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Bloodstream infection (BSI) is a major cause of death in developed countries and the detection of microorganisms is essential in managing patients. Despite major progress has been made to improve identification of microorganisms, blood culture (BC) remains the gold standard and the first line tool for detecting BSIs. Consensus guidelines are available to ensure optimal BSI procedures, but BC practices often deviate from the recommendations. This review provides an update on clinical and technical issues related to blood collection and to BC performance, with a special focus on the blood sample strategy to optimize the sensitivity and specificity of BCs.

In this trial, subclavian-vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular-vein or femoral-vein catheterization. (Funded by the Hospital Program for Clinical Research, French Ministry of Health; ClinicalTrials.gov number, NCT01479153.).

Conclusion: There are at least 6 biomarkers where higher concentrations are associated with an increased risk of abdominal aortic aneurysm (AAA). Summary: Most important clinical risk factors for AAA have been identified through epidemiologic studies. They include advanced age, male sex, white race, smoking and family history. AAA pathophysiology involves inflammatory cells infiltrating the wall of the aorta with proteolysis of elastin and collagen in the media and adventitia. There is also smooth muscle cell apoptosis associated with thinning of the media (Nordon IM et al, Nat Rev Cardiol 2011;8:92-102). Some studies have also identified circulating inflammatory hemostatic proteolytic and extracellular matrix biomarkers associated with AAA presence or progression (Golledge J et al, Circulation 2008;118:2382-92). However, few studies have examined multiple biomarkers simultaneously. The authors focused on already measured biomarkers in the Atherosclerosis Risk in Communities (ARIC) cohort, to examine association of multiple circulating biomarkers with incident AAA. Biomarkers of inflammation, hemostasis, thrombin generation, cardiac dysfunction and vascular stiffness were identified with incident AAAs during follow-up using hospital discharge codes in the ARIC cohort. Six biomarkers (white blood cell count, fibrinogen, D-dimer, troponin T, N-terminal pro-brain natriuretic peptide and high-sensitivity C-reactive protein) were strongly associated with AAA incidence. Compared with having none of these 6 biomarkers in the highest quartile, hazard ratios for AAA with those with 1, 2, 3, 4, or 6 biomarkers in the highest quartile were 2, 3.3, 4.0, and 9.9, respectively (P for trend <.0001) after adjustment for other risk factors. Comment: The authors' results suggest that multiple positive biomarkers can identify a subgroup of patients at high risk for AAA. However, biomarkers in this study were measured only once and not at the same time. Biologic availability or change over time in biomarkers potentially could attenuate or enhance reported hazard ratios. In addition, the authors were not able to consider biomarkers such as procollagen or its degradation products. A failure to account for these and other potential biomarkers could also potentially overestimate or underestimate hazard ratios. Finally, the study documents as association of biomarkers with AAA but not a cause and effect relationship.

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BackgroundWhile the relationship between average adherence to HIV potent antiretroviral therapy is well defined, the relationship between patterns of adherence within adherence strata has not been investigated. We examined medication event monitoring system (MEMS) defined adherence patterns and their relation to subsequent virologic rebound.Methods and ResultsWe selected subjects with at least 3-months of previous virologic suppression on a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen from two prospective cohorts in France and North America. We assessed the risk of virologic rebound, defined as HIV RNA of >400 copies/mL according to several MEMS adherence measurements.Seventy two subjects were studied, five of them experienced virologic rebound. Subjects with and without virologic rebound had similar baseline characteristics including treatment durations, regimen (efavirenz vs nevirapine), and dosing schedule. Each 10% increase in average adherence decreased the risk of virologic rebound (OR = 0.56; 95% confidence interval (CI) [0.37, 0.81], P<0.002). Each additional consecutive day off therapy for the longest treatment interruption (OR = 1.34; 95%CI [1.15, 1.68], P<0.0001) and each additional treatment interruption for more than 2 days (OR = 1.38; 95%CI [1.13, 1.77], P<0.002) increased the risk of virologic rebound. In those with low-to-moderate adherence (i.e. <80%), treatment interruption duration (16.2 days versus 6.1 days in the control group, P<0.02), but not average adherence (53.1% vs 55.9%, respectively, P = 0.65) was significantly associated with virologic rebound.ConclusionsSustained treatment interruption may pose a greater risk of virologic rebound on NNRTI therapy than the same number of interspersed missed doses at low-to-moderate adherence.

Resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs) increases with the wider use of this class of antiretroviral therapy. The association between adherence and resistance to NNRTI-based regimens is poorly understood. Predictors of virologic failure and resistance according to a baseline evaluation of nonadherence risk factors were determined in a cohort of 71 human immunodeficiency virus (HIV)-infected patients with early virologic response who received an NNRTI-based regimen. During the median follow-up of 29 months, 20 (28%) of 71 patients experienced virologic failure with an NNRTI-based regimen. Virologic failure was associated with repeated drug holidays (> or =48 h of unplanned drug cessation), depression, younger age, and low adherence to therapy during baseline evaluation. Moreover, repeated drug holidays was the only risk factor for developing a major mutation conferring cross-resistance to the NNRTI class (hazard ratio, 22.5; 95% confidence interval, 2.8-180.3; P<.0001). Patients' previous adherence to therapy and drugs genetic barriers, not only the number of pills or doses involved, should be taken into consideration in the decision to simplify highly active antiretroviral therapy.

ICU patients with liver cirrhosis still have a high crude mortality. In this specific population ARF is associated with an excess mortality, depending on the severity of renal dysfunction.