CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Editor: Deborah Sesok-Pizzini, MD, MBA, professor, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and chief, Division of Transfusion Medicine, Children’s Hospital of Philadelphia.
Mortality and morbidity in a defined population of patients who decline blood transfusion
Characteristics and antibiotic use associated with short-term risk of C. difficile infection in hospital patients
Clostridium difficile infection is recognized as the leading cause of infectious nosocomial diarrhea. Since molecular testing has improved the sensitivity and specificity of C. difficile infection (CDI) diagnosis, most hospitals discourage repeating a negative test within seven days. However, there is a rare possibility that a patient may have repeat CDI testing that is positive within 14 days after an initial negative finding. To help guide laboratory practice, the authors conducted a study to determine which patients would likely benefit from repeat testing policies. The investigators performed a case-control study and identified patients who converted from polymerase chain reaction (PCR) negative to positive within 14 days. Each case was matched with three controls. The authors used conditional logistic regression to estimate the association between patient characteristics and CDI. In the 30 patients from the study who had a positive PCR within 14 days after a first negative PCR, 15 (50 percent) of the positive findings occurred within seven days of the initial test. These patients had a higher proportion of intravenous vancomycin use in the previous eight weeks and were less likely to have recent antiviral agent use compared with controls. In summary, the authors noted that in hospitalized patients, vancomycin use is associated with short-term risk for hospital-acquired CDI. Repeat testing guidelines should take into consideration these patients.
Aldrete S, Magee MJ, Friedman-Moraco RJ, et al. Characteristics and antibiotic use associated with short-term risk of Clostridium difficile infection among hospitalized patients. Am J Clin Pathol. 2015;143:895–900.
Correspondence: Dr. Colleen Kraft at colleen.kraft@emory.edu
Mortality and morbidity in a defined population of patients who decline blood transfusion
For severely anemic patients, blood transfusions are the mainstay for adequate oxygen delivery and consumption in vital organs. For some patients, blood transfusion is not an option due to unavailability of blood, medical conditions, or opposition to transfusion based on religious or other personal beliefs. Examining patients who may be severely anemic for outcomes may help provide important information for managing this population. The authors conducted a retrospective study of consecutive patients who were at least 18 years old and could not be transfused, who had surgery at a patient blood-management center between 2003 and 2012, and who had at least one hemoglobin measurement of not more than 8 g/dL during the postoperative period. The primary outcome was mortality, occurring any time after the surgery until discharge or until 30 days post-surgery, whichever came first. A total of 293 patients were enrolled in the study. The results showed an overall mortality rate of 8.2 percent. Unadjusted odds ratio of death per each 1 g/dL decrease in the nadir postoperative hemoglobin was 2.04, and odds ratio of death after adjusting for other significant factors was 1.82. Overall, the study confirms the risk of severe anemia when blood transfusion is not an option, particularly when hemoglobin levels are below 5 to 6 g/dL. Patients with nadir hemoglobin levels of 7 to 8 g/dL (or perhaps even 6 to 7 g/dL) are at lower risk and have better survival rates. Of interest, most of the patients with nadir hemoglobin levels above 3 g/dL can still survive without transfusion, suggesting the value of other management strategies for these patients.
Shander A, Javidroozi M, Naqvi S, et al. An update on mortality and morbidity in patients with very low postoperative hemoglobin levels who decline blood transfusion. Transfusion. 2014;54:2688–2695.
Correspondence: Dr. Aryeh Shander at aryeh.shander@ehmc.com