Risk factors and prognosis of catheter-related bloodstream infection in critically ill patients: a multicenter study.

OBJECTIVE: To assess the risk factors associated with CR-BSI development in critically ill patients with non-tunneled, non-cuffed central venous catheters (CVC) and the prognosis of the episodes of CR-BSI. Design and setting; prospective, observational, multicenter study in nine Spanish Hospitals. PATIENTS: All subjects admitted to the participating ICUs from October 2004 to June 2005 with a CVC. INTERVENTIONS: None. MEASUREMENT AND RESULTS: Overall, 1,366 patients were enrolled and 2,101 catheters were analyzed. Sixty-six episodes of CR-BSI were diagnosed. The incidence of CR-BSI was significantly higher in CVC compared with peripherically inserted central venous catheters (PICVC) without significant differences among the three locations of CVC. In the multivariate analysis, duration of catheterization and change over a guidewire were the independent variables associated with the development of CR-BSI whereas the use of a PICVC was a protective factor. Excluding PICVC, 1,598 conventional CVC were analyzed. In this subset, duration of catheterization, tracheostomy and change over a guidewire were independent risk factors for CR-BSI. A multivariate analysis of predictors for mortality among 66 patients with CRSI showed that early removal of the catheter was a protective factor and APACHE II score at the admission was a strong determinant of in-hospital mortality. CONCLUSIONS: Peripherically inserted central venous catheters is associated with a lower incidence of CR-BSI in critically ill patients. Exchange over a guidewire of CVC and duration of catheterization are strong contributors to CR-BSI. Our results reinforce the importance of early catheter removal in critically ill patients with CR-BSI.

A 7-year study of severe hospital-acquired pneumonia requiring ICU admission.

OBJECTIVE: To examine the characteristics, prognostic factors, and outcome of patients with severe hospital-acquired pneumonia admitted to the ICU. DESIGN AND SETTING: Prospective observational clinical study in two medical-surgical ICUs with 16 and 20 beds PATIENTS AND PARTICIPANTS: During a 7-year period all hospitalized patients requiring admission to either ICU for hospital-acquired pneumonia were followed up. MEASUREMENTS AND RESULTS: We diagnosed 96 episodes of severe hospital-acquired pneumonia, and in 67 cases a causal diagnosis was made. Most episodes were late-onset pneumonia. Gram-negative micro-organisms were isolated in 51% of episodes diagnosed, and Pseudomonas aeruginosa was the most frequent pathogen isolated (24%). Clearly significant variations happened between hospitals, particularly affecting the incidence of Aspergillus spp. and Legionella pneumophila. Forty-nine patients developed septic shock (51%). Fifty-one patients died (53%). Aspergillosis and pneumonia due to P. aeruginosa were associated with the highest mortality. Septic shock (OR: 14.27) and chronic obstructive pulmonary disease (OR: 6.11) were independently associated with a poor prognosis. CONCLUSIONS: Patients with severe hospital-acquired pneumonia admitted to the ICU present high mortality. The presence of septic shock and chronic obstructive pulmonary disease in conjunction with specific microorganisms are associated with a poor prognosis. Local epidemiological data combined with a patient-based approach may allow a more accurate therapy decision making.

Epidemiology, antibiotic therapy and clinical outcomes of healthcare-associated pneumonia in critically ill patients: a Spanish cohort study.

PURPOSE: Information about healthcare-associated pneumonia (HCAP) in critically ill patients is scarce. METHODS: This prospective study compared clinical presentation, outcomes, microbial etiology, and treatment of HCAP, community-acquired pneumonia (CAP), and immunocompromised patients (ICP) with severe pneumonia admitted to 34 Spanish ICUs. RESULTS: A total of 726 patients with pneumonia (449 CAP, 133 HCAP, and 144 ICP) were recruited during 1 year from April 2011. HCAP patients had more comorbidities and worse clinical status (Barthel score). HCAP and ICP patients needed mechanical ventilation and tracheotomy more frequently than CAP patients. Streptococcus pneumoniae was the most frequent pathogen in all three groups (CAP, 34.2 %; HCAP, 19.5 %; ICP, 23.4 %; p = 0.001). The overall incidence of Gram-negative pathogens, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa was low, but higher in HCAP and ICP patients than CAP. Empirical treatment was in line with CAP guidelines in 73.5 % of patients with CAP, in 45.5 % of those with HCAP, and in 40 % of those with ICP. The incidence of inappropriate empirical antibiotic therapy was 6.5 % in CAP, 14.4 % in HCAP, and 21.8 % in ICP (p < 0.001). Mortality was highest in ICP (38.6 %) and did not differ between CAP (18.4 %) and HCAP (21.2 %). CONCLUSIONS: HCAP accounts for one-fifth of cases of severe pneumonia in patients admitted to Spanish ICUs. The empirical antibiotic therapy recommended for CAP would be appropriate for 90 % of patients with HCAP in our population, and consequently the decision to include coverage of multidrug-resistant pathogens for HCAP should be cautiously judged in order to prevent the overuse of antimicrobials.

Discrepancy between clinical criteria for diagnosing acute respiratory distress syndrome secondary to community acquired pneumonia with autopsy findings of diffuse alveolar damage.

Diffuse alveolar damage (DAD) is the underlying pathological finding in most cases of acute respiratory distress syndrome (ARDS). The objective of this study was to compare clinical criteria for ARDS secondary to community acquired pneumonia with autopsy findings of DAD and to determine the discrepancy rate between the two. We compared prospectively obtained clinical diagnosis of ARDS secondary to community acquired pneumonia with autopsy findings of DAD and pneumonia. Forty nine patients dead with a clinical diagnosis of ARDS secondary to pneumonia who underwent autopsy between 1986 and 2004 in our ICU were included with systematic histopathological analysis of all lung lobes. The discrepancy rate between the premortem clinical diagnosis of ARDS secondary to pneumonia and DAD at autopsy was determined. Seven patients were found to have neither infection nor DAD at autopsy. Six patients showed pathologic signs of DAD without evidence of infection. Out of 38 patients meeting clinical criteria for ARDS secondary to pneumonia and proven pneumonia at autopsy, 25 met criteria for DAD at autopsy. Therefore, 18 out of 49 patients who were clinically diagnosed with ARDS did not actually show pathological signs of DAD, resulting in a discrepancy rate of 37%. Despite an acceptable correspondence between clinical criteria for ARDS secondary to pneumonia and autopsy findings of DAD a significant number of patients had neither signs of DAD nor infection.

[Serious postoperative complications after esophagectomy for esophageal carcinoma: analysis of risk factors]. / Complicaciones postoperatorias graves tras esofagectomía para carcinoma esofágico: análisis de factores de riesgo.

INTRODUCTION: To identify risk factors for postoperative morbidity and mortality in patients undergoing esophagectomy for esophageal cancer. DESIGN AND PATIENTS: The population comprised 159 patients with locally advanced esophageal cancer, undergoing esophagectomy between January 1985 and December 2004. RESULTS: Infections were the main cause of both complications and postoperative mortality. The 54% of our patients presented serious complications. The mortality of the series was 12.5%. Multiorganic failure secondary to sepsis was the more frequent cause of death. The postoperative complications showed a significant association with: alcoholism (p < 0.04), hepatic cirrhosis (p < 0.03), the location of the tumor in middle third of the esophagus (p < 0.04), and the APACHE II score greater of 10 (p < 0.003). Mortality was associated significantly with the presence of chronic pulmonary disease (p = 0,03) and with an APACHE II score superior to 10 (p = 0,02). CONCLUSIONS: The APACHE II score superior to 10 can be used so much as prognostic factor of mortality like of serious complications. Chronic obstructive pulmonary disease is a risk factor for postoperative mortality. Alcoholism, hepatic cirrhosis and the location of the tumor, are factors associated to postoperative serious complications.