No abstract

This study investigates the effect of an initial specimen diversion device on the rate of culture contamination in hospitalized patients. It finds that the device is associated with a significant reduction in contamination. This intervention may result in a reduction in costs, antibiotic use and duration of hospitalization.

Background Blood culture contamination leads to unnecessary interventions and costs. It may be caused by bacteria in deep skin structures unsusceptible to surface decontamination. This study was designed to test whether diversion of blood obtained at venipuncture into a lithium heparin tube prior to aspiration of blood culture reduces contamination. Methods The order of blood draws for biochemistry and blood cultures was randomized. Following standard disinfection and venipuncture, blood was either aspirated into a sterile lithium heparin tube before blood culture bottles (diversion group) or blood cultures first and then lithium heparin tube (control group). All study personnel were blinded with the exception of the phlebotomist. Results After exclusions, 970 blood culture/biochemistry sets were analyzed. Contamination occurred in 24 of 480 (5.0%) control vs 10 of 490 (2.0%) diversion group cultures (P = .01). True pathogens were identified in 26 of 480 (5.4%) control vs 18 of 490 (3.7%) diversion cultures (P = .22). Despite randomization, demographic differences were apparent between the 2 groups. A post hoc analysis of 637 cultures from 610 medical patients admitted from home neutralized demographic differences. Culture contamination remained more frequent in the control vs diversion group (17/312 [5%] vs 7/325 [2%]; P = .03). Fewer diversion group patients were admitted to hospital (control: 200/299 [66.9%] vs diversion: 182/311 [58.5%]; P = .03), and length of stay was shorter (control: 30 hours [interquartile range {IQR}, 6–122] vs diversion: 22 [IQR, 5–97]; P = .02). Conclusions Use of lithium heparin tubes for diversion prior to obtaining blood cultures led to a 60% decrease in contamination. This technique is easy and inexpensive and might decrease overall hospital length of stay. Clinical Trials Registration NCT03966534.

Patients with COVID-19 are at increased risk of thromboembolism. In a recent study of 184 patients with COVID-19, there was a cumulative incidence of venous thromboembolism of 27% and arterial thrombotic events of 3.7%. 1 Abnormal coagulation parameters, particularly elevated D-dimer and fibrinogen, have been shown to be associated with poor prognosis in these patients, 2 and anticoagulation is associated with decreased mortality in severe COVID-19. 3 Antiphospholipid antibodies, mainly lupus anticoagulant (LAC) and anticardiolipin antibodies (aCL), contribute to an acquired prothrombotic state. They are associated with significantly increased risk of arterial, venous, and microvascular thrombosis. The prevalence of LAC or aCL in healthy individuals is 1%-5% with a predominance among females though it may increase in elderly and with chronic disease. Many infections have been shown to be accompanied by an increase in antiphospholipid antibodies, which is often transient, but can persist and trigger thromboembolic events. 4 The purpose of this retrospective study at the Shaare Zedek Medical Center (SZMC) in Jerusalem was to determine whether patients with COVID-19 have elevated antiphospholipid antibodies and whether there is a correlation between the level of antiphospholipid antibodies and the severity of the disease. The study was approved e18 | LETTER TO THE EDITOR

Purpose of reviewThe aim of this study was to outline the management of the patient with the open abdomen.Recent findingsAn open abdomen approach is used after damage control laparotomy, to decrease risk for postsurgery intra-abdominal hypertension, if reoperation is likely and after primary abdominal decompression.Temporary abdominal wall closure without negative pressure is associated with higher rates of intra-abdominal infection and evisceration. Negative pressure systems improve fascial closure rates but increase fistula formation. Definitive abdominal wall closure should be considered once oedema has subsided and the patient has stabilized. Delayed abdominal closure after trauma (>24–48 h) is associated with less achievement of fascial closure and more complications. Protective lung ventilation should be employed early, particularly if respiratory compromise is evident. Conservative fluid management and less sedation may decrease delirium and increase definitive abdominal closure rates. Extubation may be performed before definitive abdominal closure in selected patients. Antibiotic therapy should be brief, targeted and guideline concordant. Survival depends on the underlying disease, the closure method and the course of hospitalization.SummaryChanges in the treatment of patients with the open abdomen include negative temporary closure, conservative fluid management, early protective lung ventilation, decreased sedation and extubation before abdominal closure in selected patients.