A Nationwide, Prospective Study of Tracheal Intubation in Critically Ill Adults in Spain: Management, Associated Complications, and Outcomes.

OBJECTIVES: Our aims were to explore current intubation practices in Spanish ICUs to determine the incidence and risk factors of peri-intubation complications (primary outcome measure: major adverse events), the rate and factors associated with first-pass success, and their impact on mortality as well as the changes of the intubation procedure observed in the COVID-19 pandemic. DESIGN: Prospective, observational, and cohort study. SETTING: Forty-three Spanish ICU. PATIENTS: A total of 1837 critically ill adult patients undergoing tracheal intubation. The enrollment period was six months (selected by each center from April 16, 2019, to October 31, 2020). INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: At least one major adverse peri-intubation event occurred in 40.4 % of the patients (973 major adverse events were registered) the most frequent being hemodynamic instability (26.5%) and severe hypoxemia (20.3%). The multivariate analysis identified seven variables independently associated with a major adverse event whereas the use of neuromuscular blocking agents (NMBAs) was associated with reduced odds of major adverse events. Intubation on the first attempt was achieved in 70.8% of the patients. The use of videolaryngoscopy at the first attempt was the only protective factor (odds ratio 0.43; 95% CI, 0.28-0.66; p < 0.001) for first-attempt intubation failure. During the COVID-19 pandemic, the use of videolaryngoscopy and NMBAs increased significantly. The occurrence of a major peri-intubation event was an independent risk factor for 28-day mortality. Cardiovascular collapse also posed a serious threat, constituting an independent predictor of death. CONCLUSIONS: A major adverse event occurred in up to 40% of the adults intubated in the ICU. Peri-intubation hemodynamic instability but not severe hypoxemia was identified as an independent predictor of death. The use of NMBAs was a protective factor for major adverse events, whereas the use of videolaringoscopy increases the first-pass success rate of intubation. Intubation practices changed during the COVID-19 pandemic.

Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort.

BACKGROUND: Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster. METHODS: Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3. RESULTS: Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3. CONCLUSIONS: During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis.

Fungal infections in immunocompromised critically ill patients.

Diverse pathogenic fungi can produce severe infections in immunocompromised patients, thereby justifying intensive care unit (ICU) admissions. In some cases, the infections can develop in immunocompromised patients who were previously admitted to the ICU. Aspergillus spp., Pneumocystis jirovecii, Candida spp., and Mucorales are the fungi that are most frequently involved in these infections. Diagnosis continues to be challenging because symptoms and signs are unspecific. Herein, we provide an in-depth review about the diagnosis, with emphasis on recent advances, and treatment of these invasive fungal infections in the ICU setting.

Clinical outcomes in combination versus mono antibiotic therapy in ICU admitted patients with a suspected infection - A substudy of the DIANA study.

PURPOSE: In a retrospective cohort study of intensive care unit (ICU) admitted adult patients with suspected or confirmed infection, associations between combination versus mono empirical antibiotic therapy and clinical cure at day 7 as well as mortality at day 7 and 28, were investigated. MATERIALS AND METHODS: Patients from the DIANA study were grouped and analysed by combination versus mono antibiotic therapy. Clinical cure was defined as survival and resolution of all signs and symptoms related to the infection. Odds ratios (ORs) were calculated by logistic regression analyses. RESULTS: Of the 1398 included patients, 568 patients (41%) received combination therapy. In total, 641(46%) patients achieved clinical cure and 135 (10%) patients had died as of day 7. There were no significant associations between combination and mono therapy relating to clinical cure and mortality. CONCLUSIONS: This study found no differences in clinical cure and mortality between empirical combination versus mono therapy in a large cohort of ICU patients with a suspected infection.

Invasive Fungal Diseases in Adult Patients in Intensive Care Unit (FUNDICU): 2024 consensus definitions from ESGCIP, EFISG, ESICM, ECMM, MSGERC, ISAC, and ISHAM.

PURPOSE: The aim of this document was to develop standardized research definitions of invasive fungal diseases (IFD) in non-neutropenic, adult patients without classical host factors for IFD, admitted to intensive care units (ICUs). METHODS: After a systematic assessment of the diagnostic performance for IFD in the target population of already existing definitions and laboratory tests, consensus definitions were developed by a panel of experts using the RAND/UCLA appropriateness method. RESULTS: Standardized research definitions were developed for proven invasive candidiasis, probable deep-seated candidiasis, proven invasive aspergillosis, probable invasive pulmonary aspergillosis, and probable tracheobronchial aspergillosis. The limited evidence on the performance of existing definitions and laboratory tests for the diagnosis of IFD other than candidiasis and aspergillosis precluded the development of dedicated definitions, at least pending further data. The standardized definitions provided in the present document are aimed to speed-up the design, and increase the feasibility, of future comparative research studies.

Use of hospital resources in ICU inpatients with infections caused by carbapenem-resistant Gram-negative bacteria: A real clinical practice-based study in Spain / Uso de recursos hospitalarios en pacientes hospitalizados en UCI debido a infecciones causadas por bacterias gramnegativas resistentes a carbapenémicos: un estudio basado en la práctica clínica real en España

Introduction: Carbapenem-resistant Gram-negative bacteria (CRGN) are an urgent public health threat because of the limited treatment options, its rapid spreading and high clinical impact and mortality rates. However, the burden and the use of resources of these infections have not been investigated. The aim of the current study is to understand the use of resources associated to the clinical management of CRGN infections in real clinical practice conditions. Methods: An observational retrospective chart review study was performed. Data regarding patient demographics, clinical management and use of resources associated to hospitalization were retrieved from clinical charts of ICU inpatients with a confirmed CRGN infection. Three reference Spanish hospitals were selected according to their patient volume and geographical coverage. Descriptive analyses of the clinical management and the use of resources and its cost were performed and then total costs by type of resource were calculated. Results: A total of 130 patients were included in the study. The higher number of patients (n=43; 33%) were between 61 and 70 years old. Ninety-four (72%) patients were male and 115 (88%) suffered from comorbidities. The mean total cost associated to the resources used in patients with CRGN infections hospitalized in ICU was 96,878€ per patient. These total costs included 84,140€ of total hospital stay, 11,021€ of treatments (558€ of antibiotics; 10,463€ of other treatments) and 1717€ costs of diagnostic tests. Conclusions: CRGN infection causes a high use of hospital resources, being the length of stay either in hospital wards or ICU the driver of the total costs. Diagnostic tests and treatments, including antibiotics, represent the lowest part of the use of resources and costs (13% of total costs).(AU)

Introducción: Las bacterias gramnegativas resistentes a carbapenémicos (CRGN) son una amenaza urgente de salud pública por las limitadas opciones de tratamiento, su rápida dispersión y el alto impacto clínico y tasas de mortalidad. Sin embargo, la carga y el uso de recursos de estas infecciones no han sido investigadas. El objetivo de este estudio es comprender el uso de recursos asociado al manejo clínico de las infecciones por CRGN en condiciones de práctica clínica real. Métodos: Se llevó a cabo un estudio observacional retrospectivo de revisión de historias clínicas. Se recogieron datos demográficos, del manejo clínico y del uso de recursos asociado a la hospitalización de historias clínicas de pacientes hospitalizados en UCI con una infección confirmada por CRGN. Se seleccionaron tres hospitales españoles de referencia por su cobertura geográfica. Se realizaron análisis descriptivos del manejo clínico y el uso de recursos y sus costes en episodios de infecciones por CRGN, y se calcularon los costes totales para cada tipo de recurso. Resultados: Se incluyeron en el estudio un total de 130 pacientes. La mayoría de los pacientes (n=43;33%) tenían entre 61-70 años. Noventa y cuatro pacientes (72%) eran hombres y 115 (88%) presentaron comorbilidades. El coste medio total asociado a los recursos usados durante el episodio de infección por CRGN por paciente fue de 96.878€. Este coste total incluye 84.140€ de la estancia en el hospital, 11.021€ de los tratamientos (558€ de antibióticos y 10.463€ de otros tratamientos) y 1.717€ del coste de test diagnósticos. Conclusiones: El episodio de infección por CRGN causa un alto uso de recursos hospitalarios, siendo la duración de la estancia tanto en planta hospitalaria como en UCI el factor con mayor peso de los costes totales. Los test diagnósticos clínicos y los tratamientos, incluyendo los antibióticos, representan la parte más pequeña del uso de recursos y sus costes (13% del coste total).(AU)

Impact of one year of pandemic on Spanish Intensive Care Units / Impacto de un año de pandemia en las Unidades de Cuidados Intensivos de España

Objective. To measure the impact of the pandemic inSpanish ICUs.Material and methods. On-line survey, conducted inApril 2021, among SEMICYUC members. Participants wereasked about number of patients admitted, increase in thenumber of beds and staff, structures created in the hospitaland self-assessment of the work performed.Results. We received 246 answers from 157 hospitals.67.7% of the ICUs were expanded during the pandemic, overall increase in beds of 58.6%. The ICU medical staff increasedby 6.1% and there has been a nursing shortage in 93.7% ofunits. Patients exceeded 200% the pre-pandemic ICU capacity.In 88% of the hospitals the collaboration of other specialistswas necessary. The predominant collaboration model consisted of the intensive care medicine specialist being responsiblefor triage and coordinating patient management. Despite that53.2% centres offered training for critical care, a deteriorationin the quality of care was perceived. 84.2% hospitals drew upa Contingency Plan and in 77.8% of the hospitals a multidisciplinary committee was set up to agree on decision-making.Self-evaluation of the work performed was outstandingand 91.9% felt proud of what they had achieved, however, upto 15% considered leaving their job.Conclusions. The Spanish ICUs assumed an unprecedented increase in the number of patients. They achieved it withouthardly increasing their staff and, while intensive care medicinetraining was carried out for other specialists who collaborated.The degree of job satisfaction was consistent with pre-pandemic levels. (AU)

Objetivo. Medir el impacto de la pandemia COVID-19 en las UCI españolas. Material y métodos. Cuestionario online, realizado en abril 2021 entre socios de SEMICYUC. Se interrogó acerca delnúmero de pacientes ingresados, incremento en número decamas y personal, estructuras creadas en el hospital y autoevaluación del trabajo realizado.Resultados. Recibimos 246 respuestas de 157 hospitales. El 67.7% de las UCI se expandieron durante la pandemia,con un incremento de camas del 58.6%. El personal médicode las UCI aumentó un 6.1% y hubo escasez de enfermería enel 93.7% de las unidades. Los pacientes excedieron un 200%la capacidad pre-pandemia y en el 88% de los hospitales fuenecesaria la colaboración de otros especialistas, siendo elmodelo predominante aquel en que el especialista en medicina intensiva era responsable del triaje y coordinaba el tratamiento del paciente. A pesar de que en el 53.2% de los centros se ofreció formación en medicina intensiva se detectó undeterioro de la calidad asistencial. El 84.2% de los hospitaleselaboraron un plan de contingencia y el 77.8% conformaronun comité multidisciplinar para consensuar decisiones. Laevaluación del trabajo fue sobresaliente y el 91.9% se sienteorgulloso del resultado, pero hasta el 15% consideró abandonar la especialidad.Conclusiones. Las UCI españolas asumieron un incremento de pacientes sin precedentes, sin apenas aumento delpersonal y mientras formaban a otros especialistas que colaboraron. El grado de satisfacción con el trabajo realizado fuesimilar al pre-pandemia. (AU)

A systematic literature review and expert consensus on risk factors associated to infection progression in adult patients with respiratory tract or rectal colonisation by carbapenem-resistant Gram-negative bacteria / Revisión sistemática de la literatura y consenso de expertos sobre los factores de riesgo asociados a la progresión de la infección en pacientes adultos con colonización del tracto respiratorio o rectal por bacterias gramnegativas resistentes a carbapenémicos

Objective. Risk factors (RFs) associated with infection progression in patients already colonised by carbapenem-resistant Gram-negative bacteria (CRGNB) have been addressed in few and disperse works. The aim of this study is to identify the relevant RFs associated to infection progression in patients with respiratory tract or rectal colonisation.Material and methods. A systematic literature review was developed to identify RFs associated with infectionprogression in patients with CRGNB respiratory tract or rectal colonisation. Identified RFs were then evaluated and discussed by the expert panel to identify those that are relevant according to the evidence and expert’s experience.Results. A total of 8 articles were included for the CRGNB respiratory tract colonisation and 21 for CRGNB rectal colonisation, identifying 19 RFs associated with pneumonia development and 44 RFs associated with infection progression, respectively. After discussion, the experts agreed on 13 RFs to be associated with pneumonia development after respiratory tract CRGNB colonisation and 33 RFs to be associated with infection progression after rectal CRGNB colonisation. Respiratory tract and rectal colonisation, previous stay in the ICU and longer stay in the ICU were classified as relevant RF independently of the pathogen and site of colonisation. Previous exposure to antibiotic therapy or previous carbapenem use were also common relevant RF for patients with CRGNB respiratory tract and rectal colonisation. (AU)

Objetivo. Los factores de riesgo (FR) asociados a la progresión de la infección en pacientes ya colonizados por bacterias gramnegativas resistentes a carbapenémicos (BGNRC) han sido abordados en pocos y dispersos trabajos. El objetivo de este estudio es identificar los factores de riesgo relevantes asociados a la progresión de la infección en pacientes con colonización del tracto respiratorio o rectal.Material y métodos. Se realizó una revisión sistemática de la literatura para identificar los FR asociados a la progresión de la infección en pacientes con colonización del tracto respiratorio o rectal por BGNRC. Los FR identificados fueron luego evaluados y discutidos por el panel de expertos para identificar aquellos que son relevantes según la evidencia disponible y la experiencia de los expertos.Resultados. Un total de 8 artículos fueron incluidos en el análisis de los FR en la colonización del tracto respiratorio y 21 para la colonización rectal, identificándose 19 FR asociados al desarrollo de neumonía y 44 FR asociados a la progresión de la infección respectivamente. Tras la sesión de discusión, los expertos acordaron que 13 FR se asociaban al desarrollo de neumonía tras la colonización del tracto respiratorio por BGNRC y 33 FR a la progresión de la infección tras la colonización rectal por BGNRC. La colonización del tracto respiratorio y rectal, la estancia previa en la UCI y una estancia prolongada en la UCI se clasificaron como FR relevantes independientemente del patógeno y del lugar de colonización. La exposición previa a antibióticos o el uso previo de carbapenémicos se clasificaron como FR relevantes para varios de los patógenos tanto en pacientes con colonización del tracto respiratorio como rectal. (AU)

Clindamycin but not Intravenous Immunoglobulins reduces mortality in a retrospective cohort of critically ill patients with bacteremic Group A Streptococcal infections / Tratamiento con clindamicina, y no con inmunoglobulinas intravenosas, disminuye la mortalidad en una cohorte retrospectiva de pacientes críticos con bacteriemia por Streptococcus del Grupo A

Objectives. Mortality of patients requiring Intensive Care Unit (ICU) admission for an invasive group A streptococcal (GAS) infection continues being high. In critically ill patients with bacteremic GAS infection we aimed at determining risk factors for mortality. Patients and methods. Retrospective multicentre study carried out in nine ICU in Southern Spain. All adult patients admitted to the participant ICUs from January 2014 to June 2019 with one positive blood culture for S. pyogenes were included in this study. Patient characteristics, infection-related variables, therapeutic interventions, failure of organs, and outcomes were registered. Risk factors independently associated with ICU and in-hospital mortalities were determined by multivariate regression analyses. Results. Fifty-seven patients were included: median age was 63 (45-73) years, median SOFA score at admission was 11 (7-13). The most frequent source was skin and soft tissue infection (n=32) followed by unknown origin of bacteremia (n=12). In the multivariate analysis, age (OR 1.079; 95% CI 1.016-1.145), SOFA score (OR 2.129; 95% CI 1.339-3.383) were the risk factors for ICU mortality and the use of clindamycin was identified as a protective factor (OR 0.049; 95% CI 0.003-0.737). Age and SOFA were the independent factors associated with hospital mortality however the use of clindamycin showed a strong trend but without reaching statistical significance (OR 0.085; 95% CI 0.007-1.095). (AU)

Objetivo. La mortalidad de los pacientes que requieren ingreso en la Unidad de Cuidados Intensivos (UCI) por una infección invasiva por estreptococos del grupo A (GAS) continúa siendo inaceptablemente alta. El objetivo del estudio fue determinar los factores de riesgo de mortalidad en pacientes críticos con infección estreptocócica bacterémica del grupo A. Pacientes y métodos. Estudio retrospectivo multicéntrico realizado en nueve UCI del sur de España. Se incluyeron pacientes consecutivos ingresados en las UCI participantes desde enero de 2014 hasta junio de 2019 con un hemocultivo positivo para S. pyogenes. Se registraron las características de los pacientes, las variables relacionadas con la infección, las intervenciones terapéuticas, el fracaso de los órganos y el pronóstico. Se determinaron mediante análisis de regresión multivariante los factores de riesgo asociados de forma independiente con la mortalidad en UCI y hospitalaria. Resultados. Se incluyeron cincuenta y siete pacientes: la mediana de edad fue de 63 (45-73) años, la mediana de la puntuación SOFA al ingreso fue de 11 (7-13). El foco más frecuente fue la infección de la piel y los tejidos blandos (n=32) seguida de la bacteriemia de origen desconocido (n=12). En el análisis multivariante, la edad (OR 1,079; IC del 95%: 1,016-1,145), y la puntuación SOFA (OR 2,129; IC del 95%: 1,339-3,383) se identificaron como factores de riesgo para la mortalidad en UCI. El uso de clindamicina se identificó como un factor protector (OR 0,049; IC del 95%: 0,003-0,737). La edad y la SOFA se asociaron de forma independiente con la mortalidad hospitalaria, mientras que el tratamiento con clindamicina mostró una tendencia fuerte pero sin alcanzar significación estadística (OR 0,085; IC del 95%: 0,007-1,095). (AU)

Del empirismo a la evidencia científica en el tratamiento con antivíricos en los casos graves de infección por Coronavirus en tiempos de epidemia / From empiricism to scientific evidence in antiviral treatment in severe cases of Coronavirus infection in times of epidemic

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From empiricism to scientific evidence in antiviral treatment in severe cases of coronavirus infection in times of epidemic / Del empirismo a la evidencia científica en el tratamiento con antivíricos en los casos graves de infección por Coronavirus en tiempos de epidemia

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Biomarkers of fungal infection: expert opinion on the current situation / Biomarcadores de infección fúngica: opinión de expertos sobre la situación actual

The introduction of non-culture-based diagnostic techniques is revolutionizing the world of microbiological diagnosis and infection assessment. Fungi are no exception, and the introduction of biomarkers has opened up enormous expectations for better management of these entities. Biomarkers are diverse, their targets are also diverse and their evaluation has been done preferably in an individualized use and with deficient designs. Less is known about the value of the combined use of biomarkers and the impact of the negativity of two or more biomarkers on antifungal treatment decisions has been poorly studied. Given the paucity of prospective, randomized and definitive studies, we have convened experts from different fields, with an interest in invasive fungal infections, to answer some questions about the current relevant use of fungal biomarkers. This document summarizes the answers of these experts to the different questions

La introducción de técnicas de diagnóstico no basadas en cultivo está revolucionando el mundo del diagnóstico microbiológico y de la aproximación a las infecciones. Los hongos no son una excepción, y la introducción de biomarcadores ha abierto enormes expectativas para una mejor manejo de estas enfermedades. Hay diversos biomarcadores cuyo significado es también diverso pero su evaluación se ha hecho preferentemente en un uso individual y con estudios con distintos diseños. Se sabe menos sobre el valor de la combinación de biomarcadores y el impacto de la negatividad de dos o más de los mismos en las decisiones de tratamiento antifúngico ha sido poco estudiado. Dada la escasez de datos prospectivos, en estudios aleatorizados y definitivos, hemos convocado a expertos de diferentes campos con un interés en las infecciones micóticas invasivas, para responder a algunas preguntas sobre el uso actual y relevante de los biomarcadores fúngicos. Este documento resume las respuestas del grupo de expertos a las preguntas que se les formularon sobre el tema

Practical approach to the management of catheter-related bloodstream infection

Catheter-related bloodstream infections (CRBSI) is a common cause of nosocomial infection associated resulting in substantial morbidity, mortality, increased length of hospital stays and health-care costs. New clinical practice guidelines for the management of adults with CRBSI have been published in 2018 by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). This review focuses on updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Our aim is to show some of the key aspects concerning the following topics: diagnosis, empirical and targeted therapy

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Estudio caso-control del impacto clínico de la traqueobronquitis asociada a la ventilación mecánica en pacientes adultos, que no desarrollan neumonía asociada a ventilación mecánica / A case-control study on the clinical impact of ventilator associated tracheobronchitis in adult patients who did not develop ventilator associated pneumonia

Objetivos: El objetivo primario fue determinar si la traqueobronquitis asociada a ventilación mecánica (TAV) está asociada con un aumento de estancia en UCI. Los objetivos secundarios incluyeron prolongación de estancia hospitalaria, así como mortalidad en UCI y hospitalaria. Diseño: Estudio retrospectivo caso-control. Apareamos cada caso con un control en base a los siguientes criterios: periodo de VM al menos tan extenso, como el tiempo en que el caso desarrolla la TAV ± 2 días, gravedad evaluada por la escala APACHE II al ingreso en UCI, igual ± 3, igual motivo de ingreso del paciente, igual edad ± 10 años. Pacientes: Pacientes adultos ingresados en una UCI polivalente de 30 camas, con el diagnóstico de TAV en el periodo 2013-2016. Resultados: Identificamos 76 pacientes con TAV que ingresaron en UCI en el periodo de estudio. No se encontraron controles adecuados para 3 pacientes con TAV. No se encontraron diferencias significativas entre ambos grupos en cuanto a características demográficas, motivo de ingreso y comorbilidades. La estancia media en UCI de los pacientes con traqueobronquitis asociada a ventilación mecánica fue más prolongada en los casos que en los controles, mediana 22d (14-35), comparada con los controles mediana 15d (8-27), p=0,02. Los casos presentaron mayor número de días de VM respecto a los controles, mediana 18 días (9-28) vs. 9 días (5-16) p = 0,03. No encontramos diferencias significativas respecto a la estancia hospitalaria 40d (28-61) vs. 35d (23-54), p= 0,32; mortalidad en UCI (20,5 vs. 31,5% p=0,13) y mortalidad hospitalaria (30,1 vs. 43,8% p= 0,09). Realizamos un análisis del subgrupo de pacientes con TAV con documentación microbiológica y tratamiento empírico adecuado sin encontrar diferencias significativas en ninguno de los aspectos analizados. Conclusiones: La TAV, prolonga los días de estancia en UCI y de ventilación mecánica. Este efecto desaparece cuando los pacientes reciben tratamiento empírico adecuado

Objectives: The main objective was to determine whether ventilator-associated tracheobronchitis (VAT) is related to increased length of ICU stay. Secondary endpoints included prolongation of hospital stay, as well as, ICU and hospital mortality. Design: A retrospective matched case-control study. Each case was matched with a control for duration of ventilation (± 2 days until development of ventilator-associated tracheobronchitis), disease severity (Acute Physiology and Chronic Health Evaluation II) at admission ± 3, diagnostic category and age ±10 years. Patients: Critically ill adults admitted to a polyvalent 30-beds ICU with the diagnosis of VAT in the period 2013-2016. Main results: We identified 76 cases of VAT admitted to our ICU during the study period. No adequate controls were found for 3 patients with VAT. There were no significant differences in demographic characteristics, reasons for admission and comorbidities. Patients with VAT had a longer ICU length of stay, median 22 days (14-35), compared to controls, median 15 days (8-27), p=.02. Ventilator days were also significantly increased in VAT patients, median 18 (9-28) versus 9 days (5-16), p=.03. There was no significant difference in total hospital length of stay 40 (28-61) vs. 35days (23-54), p=.32; ICU mortality (20.5 vs. 31.5% p=.13) and hospital mortality (30.1 vs. 43.8% p=.09). We performed a subanalysis of patients with microbiologically proven VAT receiving adequate antimicrobial treatment and did not observe significant differences between cases and the corresponding controls. Conclusions: VAT is associated with increased length of intensive care unit stay and longer duration of mechanical ventilation. This effect disappears when patients receive appropriate empirical treatment

Executive summary of clinical practice guideline for the management of invasive diseases caused by Aspergillus: 2018 Update by the GEMICOMED-SEIMC/REIPI / Resumen ejecutivo del documento de consenso del GEMICOMED perteneciente a la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC) sobre el tratamiento de las infecciones invasoras producidas por Aspergillus

Aspergillus infection is a significant cause of morbi-mortality in an at-risk population. The Study Group of Fungal Infections (GEMICOMED) from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) has reviewed announcements made in invasive aspergillosis management. We have organized our recommendations in such a way as to provide a guide in resolving different clinical situations concerning the entire spectrum of invasive diseases caused by Aspergillus in various populations. Diagnostic approach, treatment and preventions strategies are outlined. It is not our aim that these guidelines supplant clinical judgment with respect to specific patients; however, it is our objective to perform a comprehensive summary of quality of care evidence for invasive aspergillosis management in different settings

Las infecciones causadas por Aspergillus causan una elevada morbimortalidad en la población susceptible. EL Grupo de Estudio de Micología Médica de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (GEMICOMED/SEIMC) ha revisado las novedades más importantes sobre el manejo de las infecciones invasoras causadas por Aspergillus. Hemos organizado nuestras recomendaciones en 3 apartados: diagnóstico, tratamiento y profilaxis en diferentes grupos de pacientes susceptibles de padecer estas infecciones. Se revisan distintas situaciones clínicas que pueden estar causadas por este hongo. Nuestro objetivo no es que estas guías de tratamiento suplanten el juicio clínico de los médicos ante un determinado paciente; sin embargo, sí deseamos poder ofrecer un resumen comprensible sobre las evidencias que existen para realizar un óptimo manejo de la infección invasora causada por Aspergillus en diferentes situaciones clínicas

Aspergilosis invasiva en el paciente crítico / Invasive aspergillosis in critically ill patients

Los pacientes críticos sin una grave inmunosupresión es una población en la que la aspergilosis invasiva (AI) es una enfermedad en alza. El tratamiento crónico con corticoides, la enfermedad pulmonar obstructiva crónica y la cirrosis hepática son factores de riesgo repetidamente identificados en las series publicadas. No obstante, debido a la inespecificidad de los síntomas y signos en el paciente crítico y a la relativa baja capacidad diagnóstica de las pruebas complementarias, el diagnóstico de la AI supone un reto para el especialista en medicina intensiva. La aplicación de algoritmos diagnósticos adaptados al paciente crítico, cuya activación dependerá del aislamiento de Aspergillus en una muestra respiratoria, es la metodología diagnóstica más eficaz en esta población. Entre los elementos diagnósticos, la determinación de galactomanano en el líquido broncoalveolar es la prueba diagnóstica que ha demostrado más utilidad. Una vez establecida la sospecha el tratamiento debe iniciarse precozmente. El voriconazol, la anfotericina B y el isavuconazol son los tratamientos más eficaces. Aunque el voriconazol y la anfotericina B son los fármacos con mayores evidencias científicas, adolecen de problemas con relación a efectos adversos y dificultades farmacocinéticas. Por ello, el isavuconazol, que ha demostrado una elevada eficacia y seguridad en otras poblaciones, supone una potencial alternativa de extremado interés para el paciente crítico

Critically ill patients without severe immunosuppression make up a population in which invasive aspergillosis (IA) has been identified as an emergent pathology. Chronic treatment with corticosteroids, chronic obstructive pulmonary disease, and liver cirrhosis are repeatedly identified risk factors. However, due to the non-specificity of the symptoms and signs in the critical patient, and the relative low diagnostic capacity of the complementary tests, the diagnosis of the IA is a challenge for the specialist in critical care medicine. The application of diagnostic algorithms adapted to critical patients, in whom activation will depend on the isolation of Aspergillus in a respiratory specimen, is the most efficient diagnostic methodology in this population. Among the diagnostic approaches, the determination of galactomannan in bronchoalveolar fluid is the most useful diagnostic test. Once the suspicion is established, treatment should be started as soon as possible. Voriconazole, amphotericin B, and isavuconazole are the most effective treatments. Although voriconazole and amphotericin B are the drugs with the most scientific evidence, they are related with adverse effects and pharmacokinetic difficulties. Therefore, isavuconazole, which has shown high efficacy and safety in other populations, is a potential alternative of great interest for critically ill patients