Monday, October 30, 2006

October 2006 JMLA case: Expert synthesis of the literature to support critical care decision-making

The October issue of the Journal of the Medical Library Association (JMLA) includes the inaugural edition of the journal's new recurring case feature. This month's case addresses a complex information need that arises during a librarian's participation on critical care rounds.

The clinical question

You are a librarian collaborating with the clinical team in your hospital’s intensive care unit. A 64 year old male was admitted to the ICU 10 days previously for respiratory failure and hepatic encephalopathy associated with advanced liver failure. He developed signs of possible ventilator-associated pneumonia and underwent bronchoscopy with bronchoalveolar lavage (BAL); the BAL fluid culture was positive for one of the Acinetobacter species. Antibiotic sensitivity testing indicates 48 hours later that his strain of Acinetobacter is resistant to the antibiotics commonly employed to treat bacterial pneumonia on the unit and also to those recommended by recent practice guidelines. This is a problem that the team has encountered in several patients over the last several months.

During morning rounds, the clinical team’s discussion focuses on the best approach to treatment for this patient. The team’s pharmacist recalls that an older antibiotic, colistin, was discussed as a possible option for such infections at a recent conference he attended. As this team’s evidence consultant, you are charged with identifying quality information regarding the risks and benefits of using colistin for therapy in similar patients.

The question: What is the evidence basis for the use of intravenous colistin for multi-drug resistant Acinetobacter infections in the adult, non-neutropenic, critical care population?

The full-text of the case examines the process of addressing this question, including researching and understanding the medical concepts comprising the question, searching the literature, selecting the "best" articles (based on relevance and methodological rigor), and summarizing the information for presentation to the team. It also includes clinician commentary on the clinical significance of this issue, the utility of the librarian's assistance in this setting, and the potential tremendous impact of the information provided by the librarian.

In the upcoming days, we will post a series of follow-up posts examining issues related to this question in further detail. We will periodically collate and address comments and questions shared by you and other readers in the Comments section of these posts. We invite your participation!

The full case is now available online in PubMed Central.