Introduction. A significant number of critically ill patients, as high as 60% among patients with septic shock, suffer from critical illness-related corticosteroid insufficiency (CIRCI), which refers to an inadequate corticosteroid response to the level of stress.

Objectives. This study aimed to determine the strategies employed in managing patients with critical illness-related corticosteroid insufficiency and the outcomes of these patients at a tertiary hospital.

Methods. This was a single-center, mixed-methods study which consisted of a review of charts of patients 19 years old and above admitted for shock or developed refractory hypotension from January 2017-December 2019, and key informant interviews and focus group discussion among clinicians who have experience in managing CIRCI.

Results. A total number of 362 patient charts reviewed showed a relatively low rate of initiation of corticosteroids for patients with refractory shock, at just 28.57% of the entire population. After corticosteroids were initiated, patients were in shock for a median of just one day and the median blood pressure improved to 100/60 mm Hg. In this cohort, patients who were started on steroids had more severe illness, as measured by the Mortality Probability Model (MPM) score, which had a median of 43.65% for the group on steroids and just 25.0% for the non-steroid group (p ? 0.0001). Patients who were started on steroids had a statistically significant longer median days on a ventilator, 5 days vs. 3 days for the non-steroid group (p = 0.0297); longer median length of intensive care unit (ICU) stay, 8 days vs. 5 days for the non-steroid group (p = 0.0410), and a higher morbidity and mortality rate. The need for steroids, the presence of septic shock, and a higher MPM score were significant predictors of mortality.

Discussions among clinicians revealed significant variability in practices in the management of CIRCI.

Conclusion. The presence of clinical features of CIRCI is a poor prognostic factor. Timely recognition, work-up, and interventions to address CIRCI are paramount in critical care.

Shock ; Critical Illness

BACKGROUND: The worldwide incidence of osteomyelitis is approximately 21.8 cases per 100,000 person-years. The cornerstone of treatment is prolonged (4-6 weeks) intravenous antibiotic administration. This entails additional cost, inconvenience, and added manpower from the healthcare system. Thus, studies have explored the possible use of oral antibiotics as alternatives to improve patient compliance and reduce costs. Our meta-analysis aimed to compare the efficacy of oral versus intravenous antibiotics in treating adult patients with osteomyelitis. MATERIALS AND METHODS: Electronic databases (PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, and Research Gate) from 1966 to April 2020 were searched using the terms “oral antibiotics”, “osteomyelitis”, “randomized controlled trial”. Only studies that directly compared oral versus intravenous antibiotics and confirmed osteomyelitis through biopsy and/or imaging were included. Primary outcome is remission (resolution of symptoms with no relapse and bacteriologic eradication); secondary outcomes, (a) relapse (persistence of the pathogen after treatment) and (b) adverse events. The validity of included studies was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We performed a random-effects model in Review Manager Version 5.3 with 95% confidence interval. The I 2 test was used to assess heterogeneity. RESULTS: Seven of 89 trials comprised of 1,282 patients were included in the final analysis. All studies included patients with osteomyelitis of the lower extremities. Oral antibiotics used were Ciprofloxacin, Ofloxacin, and Co-trimoxazole; intravenous antibiotics used were deemed appropriate by the infectious disease specialist. Patients were only given either oral or intravenous antibiotics. Results showed an 8% increase in remission rates [RR 1.08 (0.81 to 1.44, 95% CI, Z = 0.52, p=0.60)] with no heterogeneity (I2 = 0%) in the intravenous antibiotics group. However, this was not statistically significant. Furthermore, there was a 62% decrease in relapse rates in the intravenous antibiotics group [RR 1.62 (0.85 to 3.07, 95% CI, Z = 1.47, p = 0.14)] with no heterogeneity (I2 = 0%) but was not statistically significant. CONCLUSION: Oral are comparable to intravenous antibiotics in treating osteomyelitis in terms of remission and relapse rates. However, larger and double-blinded trials should be done to generate more robust data to validate these claims.
Osteomyelitis ; Administration, Intravenous ' ; Parenteral Nutrition