 80% male, with an average age of 76 years.

The endovascular repair group had significantly lower perioperative mortality than the open surgery group (1.2% vs. 4.8%), and this reduction in mortality was greater for older patients. Patients age 85 years or older had an 8.5% lower absolute risk of mortality if they were in the endovascular group. The endovascular group maintained a survival advantage for three years post-surgery, after which the survival curves of the two cohorts converged.

At four years, the endovascular group had higher rates of rupture (1.8% vs. 0.5%) and reintervention related to abdominal aortic aneurysm (9.0% vs. 1.7%). However, the open surgery group was more likely to require surgery for laparotomy-related complications (9.7% vs. 4.1%) or hospitalization without surgery for bowel obstruction or abdominal wall hernia (14.2% vs. 8.1%). The study was published in the Jan. 31 New England Journal of Medicine.

The study confirms the findings of previous research on the perioperative mortality of both methods, study authors said. The study did find a longer-lasting survival benefit for endovascular repair than had previously been seen, probably because older patients were not included in initial clinical trials, the authors said. They cautioned that, as an observational study, the research could have been confounded by unknown factors that influenced patients' and physicians' decisions about which procedure to choose, although the researchers attempted to minimize this problem by propensity-score matching the two cohorts.

Appropriate VTE prophylaxis often lacking in hospitalized patients

Rates of appropriate prophylaxis for venous thromboembolism (VTE) in hospitalized patients are less than ideal, according to a worldwide study.

The ENDORSE Investigators performed an observational cross-sectional study of medical and surgical patients to determine how many hospitalized patients were at risk for VTE and what proportion received appropriate prophylaxis, as recommended by 2004 guidelines from the American College of Chest Physicians. Patients were seen at 358 acute care hospitals in 32 countries between August 2006 and January 2007. The results of the study, which was industry-sponsored, appeared in the Feb. 2 Lancet.

Of 68,183 patients, 55% were medical and 45% were surgical. Researchers determined that 35,329 patients (19,842 surgical and 15,487 medical) were at risk for VTE. Among at-risk surgical and medical patients, appropriate prophylaxis was administered in 11,613 (58.5%) and 6,119 (39.5%), respectively. Prophylaxis varied by type of surgery; for example, 88% of patients having knee or hip replacement received prophylaxis compared with 50% of those having urological surgery. Among medical patients, patients with acute noninfectious respiratory disease had the highest rate of prophylaxis (45%), while patients with active malignant disease or ischemic stroke had the lowest (37%).

The study used data from patient charts, which could have introduced some inaccuracies, and was not able to determine adherence to prophylaxis during the entire hospital stay, among other limitations. However, the authors wrote, their data have important implications for national health care and provide a “global overview” of the difference between evidence-based guidelines and actual practice. They called for the implementation of hospital-wide strategies to assess VTE risk and ensure appropriate prophylaxis.

Tight glucose control may protect kidneys in the critically ill

Intensive insulin therapy may have a renoprotective effect in critically ill patients, according to a study.

Two previously published randomized, controlled trials have indicated that tight glucose control protects the kidneys in critically ill patients. Researchers reanalyzed data from these trials to more closely examine the effect of intensive insulin therapy on renal function. The results appear in the March Journal of the American Society of Nephrology.

The study involved data from 2,707 critically ill medical and surgical patients who did not have end-stage renal disease before hospital admission and were randomly assigned to receive intensive or conventional insulin therapy during hospitalization. Overall, the incidence of acute kidney injury was statistically significantly lower in patients receiving intensive insulin therapy than in those receiving conventional therapy (4.5% vs. 7.6%). A greater renoprotective effect was seen among patients who maintained normal glucose levels.

In surgical patients, oliguria and the need for renal replacement therapy were statistically significantly less common in those receiving intensive insulin therapy compared with conventional therapy (2.6% vs. 5.6% and 4.0% vs. 7.4%, respectively). Medical patients did not derive as much renoprotective benefit from intensive insulin therapy, possibly because patients in this group are usually sicker at hospital admission.

The authors acknowledged several limitations of their study, including examination of a secondary outcome and the limited sample size of some subgroups. However, they concluded that tight glucose control has a renoprotective effect in the critically ill, especially surgical patients.