[Update of the recommendations of the Pneumonia Zero project]. / Actualización de las recomendaciones del proyecto Neumonía Zero.

The SARS-Cov-2 pandemic has had a negative impact on the implementation of the Zero Pneumonia recommendations and has been accompanied by an increase in rates of ventilator- associated pneumonia (VAP) in intensive care units in Spain. With the aim of reducing the current rates to 7 episodes per 1000 days of MV, the recommendations of the initial project have been updated.Twenty-seven measures were identified and classified into 12 functional measures (semi- sitting position, strict hand hygiene, airway manipulation training, daily assessment of possible extubation, protocolisation of weaning, early tracheostomy, non-invasive ventilation, microbiological surveillance, tubing change, humidification, respiratory physiotherapy, post- pyloric enteral nutrition), 7 mechanical measures (pneumotap pressure control, subglottic suction tubes, subglottic suctioning of tubes, subglottic suctioning of tubes, post-pyloric enteral nutrition, subglottic suction tubes, small-bore/small-bowel tube nutrition, closed/open circuit secretion suctioning, respiratory filters, tooth brushing, negative pressure techniques for secretion suctioning) and 8 pharmacological (selective digestive decontamination, oropharyngeal decontamination, short course of antibiotics, chlorhexidine mouth hygiene, inhaled antibiotics, antibiotic rotation, probiotics, monoclonal antibodies).Each measure was analysed independently, by at least two members of the working group, through a systematic review of the literature and an iterative review of recommendations from scientific societies and/or expert groups.For the classification of the quality of the evidence and strength of the recommendations, the GRADE group proposal was followed. To determine the level of recommendation, each measure was scored by all members of the working group in relation to its effectiveness, tolerability and applicability in Spanish ICUs in the short term. The support of external experts was requested for some of the measures reviewed. Those measures that achieved the highest score were selected.

[Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units]. / Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

Ventilator-associated pneumonia by methicillin-susceptible Staphylococcus aureus: do minimum inhibitory concentrations to vancomycin and daptomycin matter?

The use of vancomycin minimum inhibitory concentration (MIC) as an outcome predictor in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia has become an important topic for debate in the last few years. Given these previous results, we decided to investigate whether MICs to vancomycin or daptomycin had any effect on the evolution of patients with ventilator-associated pneumonia (VAP) due to MSSA. An observational, retrospective, multicenter study was conducted among patients with MSSA VAP. We analyzed the relationship between vancomycin and daptomycin MICs and early clinical response (72 h), 30-day mortality, intensive care unit (ICU) length of stay (LOS), and duration on mechanical ventilation. Univariate and multivariate analyses were performed. Sixty-six patients from 12 centers were included. Twenty-six patients (39%) had an infection due to MSSA strains with a vancomycin MIC ≥1.5 µg/mL. Daptomycin MIC was determined in 58 patients, of whom 17 (29%) had an MIC ≥1.0 µg/mL. Ten patients (15%) did not respond to first-line treatment. Only daptomycin MIC ≥1.0 µg/mL had a significant association [odds ratio (OR): 30.00; 95% confidence interval (CI): 2.91-60.41] with early treatment failure. The 30-day mortality was 12% (n = 8). Any variable was associated with mortality in the multivariate analysis. None of the variables studied were associated with ICU LOS or duration on mechanical ventilation. In patients with MSSA VAP, vancomycin MIC does not influence the response to antibiotic treatment or the 30-day mortality. Daptomycin MIC was directly related to early treatment failure.

Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

Skin antisepsis in invasive procedures. / Antisepsia cutánea en los procedimientos invasivos.

Skin antisepsis in invasive procedures aims to reduce the bacterial load at the site of incision or puncture. Alcohol solutions seem to be more effective in preventing surgical site infection. From the safety point of view there is the potential risk of ignition when using alcohol solutions. Given the potential neurotoxicity of alcohol and chlorhexidine gluconate, contact of antiseptic solutions with the central nervous system should be avoided. This article is part of a supplement entitled "Antisepsis in the critical patient", which is sponsored by Becton Dickinson.

"Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients. / Recomendaciones de "no hacer" en el tratamiento de los pacientes críticos de los grupos de trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.