Recently published papers: choose well, treat well, get well – which matters most?

Choice underpins everything we do as critical care clinicians. We choose whether to treat, when to treat and how to treat from an ever-increasing selection of alternatives, and whether to afford the costs associated with the decisions we have made. Some recent articles have looked at how one chooses to ventilate patients (noninvasively or not), how to deal with and avoid ventilator-acquired pneumonia, and which regimens of antibiotics to use and how it affects outcome. It is these articles on which we shall focus. Choosing the antibiotic to use in early sepsis is influenced by many things: likely causative organisms for the source found, if any; local variations of pathogens; and known patterns of resistance. Logically, then, targeting sepsis with the correct initial antibiotic choice should influence overall patient outcome. But does it? Garnacho-Montero and colleagues looked at how adequate empirical antibiotic choice affected outcome and the mortality rate in 400 patients on admission to the intensive care unit (ICU) [1]. Adequate meant at least one effective drug (two drugs for Pseudomonas infection), as judged by antimicrobial susceptibility, included in the empirical antibiotic treatment. Garnacho-Montero and colleagues found that inhospital mortality was eight times more probable in patients receiving inadequate antimicrobial therapy in the first 24 hours, and that adequate therapy reduced mortality by almost two-thirds in surgical sepsis (where surgery is a necessary part of infection treatment). Antibiotic therapy in the preceding month and, not surprisingly, fungal infection meant empirical therapy was likely to be inadequate. Early adequate antibiotics do seem to matter, but not as much in ventilator-acquired pneumonia (VAP) as expected when considered by Leroy and colleagues [2]. Although adequate antibiotics were associated with a significantly lower mortality rate, they were not an independent prognostic factor. However, thrombocytopaenia and extensive lung radiographic appearances (as these authors have stated previously [3]) were an independent prognostic factor. Still with the antibiotic theme, many units are adopting rotating schedules of antibiotics in an effort to combat multiresistance. Raymond and colleagues have already suggested that this regimen may improve mortality on the ICU [4], but what happens when patients are discharged to the ward? It seems that if the regimen is carried over, then so are the benefits — even to patients on the ward admitted from elsewhere [5]. Interestingly, the length of stay on the ward seemed to increase with the rotating regimen but, as Raymond and colleagues point out, …