Mortality and morbidity attributable to inadequate empirical antimicrobial therapy in patients admitted to the ICU with sepsis: a matched cohort study.

OBJECTIVES: To determine the attributable mortality and excess length of stay (LOS) associated with the use of inadequate empirical antimicrobial therapy in patients with sepsis at admission to the intensive care unit (ICU). METHODS: A retrospective matched cohort study was performed using a prospectively collected database at a 40 bed general ICU at a university public hospital. Patients who received inadequate antimicrobial therapy at admission to the ICU (exposed) were matched with controls (unexposed) on the basis of origin of sepsis, inflammatory response at admission, surgical or medical status, hospital- or community-acquired sepsis, APACHE II score (+/-2 points) and age (+/-10 years). Clinical outcome was assessed by in-hospital mortality, and this analysis was also performed in those pairs without nosocomial infection in the ICU. RESULTS: Eighty-seven pairs were successfully matched. Fifty-nine exposed patients died [67.8% mortality (95% CI, 58.0-77.6%)] and 25 unexposed controls died [28.7% mortality (95% CI, 19.2-38.2%)] (P < 0.001). Excess in-hospital mortality was estimated to be 39.1%. The rate of nosocomial infection was significantly higher in patients with inadequate empirical therapy (16.1%) than in those treated empirically with adequate antibiotics (3.4%) (P = 0.013). Excess in-hospital mortality was 31.4% after excluding those 17 pairs that developed a nosocomial infection in the ICU. Inadequate antimicrobial therapy was associated with a significant increment in duration of hospitalization (15 days in surviving pairs). CONCLUSIONS: Inadequate antimicrobial therapy at admission to the ICU with sepsis is associated with excess mortality and increases LOS.

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.

Timing of adequate antibiotic therapy is a greater determinant of outcome than are TNF and IL-10 polymorphisms in patients with sepsis.

INTRODUCTION: Genetic variations may influence clinical outcomes in patients with sepsis. The present study was conducted to evaluate the impact on mortality of three polymorphisms after adjusting for confounding variables, and to assess the factors involved in progression of the inflammatory response in septic patients. METHOD: The inception cohort study included all Caucasian adults admitted to the hospital with sepsis. Sepsis severity, microbiological information and clinical variables were recorded. Three polymorphisms were identified in all patients by PCR: the tumour necrosis factor (TNF)-alpha 308 promoter polymorphism; the polymorphism in the first intron of the TNF-beta gene; and the IL-10-1082 promoter polymorphism. Patients included in the study were followed up for 90 days after hospital admission. RESULTS: A group of 224 patients was enrolled in the present study. We did not find a significant association among any of the three polymorphisms and mortality or worsening inflammatory response. By multivariate logistic regression analysis, only two factors were independently associated with mortality, namely Acute Physiology and Chronic Health Evaluation (APACHE) II score and delayed initiation of adequate antibiotic therapy. In septic shock patients (n = 114), the delay in initiation of adequate antibiotic therapy was the only independent predictor of mortality. Risk factors for impairment in inflammatory response were APACHE II score, positive blood culture and delayed initiation of adequate antibiotic therapy. CONCLUSION: This study emphasizes that prompt and adequate antibiotic therapy is the cornerstone of therapy in sepsis. The three polymorphisms evaluated in the present study appear not to influence the outcome of patients admitted to the hospital with sepsis.

Acinetobacter baumannii ventilator-associated pneumonia: epidemiological and clinical findings.

OBJECTIVE: To investigate prognostic factors and predictors of Acinetobacter baumannii isolation in ventilator-associated pneumonia (VAP). We specifically analyzed these issues for imipenem-resistant episodes. DESIGN AND SETTING: All episodes of VAP are prospectively included in a database. Information about risk factors was retrieved retrospectively. PATIENTS: Eighty-one patients exhibiting microbiologically documented VAP: 41 by A. baumannii (26 by imipenem-resistant) and 40 by other pathogens. MEASUREMENTS AND RESULTS: The following variables were noted: underlying diseases, severity of illness, duration of mechanical ventilation and of hospitalization before VAP, prior episode of sepsis, previous antibiotic, corticosteroid use, type of nutrition, renal replacement therapy, reintubation, transportation out of the ICU, micro-organisms involved in VAP, concomitant bacteremia, clinical presentation, Sequential Organ Failure Assessment (SOFA) scale on the day of diagnosis, and adequacy of empirical antibiotic therapy. Prior antibiotic use was found to be associated with development of VAP by A. baumannii (OR 14). Prior imipenem exposure was associated with the isolation of imipenem-resistant strains (OR 4). SOFA score on the day of diagnosis was the only predictor of in-hospital mortality (OR 1.22); adequacy of empirical antibiotic therapy was a protective factor (OR 0.067). CONCLUSIONS: Our results confirm that prior exposure to antimicrobials is an independent predictor for the development of A. baumannii VAP, the prognosis of which is similar to that of infections caused by other pathogens. This study highlights the importance of initial antibiotic choice in VAP or whatever cause.

[Computed tomography as a tool to detect potential brain-dead donors]. / Utilidad de la tomografía computarizada como herramienta para detectar potenciales donantes en muerte encefálica.

BACKGROUND AND OBJECTIVE: To assess the ability of urgent head computed tomography (CT) scan screening to detect patients who can evolve to brain death (BD). PATIENTS AND METHOD: Patients who underwent urgent head CT scan and meet the following criteria: midline shift greater than 5mm and/or decrease or absence of basal cisterns. A follow-up for 28 days of each patient was made. Epidemiological data (sex, age, cause of brain injury), clinical data (level of consciousness, severity index in the CT) and patient outcomes (death, BD, discharge or transfer) were recorded. This was a prospective observational study. RESULTS: One hundred and sixty-six patients were selected for study, with mean age 60.08 (SD 21.8) years. A percentage of 49.4 were men and the rest women. In the follow-up, 20,5% (n=34) had BD. In univariate analysis, intracerebral hemorrhage, Glasgow Coma Scale score less than 8 and alteration of basal cisterns were statistically significant in predicting BD (P<.05). Multivariate analysis showed that patients with compression of basal cisterns were 20 (95% confidence interval [95% CI] 2.61 to 153.78; P=.004] times more likely to progress to brain death, while the absence there of 62.6 (95% CI 13.1 to 738.8; P<.001] times more. CONCLUSIONS: Our work shows that data as easy to interpret as compression/absence of basal cisterns can be a powerful tool for screening patients at risk for progression to BD.