Human cytomegalovirus seropositivity is associated with reduced patient survival during sepsis.

BACKGROUND: Sepsis is one of the leading causes of death. Treatment attempts targeting the immune response regularly fail in clinical trials. As HCMV latency can modulate the immune response and changes the immune cell composition, we hypothesized that HCMV serostatus affects mortality in sepsis patients. METHODS: We determined the HCMV serostatus (i.e., latency) of 410 prospectively enrolled patients of the multicenter SepsisDataNet.NRW study. Patients were recruited according to the SEPSIS-3 criteria and clinical data were recorded in an observational approach. We quantified 13 cytokines at Days 1, 4, and 8 after enrollment. Proteomics data were analyzed from the plasma samples of 171 patients. RESULTS: The 30-day mortality was higher in HCMV-seropositive patients than in seronegative sepsis patients (38% vs. 25%, respectively; p = 0.008; HR, 1.656; 95% CI 1.135-2.417). This effect was observed independent of age (p = 0.010; HR, 1.673; 95% CI 1.131-2.477). The predictive value on the outcome of the increased concentrations of IL-6 was present only in the seropositive cohort (30-day mortality, 63% vs. 24%; HR 3.250; 95% CI 2.075-5.090; p < 0.001) with no significant differences in serum concentrations of IL-6 between the two groups. Procalcitonin and IL-10 exhibited the same behavior and were predictive of the outcome only in HCMV-seropositive patients. CONCLUSION: We suggest that the predictive value of inflammation-associated biomarkers should be re-evaluated with regard to the HCMV serostatus. Targeting HCMV latency might open a new approach to selecting suitable patients for individualized treatment in sepsis.

Comparison of forces acting on maxillary incisors during tracheal intubation with different laryngoscopy techniques: a blinded manikin study.

Dental trauma is a common complication of tracheal intubation. As existing evidence is insufficient to validly assess the impact of different laryngoscopy techniques on the incidence of dental trauma, the force exerted onto dental structures during tracheal intubation was investigated. An intubation manikin was equipped with hidden force sensors in all maxillary incisors. Dental force was measured while 104 anaesthetists performed a series of tracheal intubations using direct laryngoscopy with a Macintosh blade, and videolaryngoscopy with a C-MAC® , or the hyperangulated GlideScope® or KingVision® laryngoscopes in both normal and difficult airway conditions. A total of 624 tracheal intubations were analysed. The median (IQR [range]) peak force of direct laryngoscopy in normal airways was 21.1 (14.0-32.8 [2.3-127.6]) N and 29.3 (17.7-44.8 [3.3-97.2]) N in difficult airways. In normal airways, these were lower with the GlideScope and KingVision hyperangulated laryngoscopes, with a reduction of 4.6 N (p = 0.006) and 10.9 N (p < 0.001) compared with direct laryngoscopy, respectively. In difficult airways, these were lower with the GlideScope and KingVision hyperangulated laryngoscopes, with a reduction of 9.8 N (p < 0.001) and 17.6 N (p < 0.001) compared with direct laryngoscopy, respectively. The use of the C-MAC did not have an impact on the median peak force. Although sex of anaesthetists did not affect peak force, more experienced anaesthetists generated a higher peak force than less experienced providers. We conclude that hyperangulated videolaryngoscopy was associated with a significantly decreased force exerted on maxillary incisors and might reduce the risk for dental injury in clinical settings.

[Anesthesia problem cards-indispensable yet problematic : Nationwide survey on experiences from clinical practice]. / Der Anästhesieausweis ­ unverzichtbar, aber problematisch : Deutschlandweite Umfrage zu Erfahrungen aus der klinischen Anwendung.

BACKGROUND: Anesthetic procedures may lead to severe and potentially life-threatening complications (e. g. difficult airway, allergic reactions, malignant hyperthermia). Most complications can be avoided in future anesthetic procedures with adequate preparation (e. g. awake intubation, trigger-free anesthesia). In Germany, anesthesia problem cards were introduced two decades ago to identify patients at risk and to increase patient safety by creating a standardized documentation system for anesthesia-related complications. The purpose of our study was to evaluate the utility and problems of anesthesia problem cards in clinical practice. MATERIAL AND METHODS: All registered members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Professional Association of German Anesthesiologists (BDA) (n = 19,042) were invited to participate in an online survey on patient safety. A subsection of the survey focused specifically on anesthesia problem cards and their utility in clinical practice (e. g. field of application, issuing procedures, benefits and problems). RESULTS: The survey subsection on anesthesia problem cards was completed by 1783 participants. Most agreed that anesthesia problem cards are a useful tool to increase patient safety (n = 1502; 84.2%) and that they are routinely issued after the occurrence of anesthesia-related complications (n = 1664, 93.4%). One of the major problems noted was that patients frequently forget to bring their anesthesia problem cards when presenting for the preanesthetic assessment. This was observed by 1457 participants (81.7%). Furthermore, the information provided on anesthesia problem cards may be inadequately phrased (n = 874; 49.0%) or illegible (n = 833; 46.7%). In addition, the space for individual comments or problem solutions is insufficient (n = 811; 45.5%). Replacements for lost anesthesia problem cards with identical informational content can be issued in only 41.9% (n = 747) of the participants' departments. CONCLUSION: Anesthesia problem cards are considered a useful tool to increase patient safety and are frequently issued in clinical practice; however, in the document's current form its full potential for risk minimization cannot be exploited. Structural changes are required to increase documentation quality and reproducibility. Concerning its informational content, the spectrum of included complications and their individual solutions need to be expanded to meet the requirements of modern anesthetic practice.

[A Germany-wide survey on anaesthesia in thoracic surgery]. / Deutschlandweite Umfrage zur Thoraxanästhesie.

BACKGROUND/OBJECTIVE: This study's objective was to evaluate current thoracic anaesthesia practice in Germany and to quantify potential differences depending on the hospital's level of care. MATERIALS AND METHODS: A four-part online survey containing 28 questions was mailed to all anaesthesiology department chairs (n = 777) registered with the German Society of Anaesthesiology and Intensive Care Medicine. RESULTS: The general response rate was 31.5 % (n = 245). High monthly volumes (>50 operations/month) of intrathoracic procedures, performed by specialized thoracic surgeons are mostly limited to hospitals of maximum care, university hospitals, and specialized thoracic clinics. In hospitals with a lower level of care, intrathoracic operations occur less frequently (1-5/month) and are commonly performed by general (69.3 %) rather than thoracic surgeons (15.4 %). Video-assisted thoracic surgeries are the most invasive intrathoracic procedures for most hospitals with a low level of care (61.5 %). Extended resections and pneumonectomies occur mainly in hospitals of maximum care and university hospitals. Thoracic anaesthesia is primarily performed by consultants or senior physicians (59.9 %). The double lumen tube (91.4 %) is the preferred method to enable one-lung ventilation (bronchial blockers: 2.7 %; missing answer: 5.9 %). A bronchoscopic confirmation of the correct placement of a double lumen tube is considered mandatory by 87.7 % of the respondents. Bronchial blockers are available in 64.7 % of all thoracic anaesthesia departments. While CPAP-valves for the deflated lung are commonly used (74.9 %), jet-ventilators are rarely accessible, especially in hospitals with a lower level of care (15.4 %). Although general algorithms for a difficult airway are widely available (87.7 %), specific recommendations for a difficult airway in thoracic anaesthesia are uncommon (4.8 %). Laryngeal mask airways (90.9 %) and videolaryngoscopy (88.8 %) are the primary adjuncts in store for a difficult airway. While hospitals with a lower level of care admitted patients routinely (92.3 %) to an intensive care unit after thoracic surgery, larger clinics used the postanaesthesia recovery room (12.5 %) and intermediate care units (14.6 %) more frequently for further surveillance. Thoracic epidural catheters (85.6 %) are predominantly chosen for peri- and postoperative analgesia, in contrast to paravertebral blockade (single shot: 8.6 %; catheter: 8.0 %) (multiple answers possible). Ultrasound is generally accessible (84.5 %) and mostly employed for the placement of central venous (81.3 %) and arterial (43.9 %) lines as well as a diagnostic tool for pulmonary pathology (62.0 %). CONCLUSION: The study reveals considerable differences in the anaesthetic practice in thoracic surgery. These focus mostly on the postoperative surveillance, the availability of bronchial blockers, and the use of regional anaesthetic techniques. Furthermore, it is evident that specific algorithms are needed for the difficult airway in thoracic anaesthesia. A recommendation for the high-tech work environment of thoracic anaesthesia could enhance the structural quality and optimize patient outcomes. Independent of a hospital's level of care, uniform requirements could help establish national quality standards in thoracic anaesthesia.

[Preoperative risk evaluation of adult patients prior to elective non-cardiac surgery: follow-up survey of the recommendations published in 2010]. / Präoperative Risikoevaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen: Follow-up-Umfrage zu den 2010 publizierten Empfehlungen.

BACKGROUND: The joint recommendations of the German Societies of Anaesthesiology and Intensive Care Medicine, Surgery and Internal Medicine on preoperative evaluation of adult patients prior to elective, non-cardiac surgery published in November 2010 were the first practical and comprehensive guidelines for preoperative evaluation available to anesthetists in Germany. AIM: This study was carried out to analyze the state of implementation of these guidelines into clinical practice as well as changes in strategies for assessing perioperative risk from the viewpoint of anesthesia personnel in Germany. MATERIAL AND METHODS: A 25-item questionnaire concerning general characteristics of workplaces, cognizance, reasonability and convenience of the joint recommendations was developed as an online survey. Furthermore, changes in strategies for preoperative evaluation were polled. RESULTS: A total of 1,840 anesthetists completed the questionnaire. The results showed that 84.2 % were acquainted with the joint recommendations, 57.3 % evaluated them as completely reasonable and 18.2 % as partly reasonable. A total of 71.4 % indicated that the joint recommendations were implemented completely or partly in their department strategies for preoperative evaluation. From the viewpoint of personnel, anamnesis and physical examination were performed more frequently by 25.7 % while routine diagnostic testing was ordered less frequently by 39.1 %. Advantages by implementing the joint recommendations (e.g. simplification for medical staff and patients, decrease of costs, reduction of radiological examinations) were seen by 45.5 %. Problems, such as increasing expenditure of time and personnel due to implementation were mentioned by 20.3 %. CONCLUSION: The joint recommendations are well known and positively rated among anesthetists in Germany responding to the questionnaire reflecting an effective implementation process over the last 2 years. The anesthetists who completed the questionnaire stated that the use of the recommendations leads to a more reasonable approach in preoperative risk evaluation which contributes to an increase in patient safety and satisfaction.

Non-invasive continuous arterial pressure monitoring with Nexfin does not sufficiently replace invasive measurements in critically ill patients.

BACKGROUND: In this study, we tested the reliability of a non-invasive finger-cuff-based continuous arterial blood pressure monitoring device (Nexfin, BMEYE, Amsterdam, NL) in critically ill surgical patients. METHODS: Invasive intra-arterial and non-invasive arterial pressure measurements from 25 patients during a 4-h period were compared at five time points. Correlation and linear regression analysis were used and mean bias, precision [sd of bias] and limits of agreement (LOA) [bias (2.0 sd)] were calculated using the Bland-Altman method. RESULTS: Eight data pairs were excluded because of error message from the non-invasive technique, and thus a total of 117 data pairs were analysed. Overall, correlation between mean arterial pressure (MAP) was r(2)=0.50. Bias, precision, and LOA between invasive and non-invasive MAP were 6 (12) and -18 to +30 mm Hg. In patients requiring norepinephrine (83 data pairs), correlation was r(2)=0.28 and bias, precision, and LOA were 6 (13) and -20 to +32 mm Hg, whereas in patients not receiving norepinephrine (34 data pairs) r(2) was 0.80 and mean bias, precision, and LOA were 6 (11) and -16 to +28 mm Hg. In patients with peripheral oedema (49 data pairs), r(2) was 0.40 and mean bias, precision and LOA were 7 (15) and -23 to +37 mm Hg. In patients without oedema (64 data pairs), r(2) was 0.66 and mean bias, precision, and LOA were 5 (9) and -13 to +23 mm Hg. CONCLUSIONS: Non-invasive blood pressure monitoring with Nexfin does not seem to be sufficiently accurate to replace intra-arterial invasive blood pressure measurements in critically ill patients.

[Preoperative risk evaluation of adult patients for elective, noncardiac surgical interventions. Results of an on-line survey on the status in Germany]. / Präoperative Risikoevaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen. Ergebnisse einer Onlinebefragung zum Status in Deutschland.

BACKGROUND: While assessing the medical history and physical examination are the cornerstones of preoperative risk evaluation, the importance of "routine" testing has been critically discussed in recent studies. The joint recommendations of the German Societies of Anaesthesiology and Intensive Care Medicine, Surgery and Internal Medicine for preoperative evaluation of adult patients prior to elective, non-cardiac surgery, which were published in November 2010, are the first comprehensive practice guidelines for preoperative evaluation in Germany. Aim of this study was to analyze former strategies for assessing perioperative risk at anaesthesia departments in Germany. METHODS: A 29-item questionnaire concerning general hospital characteristics, strategies for preoperative evaluation and cognizance of the joint recommendations was developed as an online survey. In particular the reasons for technical assessment were surveyed (i.e. routine, patient age or pre-existing conditions, risk of operation being performed). In certain questions multiple answers were permitted. All hospitals with departments of anaesthesiology in Germany were included. Data are presented as percentages. RESULTS: A total of 396 hospitals (35.6%) completed the questionnaire. Physical examination is not performed regularly (37%) but only when indicated by the medical history. Criteria for performing preoperative electrocardiograms are comorbidities of the cardiovascular (80.1%) and pulmonary systems (42.2%) as well as patient age (52.8%) and as routine measures (10.1%). Laboratory testing was performed as a routine (43.2%) because of patient age (52.8%) or pre-existing conditions (37.3%). Preoperative chest x-ray was carried out when the medical history or physical examination suggest intrathoracic pathologies (81.3%) or was based on patient age (35.9%). The majority of hospitals (89.1%) plan to implement the joint recommendations for preoperative evaluation in the future. CONCLUSION: According to the joint recommendations preoperative testing is more and more directed to patients with an increased perioperative risk which is clinically indicated by medical history and physical examination. However, routine or age-related medical testing is still a frequently used strategy. German medical societies should focus on advanced implementation strategies to change current practices in order to avoid unnecessary diagnostic procedures and to increase patient safety and satisfaction.

[Current approaches to anesthetic management in thoracic surgery-An evaluation from the German Thoracic Registry]. / Anästhesiologisches Management bei operativen Eingriffen am Thorax ­ eine Auswertung aus dem Deutschen Thoraxregister.

BACKGROUND: While many hospitals in Germany perform thoracic surgery, anesthetic techniques and methods that are actually used are usually only known for individual departments. This study describes the general anesthetic management of three typical thoracic surgical procedures across multiple institutions. MATERIAL AND METHODS: The German Thoracic Registry recorded 4614 patients in 5 institutions between 2016 and 2019. Hospitals with a minimum number of more than 50 thoracic procedures per year are eligible for inclusion in the registry. To analyze the anesthetic management, a matching process yielded three comparable patient groups (n = 1506) that differed solely in the surgical procedure. Three surgical procedures with varying degrees of invasiveness were selected: Group A = video-assisted thoracoscopic surgery (VATS) with wedge resection, group B = VATS with lobectomy, group C = open thoracotomy. Statistical analysis was performed descriptively using relative and absolute frequencies. Dichotomous variables were compared using the χ2-test. RESULTS: The study enrolled patients with a median age of 65.6 years. The mean value of the American Society of Anesthesiologists (ASA) classification was 2.8. One lung ventilation was most commonly performed (group A = 98.2%, group B = 99.4%, group C = 98.0%) with double lumen tubes (DLT). Bronchial blockers (group A = 0.2%, group B = 0.4%, group C = 0%) were rarely used. Primary bronchoscopy was used to control double lumen tubes after insertion in the majority of cases (group A = 77.5%, group B = 73.1%, group C= 79.7%). Continuous positive airway pressure (CPAP, group A = 1.2%, group B = 1.4%, group C = 5.1%) and jet ventilation (group A = 1.6%, group B = 1.6%, group C = 1.4%) were rarely used intraoperatively. In group C, the administration of a vasopressor was also more frequently required (group A = 59.9%, group B = 77.8%, group C = 86%). A central venous catheter was established in 30.1% of all patients in group A, 39.8% in group B and 73.3% in group C. Patients in group A received an arterial catheter less frequently (71.7%) when compared to groups B (96.4%) and C (95.2%). Total intravenous anesthesia with propofol was used in most patients (group A = 67.7%, group B 61.6%, group C 75.7%). Propofol supplemented by volatile anesthetics was used less frequently (group A = 28.5%, group B = 35.5%, group C = 23.7%). With increasing invasiveness of the surgical procedure, placement of an epidural catheter was preferred (group A = 18.9%, group B = 29.5%, group C = 64.1%). Paravertebral catheters (group A = 7.6%, group B = 4.4%, group C = 4.8%) or a single infiltration of the paravertebral space were performed less frequently (group A = 7.8%, group B = 17.7%, group C = 11.6%). Postoperatively, some patients (3.4-25.7%) were transferred to the general ward. The largest proportion of patients transferred to a general ward underwent less invasive thoracic procedures (group A). When the extent of resection was greater (group B and group C) patients were mostly transferred to an intermediate care unit (IMC) or an intensive care unit (ICU). The insertion of invasive catheters was neither associated with the patients' ASA classification nor preoperative pathologic pulmonary function. CONCLUSION: Our data indicate that less invasive thoracic operations are associated with a reduction of invasive anesthetic procedures. As the presented data are descriptive, further studies are required to determine the impact of invasive anesthetic procedures on patient-related outcomes. This evaluation of the anesthetic management in experienced thoracic anesthesiology departments represents the next step towards establishing national quality standards and promoting structural quality in thoracic anesthesia.

[On the safe side? Safety culture and patient safety in German anesthesiology clinics-A nationwide survey on the status quo]. / Auf Nummer sicher? Sicherheitskultur und Patientensicherheit an deutschen anästhesiologischen Kliniken ­ Eine deutschlandweite Umfrage zum Status quo.

BACKGROUND: A good safety culture may be predominantly defined by an open and unsanctioned communication about critical and erroneous courses. In an effort to improve patient safety various instruments, such as the critical incident reporting system (CIRS) or in terms of patient handover, the use of the situation, background, assessment, recommendation (SBAR) system patient handover, have been developed and are recommended by the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). This study aimed at identifying how anesthesiologists perceive the safety culture in their current department and whether CIRS or SBAR are already established or not. MATERIAL AND METHODS: All registered members of the DGAI and the Professional Association of German Anaesthesiologists (BDA, n = 19,042) were invited to participate in an online survey on patient safety. In this survey there was a focus on the perceived safety culture and the experience with CIRS and SBAR. RESULTS: Of the participants 76.6% (n = 1372) stated that their department of anesthesiology has a good safety culture, while in 23.4% (n = 419) there was not. For the whole hospital the safety culture was only rated as being positive by 54.3% (n = 949) of the respondents. An open communication about critical and erroneous courses occurred in 76.5% (n = 1375) according to the participants, 23.0% (n = 408) had the impression that in the case of errors the respective person was being denounced. In one third of the participants' departments (n = 630, 36.6%) there were no morbidity and mortality conferences. The acronym CIRS was familiar to 98.9% (n = 1801) of the participants, 84.8% (n = 1544) of the surveyed anesthesiologists reported that CIRS was established in their departments. Critical incidents have been reported via CIRS by 54.4% (n = 839) of the respondents. Only 29.4% (n = 462) of the participants received regular feedback on CIRS reports. The acronym SBAR as a handover tool is unknown to the majority of the surveyed participants (n = 1181, 63.7%) and 86.1% (n = 1554) consider using an instrument in order to improve handover quality as possibly being beneficial. CONCLUSION: Anesthesiologists rate the quality of the safety culture of their own anesthesiology department to be higher compared to their hospital in general. In some hospitals there is denouncement in cases of erroneous courses according to the respondents. In the patients' point of view morbidity and mortality conferences should be established more often. CIRS is known to almost every surveyed anesthetist but feedback on a regular basis is sparse. This contradicts the claims of the German Coalition for Patient Safety. The acronym SBAR is unknown to the majority of surveyed participants despite the recommendation of the DGAI to implement it. There is a wish for tools in order to enhance the quality of handovers.

[Continuous lateral rotational bed therapy in patients with traumatic lung injury: an analysis from the TraumaRegister DGU®]. / Die kontinuierliche laterale Rotationstherapie bei Patienten mit Thoraxtrauma: eine Analyse aus dem TraumaRegister DGU®.

BACKGROUND: Patients with severe thoracic trauma often receive continuous lateral rotational bed therapy (CLRT) for the treatment of lung contusions. In this study, the effects of CLRT on mortality, morbidity and length of stay (LOS) in the intensive care unit (ICU) and in the hospital were evaluated. METHODS: Retrospective data from the TraumaRegister DGU® were analysed, focusing on patients with severe thoracic trauma. Patients treated with CLRT were compared to a control group with comparable trauma severity who had received conventional therapy. RESULTS: A total of 1476 patients (239 with CLRT, 1237 without CLRT) were included in this study. Both groups were similar for demographic characteristics. The median CLRT duration was 6 (4-10) days. Patients receiving CLRT were ventilated for 17 (10-26) days compared to 14 (8-22) days (p = 0.001) in the control group. The ICU length of stay differed significantly (CLRT: 23 [14-32] days; control: 19 [13-28] days; p = 0.002). Also, organ failure occurred more frequently in patients treated with CLRT (CLRT: 76.6%, control: 67.6%; p = 0.006). No differences could be detected regarding mortality rates, multiple organ failure and hospital LOS. CONCLUSIONS: The results of this retrospective analysis fail to detect a benefit for CLRT therapy in trauma patients. Considering inherent limitations of retrospective studies, caution should be exerted when interpreting these results. Further research is warranted to confirm these findings in a prospective trial.

Comparison of PulsioFlex® uncalibrated pulse contour method and a modified Fick principle with transpulmonary thermodilution measurements in critically ill patients.

Monitoring of cardiac index (CI) by uncalibrated pulse contour (PC) methods has been shown to be inaccurate in critically ill patients. We tested accuracy and trending of a new pulse contour method and a modified Fick method using central venous oxygen saturation. We studied 21 critically ill and mechanically ventilated patients (age 20-86 years) monitored by PC (PulsioFlex®) and transpulmonary thermodilution (TPTD, PiCCO2®) as reference. At baseline, reference and PC-derived CI (CIPC) were recorded and CI obtained by Fick's method (FM, CIFICK). After four hours, measurements were performed analogously for trending analysis. CI are given in l/min/m2 as mean±standard deviation. At baseline CITPTD was 3.7±0.7, CIPC 3.8±0.7 and CIFICK 5.2±1.8. After 4 hours, CITPTD was 3.5±0.6, CIPC 3.8±1.2 and CIFICK 4.8±1.7. Mean bias for PC at baseline was -0.1 (limits of agreement [LOA] -1.4 to 1.2) and -0.4 (LOA -2.6 to 1.9) after four hours. Percentage errors (PE) were 34% and 60% respectively. FM revealed a bias of -1.5 (LOA -4.8 to 1.8, PE 74%) at baseline and -1.5 (LOA -4.5 to 1.4, PE 68%) at four hours. With an exclusion window of 10% of mean cardiac index, trending analysis by polar plots showed an angular bias of 5° (radial LOA±57°) for PC and 16° (radial LOA±51°) for FM. Although PC values at baseline were marginally acceptable, both methods fail to yield clinically acceptable absolute values. Likewise, trending ability is not adequate for both methods to be used in critically ill patients.

Usefulness of broad-range PCR plus sequencing for the diagnosis of bacteremia due to a lung abscess.

The early detection and treatment of sepsis in patients is essential for a positive outcome. Microbiological analysis of blood cultures, as the gold standard for diagnosis, is rather slow. However, more rapid methods like PCR have become available recently and are being evaluated clinically. We present data from the monitoring of a patient with sepsis who was on anti-infective treatment. The patient was positive for Streptococcus pneumoniae by broad-range PCR and sequence analysis in a blood sample and resected lung tissue specimen, the latter embedded in paraffin, while blood culture diagnostics remained negative.

Severe sepsis caused by a linezolid-resistant Enterococcus faecium in a 10-year-old girl after multiple trauma.

While infections caused by Enterococcus faecium resistant to vancomycin (VRE) are increasing, linezolid-resistant strains are still rare. We present the case of a 10-year-old girl with severe sepsis caused by a linezolid-resistant E. faecium (Van-B VRE) after multiple trauma and right-sided hemipelvectomy. The off-label use of a targeted antimicrobial therapy with daptomycin (350 mg/day; approximately 8 mg/kg) for 17 days resulted in rapid normalization of infection parameters and improved clinical status. No side effects were observed and the patient was successfully discharged from the intensive care unit.