Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial.

CONTEXT: Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources. OBJECTIVE: To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days. DESIGN, SETTING, AND PATIENTS: Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater. INTERVENTION: Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy). MAIN OUTCOME MEASURES: The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive. RESULTS: Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15). CONCLUSION: Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00262431.

Efficacy of ertapenem in the treatment of early ventilator-associated pneumonia caused by extended-spectrum beta-lactamase-producing organisms in an intensive care unit.

OBJECTIVES: Ventilator-associated pneumonia (VAP) is a frequent complication of patients admitted to intensive care units (ICUs). Ertapenem is a newer carbapenem with good in vitro activity against extended-spectrum beta-lactamase (ESBL)-producing organisms. However, there are no clinical data to support the use of ertapenem in VAP. Our purpose is to evaluate the usefulness and safety of ertapenem in the treatment of VAP caused by susceptible ESBL strains. METHODS: Ertapenem 1 g daily intravenously was given to adult patients with signs and symptoms of VAP beginning within 7 days of mechanical ventilation and caused by ESBL-producing Gram-negative organisms. RESULTS: From June 2005 to June 2006, we enrolled 20 adult patients hospitalized in an ICU and diagnosed with VAP due to Gram-negative ESBL strains. Causative organisms identified as ESBL producers susceptible to ertapenem were Klebsiella pneumoniae (alone in 10 cases and with methicillin-resistant Staphylococcus aureus in 4 cases), Enterobacter cloacae (2), Proteus mirabilis (2) and Citrobacter freundii (2). Clinical success was achieved in 16/20 (80%) of the clinically evaluable patients and in 15/20 (75%) of the microbiologically evaluable patients. The drug was well-tolerated; one patient presented a transient increase in liver enzymes. CONCLUSIONS: We believe this is one of the first reports to demonstrate that ertapenem has clinical utility in treating serious infections caused by ESBL-producing organisms. Ertapenem appears to be suitable for ESBL VAP therapy. This pilot study suggests subsequent controlled randomized trials in this indication.

Epidemiological trends in nosocomial candidemia in intensive care.

BACKGROUND: Infection represents a frequent complication among patients in Intensive Care Units (ICUs) and mortality is high. In particular, the incidence of fungal infections, especially due to Candida spp., has been increasing during the last years. METHODS: In a retrospective study we studied the etiology of candidemia in critically ill patients over a five-year period (1999-2003) in the ICU of the San Martino University Hospital in Genoa, Italy. RESULTS: In total, 182 episodes of candidaemia were identified, with an average incidence of 2.22 episodes/10,000 patient-days/year (range 1.25-3.06 episodes). Incidence of candidemia increased during the study period from 1.25 in 1999 to 3.06/10,000 patient-days/year in 2003. Overall, 40% of the fungemia episodes (74/182) were due to C.albicans, followed by C. parapsilosis (23%), C.glabrata (15%), C.tropicalis (9%) and other species (13%). Candidemia due to non-albicans species increased and this was apparently correlated with an increasing use of azoles for prophylaxis or empirical treatment. CONCLUSION: The study demonstrates a shift in the species of Candida causing fungemia in a medical and surgical ICU population during a 5 year period. The knowledge of the local epidemiological trends in Candida species isolated in blood cultures is important to guide therapeutic choices.