The Latest in Critical Care: August 6, 2025
BALANCE meta-analysis, FARES-II, OPO oopsies, EOL inertia
7 vs 14 days antibiotics for bacteremia: new meta-analysis
A prior meta-analysis of 3 trials (Molina et al 2021, von Dach et al 2020, Yahav et al 2018) suggested that 7 days of antibiotics might be as effective as 14 for the treatment of bacteremia in most patients.
Then the BALANCE trial was performed, showing similar results but with numerous caveats which we described in detail here:
Adding in the BALANCE trial to produce a new larger meta-analysis of the 4 trials, treatment for bacteremia with 7 days of antibiotics appeared safe (90-day mortality 12% with 7 days vs 13.7% with 14 days, in the intention-to-treat analysis).
There was a 23% deviation from protocol in the 7-day arm in BALANCE, with clinicians opting to treat for longer courses. Thus, caution and individualized treatment decisions are required.
—Lee TC et al. JAMA Netw Open. 2025 Mar 3;8(3):e251421. doi: 10.1001/jamanetworkopen.2025.1421.
4-factor protein complex concentrate vs fresh frozen plasma for bleeding after cardiac surgery (FARES-II)
Among 420 adults who experienced bleeding after undergoing cardiac surgery with bypass, those randomized to receive 25 IU/kg of 4-factor PCC (Kcentra™) experienced better hemostasis than those receiving fresh frozen plasma. Significantly fewer patients receiving PCC required red cell transfusions. Thromboembolic events were comparable between groups, although 1.3% nominally higher in the PCC group.
—Karkouti et al., JAMA 2025;333;(20):1781-1792. doi:10.1001/jama.2025.3501
Organ procurement organizations’ alleged bad behavior lands in NYT
Organ donation after circulatory death has been increasing due to the shortage of brain dead donors. Exactly how this has been incentivized within OPOs and transplant centers is unclear, as their financial structure is as opaque as the rest of the U.S. healthcare system. However, it appears that some employees of some OPOs may have been cutting corners in pursuit of viable organs. Patients have breathed after being declared dead, and one patient being prepared for organ harvesting allegedly made a full recovery.
People continue to not want to talk about their upcoming deaths
Among 141 patients with metastatic cancer and other serious illnesses at 3 Boston hospitals’ emergency departments, those randomized to be approached by a nurse trained in having Serious Illness Conversations reported no greater engagement in advanced care planning than those not having the Conversation. The intervention included prompts to the later treating physicians to re-attempt the Conversation. Although patients did not report engagement, it did seem to improve documentation of end-of-life care planning and might have spurred some patients to discuss their preferences with their physicians.
—Ouchi et al, JAMA Network Open, 2025, doi:10.1001/jamanetworkopen.2025.16582.