Editor: Deborah Sesok-Pizzini, MD, MBA, chief medical officer, Labcorp Diagnostics, Burlington, NC, and adjunct professor, Department of Clinical Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Prevalence and determinants of anemia at discharge in pediatric ICU patients
October 2023—Several large randomized controlled trials have shown the safety of tolerating hemoglobin levels as low as 7 g/dL in critically ill hemodynamically stable children. These trials have led to recent guidelines advocating for restrictive transfusion therapy, which is significantly changing practices in pediatric critical care. For example, there has been a reduction in the amount of packed red blood cells (pRBCs) transfused in critically ill children, which mitigates the risk of transfusion reactions and adverse events, including transmission of infectious diseases. On the downside, reducing pRBC transfusion in critically ill children has resulted in more patients being anemic at discharge from the pediatric intensive care unit (PICU). Prolonged anemia has been associated with significant outpatient morbidities, such as fatigue, muscle weakness, neurocognitive disorders, and lower quality of life. Yet there are very limited data about anemia in pediatric patients who undergo congenital heart surgery. The authors conducted a large retrospective study in the PICU of a multidisciplinary university-affiliated tertiary-care health center to describe the prevalence and risk factors of anemia at PICU discharge in three groups: medical patients, cardiac surgery patients, and other surgery patients. The study was performed from January 2013 to January 2018. All patients who had a hemoglobin level available at PICU discharge were included in the study. The baseline characteristics and hemoglobin levels were obtained by searching the electronic medical records database. A total of 4,750 patients were admitted to the PICU, and discharge hemoglobin values were available for 4,124 of them. The data showed that 50.9 percent (2,100) of the patients were anemic at discharge. Anemia was defined by age based on World Health Organization recommendations for children older than six months and the Nelson Textbook of Pediatrics (Philadelphia: Springer; 2016) for infants younger than six months. Anemia at discharge was common in the cardiac surgery population—primarily in acyanotic patients (53.3 percent), whereas only 24.6 percent of cyanotic patients met the standard definitions of anemia. In addition, the cardiac surgery patients were transfused more often and at higher hemoglobin levels compared with the medical and noncardiac surgery patients. The authors noted that transfusion thresholds are still a matter of debate in the congenital heart surgery population. Anemia at admission was the strongest predictor of anemia at discharge (odds ratio, 6.51; 95 percent confidence interval, 5.40–7.85). The study found that half the PICU survivors were anemic at discharge. According to the authors, this was the first study to describe the epidemiology of anemia at PICU discharge in a large mixed cohort. The authors concluded that additional studies are needed to understand the impact of anemia in different pediatric PICU populations and determine long-term sequelae and transfusion strategies.
Jutras C, Sauthier M, Tucci M, et al. Prevalence and determinants of anemia at discharge in pediatric intensive care survivors. Transfusion. 2023;63:973–981.
Correspondence: Dr. Genevieve Du Pont-Thibodeau at genevievedpt@gmail.com
Correlation of clinical severity with stool microbiome changes in Clostridioides difficile infection
Clostridioides difficile infection is the most common cause of infectious diarrhea and pseudomembranous colitis worldwide. Its symptoms can range from mild diarrhea to life-threatening complications. Risk factors for this infection include age older than 65 years, hospitalization in an intensive care unit, clinical history of inflammatory bowel disease, use of proton pump inhibitors, and exposure to antibiotics. Treatment guidelines include targeted antimicrobial therapy and rely on the susceptibility of C. difficile to specific antibiotics, despite the emergence of antibiotic-resistant strains. Other treatment alternatives, such as fecal microbiome transplant, focus on restoring the stool microbiome. More data are needed to correlate clinical variables and 16S rRNA microbiome profiles in C. difficile-infected patients. The authors conducted a study to determine the relationship between a patient’s clinical factors and the stool bacteriome in C. difficile infection (CDI)-positive patients versus CDI-negative patients who have concurrent diarrheal symptoms. They used stool samples and clinical data from 358 hospitalized patients with nosocomial diarrhea. Of these patients, 180 were CDI negative and 178 were CDI positive. Of the 358 hospitalized patients, 24.86 percent were lost to follow-up and 11.52 percent died within the medical facility. Patients’ stool bacteriomes were profiled by amplicon deep sequencing of the 16S rRNA gene and the clinical data were correlated. The data showed that the stool bacteriome in each patient was significantly different. The results indicated that severity alone, regardless of CDI diagnosis, plays an important role in the stool bacteriome. Phyla and species varied based on CDI diagnosis. Furthermore, blood tests were run on hospitalized patients to assess the levels of white blood cells, creatinine, albumin, and C-reactive protein, which play a role in defining the severity of CDI. Severity, defined as a serum WBC count greater than 15 cells/mL or creatinine level greater than 1.5 mg/dL, or both, correlated significantly with dysbiosis of the stool bacteriome profile of CDI-positive versus CDI-negative patients. The serum WBC count was significantly higher in patients with bacterial dysbiosis, and high levels of creatinine were associated with lower microbiome diversity. C-reactive protein was significantly lower in the CDI-negative versus CDI-positive cohort, which suggests a higher level of inflammation in the latter group. The authors concluded that the stool microbiome was less diverse in CDI-positive patients than in those with diarrhea caused by other etiologic agents. They reported that their study is one of the first to investigate both the stool microbiome and clinical variables of symptomatic hospital patients.
Castaneda-Mogollon D, Doolan CP, Toppings NB, et al. Correlation of clinical severity with stool microbiome changes in Clostridioides difficile infection. Arch Pathol Lab Med. 2023;147:774–785.
Correspondence: Dr. Dylan R. Pillai at drpillai@ucalgary.ca