New antifungal antibiotics.

PURPOSE OF REVIEW: The incidence of both invasive fungal infections and respiratory mould infections is increasing and they cause significant costs, morbidity and mortality. Non-Aspergillus moulds are increasing as cause of lung infections in specific populations and new problems of susceptibility and resistance are appearing. RECENT FINDINGS: The antifungal armamentarium has markedly improved in the past 10 years and some new drugs are in the pipeline. The use of these new agents is one of the drivers of the changes in fungal epidemiology. These new antifungal drugs are discussed in this article. SUMMARY: A good selection of the antifungal, taking into consideration the pathogen, the host and the pharmacokinetic/pharmacodynamics of the drug, is paramount for clinical success.

A clinical algorithm to diagnose invasive pulmonary aspergillosis in critically ill patients.

RATIONALE: The clinical relevance of Aspergillus-positive endotracheal aspirates in critically ill patients is difficult to assess. OBJECTIVES: We externally validate a clinical algorithm to discriminate Aspergillus colonization from putative invasive pulmonary aspergillosis in this patient group. METHODS: We performed a multicenter (n = 30) observational study including critically ill patients with one or more Aspergillus-positive endotracheal aspirate cultures (n = 524). The diagnostic accuracy of this algorithm was evaluated using 115 patients with histopathologic data, considered the gold standard. Subsequently, the diagnostic workout of the algorithm was compared on the total cohort (n = 524), with the categorization based on the diagnostic criteria of the European Organization for the Research and Treatment of Cancer/Mycoses Study Group. MEASUREMENTS AND MAIN RESULTS: Among 115 histopathology-controlled patients, 79 had proven aspergillosis. The algorithm judged 86 of 115 cases to have putative aspergillosis. This diagnosis was confirmed in 72 and rejected in 14 patients. The algorithm judged 29 patients to have Aspergillus colonization. This was confirmed in 22 and rejected in 7 patients. The algorithm had a specificity of 61% and a sensitivity of 92%. The positive and negative predictive values were 61 and 92%, respectively. In the total cohort (n = 524), 79 patients had proven invasive pulmonary aspergillosis (15.1%). According to the European Organization for the Research and Treatment of Cancer/Mycoses Study Group criteria, 32 patients had probable aspergillosis (6.1%) and 413 patients were not classifiable (78.8%). The algorithm judged 199 patients to have putative aspergillosis (38.0%) and 246 to have Aspergillus colonization (46.9%). CONCLUSIONS: The algorithm demonstrated favorable operating characteristics to discriminate Aspergillus respiratory tract colonization from invasive pulmonary aspergillosis in critically ill patients.

Myocardial Edema: an Overlooked Mechanism of Septic Cardiomyopathy?

Septic cardiomyopathy is an increasingly relevant topic in clinical management of septic shock. However, pathophysiological mechanisms and long-term consequences of sepsis-induced myocardial injury are still poorly understood. Herein, new clinical and histological evidence is provided suggesting an association of myocardial edema formation with tissue injury and subsequent remodeling in septic shock patients. This preliminary data supports myocardial edema as a potentially relevant and largely unexplored mechanism of human septic cardiomyopathy.

Potential Impact of Flow Cytometry Antimicrobial Susceptibility Testing on the Clinical Management of Gram-Negative Bacteremia Using the FASTinov® Kit.

Laboratory assessment of antimicrobial susceptibility is a prerequisite for adequate management of infections. The aim of this research was to evaluate the performance of the novel FASTinov® kit for antimicrobial susceptibility testing (AST) of Gram negative bacilli directly on positive blood cultures. One hundred and two positive blood cultures from patients of a Portuguese University Hospital were included. AST were performed with routine method, Vitek2, with FASTinov® kit, and with the gold standard microdilution. Bacteria directly extracted from blood cultures were used to inoculate the FASTinov® kit. Time-to-result as well as the number of patients receiving initially inappropriate therapy (and those in whom de-escalation would have been done) and length of stay (LOS) was recorded. Seventy percent of patients were over 70 years old and 18.6% were admitted in intensive care units. Regarding the isolates, 88.2% were Enterobacteriaceae, 9.8% Pseudomonas spp. and 1% Acinetobacter spp. Extended spectrum ß-lactamases producing-Enterobacteriaceae were found in 7.8% of cases and 10.8% were multi-drug resistant. Fifty-one hours was the mean of time-to-result for routine test (Vitek2) vs. 2 h response regarding Fastinov® test. The overall agreement between FASTinov® and the reference microdilution method was 98%. According to the susceptibility phenotype, 16.7% of patients received initially inappropriate therapy and the mean hospital LOS of these patients was significantly higher. FASTinov® kit revealed an excellent correlation with the AST standard method and provided much earlier results than Vitek2.

[Rupture of venous bypass graft associated to infection of multiresistant bacteria]. / Rotura de bypass venoso associada a infecção por bactérias multirresistentes.

We report two cases of severe trauma of the upper limb requiring arterial revascularization. A brachio-brachial inverted saphenous bypass graft was done in both cases. Graft rupture attributed to local infection occurred at fourth post-operative week. Pseudomonas aeruginosa was isolated from the surgical wound in the first case and Acinetobacter baumanni in the second. The first case ended up with arm amputation mostly owing to extensive destruction of soft tissue, the patient being discharged home without any other sequel. In the second case the patient was successfully resuscitated after cardiopulmonary arrest, secondary to hemorrhagic shock. He underwent new brachio-brachial venous bypass graft avoiding the contaminated area. Irreversible ischemic signs plus growing overt infection led to arm amputation later on. This patient developed multi-organ failure and died by the fifth post-operative week. Acinetobacter baumannii and Pseudomonas aeruginosa are gram-negative bacilli widely present in hospital environment. Most of them are resistant to commonly used antibiotics. Their association with vascular conduit infections might have dreadful consequences as it happened in these cases.

Delirium recognition by family: European Portuguese validation study of the family confusion assessment method.

OBJECTIVES: To present the validation study of the European Portuguese version of the Family Confusion Assessment Method (FAM-CAM) and to assess the level of psychological distress in families and caregivers of elderly hospitalized adults with delirium. DESIGN: Validation study. SETTING: Intermediate care unit of the Intensive Medicine Service of the São João Hospital Center, Porto, Portugal. PARTICIPANTS: Families and caregivers of elderly hospitalized adults (≥48 hours). Inclusion criteria were sufficient knowledge about the individual to enable reporting on his or her mental and physical abilities and staying at the individual's bedside daily during hospitalization. Families and caregivers younger than 18 and those who did not speak Portuguese were excluded. MEASUREMENTS: A trained researcher translated the FAM-CAM according to International Society For Pharmacoeconomics and Outcomes Research guidelines. All individuals were assessed using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (reference standard) and the Confusion Assessment Method (CAM). A trained researcher administered the FAM-CAM to families and caregivers. The level of family-perceived distress was evaluated on a numerical rating scale from 0 to 4. RESULTS: The sample included 40 families and caregivers (58% adult children). According to the DSM-IV-TR, 20% of individuals had delirium. The FAM-CAM had moderate sensitivity (75%) and good specificity (91%) when assessed against the DSM-IV-TR and better sensitivity (86%) and specificity (91%) than the CAM. Fifty-seven percent of families and caregivers classified delirium as an extremely distressing experience. CONCLUSION: These preliminary results suggest that FAM-CAM is a sensitive screening tool for family detection of delirium in elderly hospitalized adults. The high level of psychological distress found corroborated previous studies. Future studies with larger samples will be needed for further validation and to allow the analysis of other psychometric properties.

Antimicrobial drug interactions in the critically ill patients.

Critically ill patients are typically polymedicated and therefore at a high risk for potential drug interactions. Clinical consequences of drugs interactions vary in severity from mild to lethal events. Since infection is an important issue in the Intensive Care Unit (ICU), a significant number of patients will receive an antimicrobial at some stage during their ICU admission. Therefore an adequate knowledge about possible interactions between antimicrobials and other drugs is necessary, since it may not only impact on the effectiveness of the antimicrobial but also in the incidence of drug adverse events. This review describes important drug interactions involving antimicrobials in the critically ill patient.

[Trauma scores in the management of politrauma patients: which one and what for?]. / Trauma scores na avaliação de politraumatizados: quais e para quê?

BACKGROUND: The improvement rescue and transport of politrauma patients (PTP) increases the number of patients admitted to the Emergency departments in very severe conditions. The early prediction of later complications and bad outcomes is paramount for a good strategy. The aim of this study was to evaluate the severity of PTP in the Trauma Room (TR) of a Level 1 Hospital, using the ISS, RTS, TRISS scores and define variables associated with bad outcomes, namely ICU admission (ICU), ARDS, MODS and Death. MATERIAL/METHODS: Prospective study with data collection of demographic, clinical, laboratory and imaging parameters of all PTP admitted to the TR. The ISS was calculated by the Abbreviated Injury Scale, RTS and TRISS by Trauma.org site formulas. Statistical analysis was performed in SPSS. RESULTS: 278 patients were admitted in TR after Manchester screening during 6 months: 244 (185 men, 59 women) were studied, average age 39,32±19.32 years. Hospital admission- 157 patients (ICU-46, Intermediate Care Unit-29, Surgery Services-82) and 85 discharged. Submitted to Surgery-75. Scores: ISS-13,58±19,32, RTS-7,30±1,01; TRISS-92,42±15,85; Glasgow Coma Score (GCS)-13,00±3,61.Severe complications: ARDS-8%; SIRS-40%; MODS-18%; Death-14%. DISCUSSION: There is statistical correlation between Surgery Type: ICU and MODS; GCS, ISS, RTS, TRISS: ICU, ARDS, MODS and Death. Multivariate analysis shows that Surgery Type, GCS and TRISS predict ICU admission (ROC-0,884); TRISS predicts ARDS (ROC-0,844); TRISS predicts MODS (ROC-0,876); TRISS and age predicts Death (ROC-0,887). CONCLUSIONS: This study confirms scores validity in PTP assessment, as they are able to predict severe complications. TRISS seems to be the best score for prediction of bad outcomes.

Fibrose do colo vesical tratada com ressecçäo endoscópica e aplicaçäo local de diacetato de triamcinolona / Vesical neck fibrosis treated with endoscopic resection and local application of triancinolone diacetate

Os autores mostram a experiência do Serviço de Urologia da 14ª Enfermaria da Santa Casa da Misericórida do Rio de Janeiro, com a utilizaçäo do diacetato de triamcinolona no tratamento da esclerose do colo vesical, com aplicaçäo local em 5 pacientes, obtendo-se resultados satisfatórios até a presente data