Use and outcome of empiric echinocandins in critically ill patients.

BACKGROUND: Echinocandins are recommended as a first-line empiric treatment for fungal infections of patients in an intensive care unit (ICU) with critical illness. The primary aim of the study was to compare outcomes among ICU patients treated with empiric anidulafungin (ANI), caspofungin (CASPO), or micafungin (MICA). METHODS: A retrospective cohort study in a mixed adult ICU. Patient demographics, reason for ICU admission, ICU risk scores and organ support therapies were analyzed. Outcome parameters included ICU and hospital stay, 30-day mortality and 1-year mortality. RESULTS: Empiric echinocandin therapy was given to 367 patients (ANI; 73 patients, CASPO; 84 patients, and MICA; 210 patients) with a median duration of 3 days in an ICU. Patient median age was 60.7 years. As a first-line therapy, 52% of patients received fluconazole. Positive Candida cultures were found in the following samples: blood, 16 (4.4%); central line, 27 (7.4%); deep site, 92 (25.1%). Median ICU stay (ANI 6.4 days, CASPO 5.3 days, MICA 8.1 days), hospital stay (ANI 33 days, CASPO 30 days, MICA 30 days), 30-day mortality (ANI 27%, CASPO 32%, MICA 32%), and 1-year mortality (ANI 33%, CASPO 44%, MICA 45%) did not differ between the groups . The cost of antifungal therapy during the ICU period was similar in the three echinocandin groups (ANI; €1 872, CASPO; €1 799, and MICA; €1783). CONCLUSION: Our results show that ICU, hospital stay, and mortality (hospital, 30-day and 1-year) did not differ among patients with empiric anidulafungin, caspofungin, or micafungin treatment in a mixed adult ICU.

ICU-treated influenza A(H1N1) pdm09 infections more severe post pandemic than during 2009 pandemic: a retrospective analysis.

BACKGROUND: We compared in a single mixed intensive care unit (ICU) patients with influenza A(H1N1) pdm09 between pandemic and postpandemic periods. METHODS: Retrospective analysis of prospectively collected data in 2009-2016. Data are expressed as median (25th-75th percentile) or number (percentile). RESULTS: Seventy-six influenza A(H1N1) pdm09 patients were admitted to the ICU: 16 during the pandemic period and 60 during the postpandemic period. Postpandemic patients were significantly older (60 years vs. 43 years, p < 0.001) and less likely to have epilepsy or other neurological diseases compared with pandemic patients (5 [8.3%] vs. 6 [38%], respectively; p = 0.009). Postpandemic patients were more likely than pandemic patients to have cardiovascular disease (24 [40%] vs. 1 [6%], respectively; p = 0.015), and they had higher scores on APACHE II (17 [13-22] vs. 14 [10-17], p = 0.002) and SAPS II (40 [31-51] vs. 31 [25-35], p = 0.002) upon admission to the ICU. Postpandemic patients had higher maximal SOFA score (9 [5-12] vs. 5 [4-9], respectively; p = 0.03) during their ICU stay. Postpandemic patients had more often septic shock (40 [66.7%] vs. 8 [50.0%], p = 0.042), and longer median hospital stays (15.0 vs. 8.0 days, respectively; p = 0.006). During 2015-2016, only 18% of the ICU- treated patients had received seasonal influenza vaccination. CONCLUSIONS: Postpandemic ICU-treated A(H1N1) pdm09 influenza patients were older and developed more often septic shock and had longer hospital stays than influenza patients during the 2009 pandemic.

Epididymitis caused by coxsackievirus A6 in association with hand, foot, and mouth disease.

Coxsackievirus A6 (CV-A6) caused hand, foot, and mouth disease (HFMD) with a unique manifestation of epididymitis. The patient underwent operation due to suspicion of testicular torsion. Epididymitis was diagnosed by ultrasound examination. Enterovirus was detected from epididymal fluid by PCR and typed by partial sequencing of viral protein 1 as CV-A6.

Critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia--a survey study.

OBJECTIVES: To explore critical care nurses' knowledge of, adherence to and barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. DESIGN: A quantitative cross-sectional survey. METHODS: Two multiple-choice questionnaires were distributed to critical care nurses (n=101) in a single academic centre in Finland in the autumn of 2010. An independent-samples t-test was used to compare critical care nurses' knowledge and adherence within different groups. The principles of inductive content analysis were used to analyse the barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. RESULTS: The mean score in the knowledge test was 59.9%. More experienced nurses performed significantly better than their less-experienced colleagues (p=0.029). The overall, self-reported adherence was 84.0%. The main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge and guidance. CONCLUSION: There is an ongoing need for improvements in education and effective implementation strategies. CLINICAL IMPLICATIONS: The results could be used to inform local practice and stimulate debate on measures to prevent ventilator-associated pneumonia. Education, guidelines as well as ventilator bundles and instruments should be developed and updated to improve infection control.

Comparison of the epidemiology, risk factors, outcome and degree of organ failures of patients with candidemia acquired before or during ICU treatment.

INTRODUCTION: The aim of this study was to compare the epidemiology, risk factors, severity and outcome of two types of ICU-treated candidemias: namely, ICU-acquired candidemia (acquired after 48-hour ICU stay) (ICUAC group), and those needing ICU treatment for candidemia acquired before ICU admission or during the first 48-hour ICU stay (non-ICUAC group). METHODS: A retrospective cohort study was conducted between 2000 and 2009 in a mixed tertiary ICU among patients with blood-culture-confirmed candidemia. RESULTS: The study involved 82 patients (53 men). The ICUAC group consisted of 38 patients (46.3%) and the non- ICUA group included 44 patients (53.6). The ICUAC group had undergone previous surgery more often and had ICU stays that were 3.7 times longer than the non-ICUAC group, whose members more often had co-morbidities (95.6% versus 73.7%, P = 0.001). The ICUAC group had significantly more frequent organ failures with cardiovascular, renal, central nervous and coagulation systems than the non-ICUAC group. ICU, hospital and one-year mortality rates did not differ between the groups (23%, 36.8% and 65.8%, respectively, in the ICUAC group and 26%, 44.4% and 64.4%, respectively, in the non-ICUAC group). Among patients with APACHE II scores greater than 25, the ICUAC group had lower one-year mortality (65.0% versus 87.5%). Among patients with APACHE II scores of 25 or less, the ICUAC group had higher mortality (66.7% versus 50.0). Candida albicans was most common cause of candidemia in both groups (76.3% and 68.9%, respectively). CONCLUSIONS: More than half of the ICU-treated candidemias were acquired prior to admission to the ICU. Patients with ICU- and non-ICU-acquired candidemias had different risk factors and different needs for ICU resources. Hospital mortality was similar in both groups; however, the groups had different mortality rates when the severity of disease and underlying diseases were taken into account.

[Infection control in the intensive care unit]. / Infektioiden torjunta teho-osastolla.

The basis of infection control is systematic monitoring of infections in the patient care units, whereby a clear-cut basis for focusing of the control is obtained. An entity of several distinct evidence-based methods, i.e. treatment bundle, is increasingly utilized. Though difficult in practice, the goal is zero tolerance, whereby all infections during the treatment should be prevented. Central principles of infection control include use of antimicrobial hand rinse in all patient care, appropriate use of protective devices and contact isolation as required by the detected microorganisms.

[Influenza A(H1N1)v-patients treated in Oulu University hospital]. / Oulun yliopistollisessa sairaalassa hoidetut influenssa a(H1N1)v-potilaat.

BACKGROUND: In Finland, the pandemic A(H1N1)v-influenza was experienced in late 2009. MATERIAL AND METHODS: A(H1N1)v-patients hospitalized in Oulu University Hospital were evaluated. RESULTS: Altogether, 159 A(H1N1)v-patients, including 37 children, were hospitalized. Their median age was 35. Eighteen (11 %) patients required admission to ICU; three of them died. As many as 62% of the patients suffered from radiologically confirmed pneumonia. The incidences of hospitalization, ICU care and death were 40,5, 4,6 and 0,8 per 100000, respectively. CONCLUSIONS: Despite the low mortality rate, a rather high number of patients required hospitalization. Findings in chest radiography were common and prominent.

Intensive care unit acquired infection has no impact on long-term survival or quality of life: a prospective cohort study.

INTRODUCTION: The aim of this study was to evaluate the impact of intensive care unit (ICU)-acquired infection on long-term survival and quality of life. METHODS: Long-term survival was prospectively evaluated among hospital survivors who had stayed in a mixed, university-level ICU for longer than 48 hours during a 14-month study period during 2002 to 2003. Health-related quality of life was assessed using the five-dimensional EuroQol (EQ-5D) questionnaire in January 2005. RESULTS: Of the 272 hospital survivors, 83 (30.5%) died after discharge during the follow-up period. The median follow-up time after hospital discharge was 22 months. Among patients without infection on admission, long-term mortality did not differ between patients who developed and those who did not develop an ICU-acquired infection (21.7% versus 26.9%; P = 0.41). Also, among patients with infection on admission, there was no difference in long-term mortality between patients who developed a superimposed (35.1%) and those who did not develop a superimposed (27.6%) ICU-acquired infection (P = 0.40). The EQ-5D response rate was 75 %. The patients who developed an ICU-acquired infection had significantly more problems with self-care (50%) than did those without an ICU-acquired infection (32%; P = 0.004), whereas multivariate analysis did not show ICU-acquired infection to be a significant risk factor for diminished self-care (odds ratio = 1.71, 95% confidence interval = 0.65-4.54; P = 0.28). General health status did not differ between those with and those without an ICU-acquired infection, as measured using the EuroQol visual-analogue scale (mean +/- standard deviation EuroQol visual-analogue scale value: 60.2 +/- 21 in patients without ICU-acquired infection versus 60.6 +/- 22 in those with ICU-acquired infection). The current general level of health compared with status before ICU admission did not differ between the groups either. Only 36% of those employed resumed their previous jobs. CONCLUSION: ICU-acquired infection had no impact on long-term survival. The patients with ICU-acquired infection more frequently experienced problems with self-care than did those without ICU infection, but ICU-acquired infection was not a significant risk factor for diminished self-care in multivariate analysis.

Intensive care acquired infection is an independent risk factor for hospital mortality: a prospective cohort study.

INTRODUCTION: The aim of this study was to elucidate the impact of intensive care unit (ICU)-acquired infection on hospital mortality. METHODS: Patients with a longer than 48 hour stay in a mixed 10 bed ICU in a tertiary-level teaching hospital were prospectively enrolled between May 2002 and June 2003. Risk factors for hospital mortality were analyzed with a logistic regression model. RESULTS: Of 335 patients, 80 developed ICU-acquired infection. Among the patients with ICU-acquired infections, hospital mortality was always higher, regardless of whether or not the patients had had infection on admission (infection on admission group (IAG), 35.6% versus 17%, p = 0.008; and no-IAG, 25.7% versus 6.1%, p = 0.023). In IAG (n = 251), hospital stay was also longer in the presence of ICU-acquired infection (median 31 versus 16 days, p < 0.001), whereas in no-IAG (n = 84), hospital stay was almost identical with and without the presence of ICU-acquired infection (18 versus 17 days). In univariate analysis, the significant risk factors for hospital mortality were: Acute Physiology and Chronic Health Evaluation (APACHE) II score >20, sequential organ failure assessment (SOFA) score >8, ICU-acquired infection, age > or = 65, community-acquired pneumonia, malignancy or immunosuppressive medication, and ICU length of stay >5 days. In multivariate logistic regression analysis, ICU-acquired infection remained an independent risk factor for hospital mortality after adjustment for APACHE II score and age (odds ratio (OR) 4.0 (95% confidence interval (CI): 2.0-7.9)) and SOFA score and age (OR 2.7 (95% CI: 2.9-7.6)). CONCLUSION: ICU-acquired infection was an independent risk factor for hospital mortality even after adjustment for the APACHE II or SOFA scores and age.

Community- and hospital-acquired infections necessitating ICU admission: spectrum, co-morbidities and outcome.

OBJECTIVES: To evaluate the spectrum of infections, co-morbidities and outcome of patients admitted into an intensive care unit (ICU) due to community- (CAI) or hospital-acquired infections (HAI). METHODS: A 14-month prospective study in a medical-surgical ICU in a tertiary level teaching hospital. RESULTS: Three hundred and thirty-five patients were included, of whom 74.9% had an infection on admission; 59.3% had CAI and 40.7% HAI, while 84 patients did not have any infection (NI). The most common infections in the CAI and HAI groups (G) were pneumonia and gastrointestinal infections. Secondary bacteremia (p<0.001), severe sepsis and septic shock (p=0.048) were more prevalent in CAIG, while histories of transient ischaemic attack or stroke (p=0.03), immunosuppressive medications (p=0.009) or malignancies (p<0.001) were more common in HAIG. APACHE II scores and ICU or hospital mortalities did not differ between the groups. The median hospital stay was longer in HAIG (24 days) than in CAIG (15) or NIG (17.5), p<0.001. CONCLUSIONS: Patients in CAIG had more often secondary bacteremia or severe sepsis or septic shock, whereas HAIG patients had more often a history of cerebrovascular problems, malignancies and immunosuppressive treatments. Eighty percent of these infection patients requiring ICU treatment survived.

Blood culture Gram stain and clinical categorization based empirical antimicrobial therapy of bloodstream infection.

Early antimicrobial treatment has a great influence on the outcome of patients with blood stream infections (BSI). The study was designed to see if the simple practice of patient categorization (community acquired, nosocomial or infection in haematological unit) combined with Gram stain data could be used to guide empirical treatment of BSI in 1901 consecutive positive blood culture findings. There were considerable differences in the occurrence of common pathogens and their antimicrobial susceptibilities between patient categories especially for Gram-positive cocci. For example, second generation cephalosporins covered more than 70% cocci in clusters and over 80% of cocci in chains in community acquired infections whereas in hospital acquired infections the corresponding figures were only 47 and 44%. We conclude that Gram stain results of positive blood cultures along with the knowledge of where the infection was acquired, would allow early accurate targeting of antimicrobial therapy for BSI.