Intensive care unit to unit capacity transfers are associated with increased mortality: an observational cohort study on patient transfers in the Swedish Intensive Care Register.

BACKGROUND: Transfers from one intensive care unit (ICU) to another ICU are associated with increased length of intensive care and hospital stay. Inter-hospital ICU transfers are carried out for three main reasons: clinical transfers, capacity transfers and repatriations. The aim of the study was to show that different ICU transfers differ in risk-adjusted mortality rate with repatriations having the least risk. RESULTS: Observational cohort study of adult patients transferred between Swedish ICUs during 3 years (2016-2018) with follow-up ending September 2019. Primary and secondary end-points were survival to 30 days and 180 days after discharge from the first ICU. Data from 75 ICUs in the Swedish Intensive Care Register, a nationwide intensive care register, were used for analysis (89% of all Swedish ICUs), covering local community hospitals, district general hospitals and tertiary care hospitals. We included adult patients (16 years or older) admitted to ICU and subsequently discharged by transfer to another ICU. Only the first admission was used. Exposure was discharge to any other ICU (ICU-to-ICU transfer), whether in the same or in another hospital. Transfers were grouped into three predefined categories: clinical transfer, capacity transfer, and repatriation. We identified 15,588 transfers among 112,860 admissions (14.8%) and analysed 11,176 after excluding 4112 repeat transfer of the same individual and 300 with missing risk adjustment. The majority were clinical transfers (62.7%), followed by repatriations (21.5%) and capacity transfers (15.8%). Unadjusted 30-day mortality was 25.0% among capacity transfers compared to 14.5% and 16.2% for clinical transfers and repatriations, respectively. Adjusted odds ratio (OR) for 30-day mortality were 1.25 (95% CI 1.06-1.49 p = 0.01) for capacity transfers and 1.17 (95% CI 1.02-1.36 p = 0.03) for clinical transfers using repatriation as reference. The differences remained 180 days post-discharge. CONCLUSIONS: There was a large proportion of ICU-to-ICU transfers and an increased odds of dying for those transferred due to other reasons than repatriation.

Causes of late mortality among ICU-treated patients with sepsis.

BACKGROUND: Patients with sepsis may have an increased risk of late mortality, but the causes of late death are unclear. This retrospective matched cohort study aimed to determine the causes of late death (≥1 year) among patients with sepsis compared to patients without sepsis. METHODS: 8760 patients with severe sepsis or septic shock (2001 consensus criteria) registered in the Swedish Intensive Care Registry (2008-2013) were compared with a 1:1 matched (gender, age, SAPS3 probability for death, ICU length of stay) control group consisting of non-septic ICU patients. Causes of death (International Classification of Diseases codes) were obtained from the Swedish Cause of Death Register (2008-2014). RESULTS: During 2008-2014, 903 patients with sepsis died at ≥365 days after their initial septic event, compared to 884 patients in the control group. Median time of follow-up was 313 days (sepsis group, interquartile range 11-838 days) vs 288 days (control group, 9-836 days). The most common causes of death were heart diseases (sepsis: 50.2%, non-septic: 48.6%) and cancer (sepsis: 33.7%, non-septic: 31.7%). Infectious diseases were significantly more common cause of death in the sepsis group (24.3% vs 19.6%, respectively; P < .05). Pneumonia was a common infectious cause of death in both groups, whereas sepsis was more common in the sepsis group. CONCLUSIONS: The most common causes of late death after ICU admission among patients with and without sepsis were heart diseases and cancer. However, patients with sepsis more frequently had infectious diseases as a cause of late death, compared to non-septic patients.

Mortality Prediction After Cardiac Surgery: Higgins' Intensive Care Unit Admission Score Revisited.

BACKGROUND: This study was performed to develop and validate a cardiac surgical intensive care risk adjustment model for mixed cardiac surgery based on a few preoperative laboratory tests, extracorporeal circulation time, and measurements at arrival to the intensive care unit. METHODS: This was a retrospective study of admissions to 5 cardiac surgical intensive care units in Sweden that submitted data to the Swedish Intensive Care Registry. Admissions from 2008 to 2014 (n = 21,450) were used for model development, whereas admissions from 2015 to 2016 (n = 6463) were used for validation. Models were built using logistic regression with transformation of raw values or categorization into groups. RESULTS: The final model showed good performance, with an area under the receiver operating characteristics curve of 0.86 (95% confidence interval, 0.83-0.89), a Cox calibration intercept of -0.16 (95% confidence interval, -0.47 to 0.19), and a slope of 1.01 (95% confidence interval, 0.89-1.13) in the validation cohort. CONCLUSIONS: Eleven variables available on admission to the intensive care unit can be used to predict 30-day mortality after cardiac surgery. The model performance was better than those of general intensive care risk adjustment models used in cardiac surgical intensive care and also avoided the subjective assessment of the cause of admission. The standardized mortality ratio improves over time in Swedish cardiac surgical intensive care.

Reducing night-time discharge from intensive care. A nationwide improvement project with public display of ICU outcomes.

PURPOSE: Discharge from an intensive care unit (ICU) during the night is an independent risk factor for adverse outcomes. A quality improvement project was conducted with the aim of reducing the incidence and the associated mortality after night-time discharge. MATERIALS AND METHODS: ICUs that submitted data to the Swedish Intensive Care Registry (SIR) agreed to appoint night-time discharge as a national quality indicator with detailed public display on the internet of various discharge proportions and outcomes. The registry was then examined for trends during a 10-year period with use of multilevel mixed-effects models. RESULTS: We analysed 163,371 patients who were discharged alive from 70 ICUs to a general ward within the same hospital during 2006-2015. The prevalence of night-time discharge fell from 7.0% (95% CI: 5.2 to 8.7%) in 2006 to 4.9% (95% CI: 4.3 to 5.5%) in 2015 (P = .035 for trend). The original increased risk of death within 30 days after night-time discharge in 2006-2010, OR 1.20 (95% CI: 1.01 to 1.42), disappeared in 2011-2015, OR 1.06 (95% CI: 0.96 to 1.17). CONCLUSIONS: During the 10-year period of the quality improvement project, the annual prevalence and risk of death within 30-days after night-time discharge were reduced. The public display and feedback of audit data could have helped in achieving this.

No association with cardiac death after sepsis: A nationwide observational cohort study.

BACKGROUND: Cardiac dysfunction is a well-known complication of sepsis, but its long-term consequences and implications for patients remain unclear. The aim of this study was to investigate cardiac outcome in sepsis by assessing causes of death up to 2 years after treatment in an Intensive Care Unit (ICU) in a nationwide register-based cohort collected from the Swedish Intensive Care Registry. METHODS: A cohort of 13 669 sepsis and septic shock ICU patients from 2008 to 2014 was collected together with a non-septic control group, matched regarding age, sex and severity of illness (n = 6582), and all without preceding severe cardiac disease. For a large proportion of the severe sepsis and septic shock patients (n = 7087), no matches were found. Information on causes of death up to 2 years after ICU admission was sought in the Swedish National Board of Health and Welfare's Cause of Death Registry. RESULTS: Intensive Care Unit mortality was nearly identical in a matched comparison of sepsis patients to controls (24% in both groups) but higher in more severely ill sepsis patients for whom no matches were found (33% vs 24%, P < 0.001). There was no association of sepsis to cardiac deaths in the first month (OR 1.03, 95%CI 0.87 to 1.20, P = 0.76) nor up to 2 years after ICU admission (OR 1.01, 95%CI 0.82 to 1.25, P = 0.94) in an adjusted between-group comparison. CONCLUSIONS: There was no association with an increased risk of death related to cardiac disease in patients with severe sepsis or septic shock when compared to other ICU patients with similar severity of illness.

Impact of Missing Physiologic Data on Performance of the Simplified Acute Physiology Score 3 Risk-Prediction Model.

OBJECTIVES: The Simplified Acute Physiology 3 outcome prediction model has a narrow time window for recording physiologic measurements. Our objective was to examine the prevalence and impact of missing physiologic data on the Simplified Acute Physiology 3 model's performance. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Sixty-three ICUs in the Swedish Intensive Care Registry. PATIENTS: Patients admitted during 2011-2014 (n = 107,310). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Model performance was analyzed using the area under the receiver operating curve, scaled Brier's score, and standardized mortality rate. We used a recalibrated Simplified Acute Physiology 3 model and examined model performance in the original dataset and in a dataset of complete records where missing data were generated (simulated dataset). One or more data were missing in 40.9% of the admissions, more common in survivors and low-risk admissions than in nonsurvivors and high-risk admissions. Discrimination did not decrease with one to two missing variables, but accuracy was highest with no missing data. Calibration was best in the original dataset with a mix of full records and records with some missing values (area under the receiver operating curve was 0.85, scaled Brier 27%, and standardized mortality rate 0.99). With zero, one, and two data missing, the scaled Brier was 31%, 26%, and 21%; area under the receiver operating curve was 0.84, 0.87, and 0.89; and standardized mortality rate was 0.92, 1.05 and 1.10, respectively. Datasets where the missing data were simulated for oxygenation or oxygenation and hydrogen ion concentration together performed worse than datasets with these data originally missing. CONCLUSIONS: There is a coupling between missing physiologic data, admission type, low risk, and survival. Increased loss of physiologic data reduced model performance and will deflate mortality risk, resulting in falsely high standardized mortality rates.

Inhibition of Constitutive Nitric Oxide Synthase Does Not Influence Ventilation-Perfusion Matching in Normal Prone Adult Sheep With Mechanical Ventilation.

BACKGROUND: Local formation of nitric oxide in the lung induces vasodilation in proportion to ventilation and is a putative mechanism behind ventilation-perfusion matching. We hypothesized that regional ventilation-perfusion matching occurs in part due to local constitutive nitric oxide formation. METHODS: Ventilation and perfusion were analyzed in lung regions (≈1.5 cm) before and after inhibition of constitutive nitric oxide synthase with N-nitro-L-arginine methyl ester (L-NAME) (25 mg/kg) in 7 prone sheep ventilated with 10 cm H2O positive end-expiratory pressure. Ventilation and perfusion were measured by the use of aerosolized fluorescent and infused radiolabeled microspheres, respectively. The animals were exsanguinated while deeply anesthetized; then, lungs were excised, dried at total lung capacity, and divided into cube units. The spatial location for each cube was tracked and fluorescence and radioactivity per unit weight determined. RESULTS: After administration of L-NAME, pulmonary artery pressure increased from a mean of 16.6-23.6 mm Hg, P = .007 but PaO2, PaCO2, and SD log(V/Q) did not change. Distribution of ventilation was not influenced by L-NAME, but a small redistribution of perfusion from ventral to dorsal lung regions was observed. Perfusion to regions with the highest ventilation (fifth quintile of the ventilation distribution) remained unchanged after L-NAME. CONCLUSIONS: We found minimal or no influence of constitutive nitric oxide synthase inhibition by L-NAME on the distributions of ventilation and perfusion, and ventilation-perfusion in prone, anesthetized, ventilated, and healthy adult sheep with normal gas exchange.

Comparing Time-Fixed Mortality Prediction Models and Their Effect on ICU Performance Metrics Using the Simplified Acute Physiology Score 3.

OBJECTIVES: To examine ICU performance based on the Simplified Acute Physiology Score 3 using 30-day, 90-day, or 180-day mortality as outcome measures and compare results with 30-day mortality as reference. DESIGN: Retrospective cohort study of ICU admissions from 2010 to 2014. SETTING: Sixty-three Swedish ICUs that submitted data to the Swedish Intensive Care Registry. PATIENTS: The development cohort was first admissions to ICU during 2011-2012 (n = 53,546), and the validation cohort was first admissions to ICU during 2013-2014 (n = 57,729). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Logistic regression was used to develop predictive models based on a first level recalibration of the original Simplified Acute Physiology Score 3 model but with 30-day, 90-day, or 180-day mortality as measures of outcome. Discrimination and calibration were excellent for the development dataset. Validation in the more recent 2013-2014 database showed good discrimination (C-statistic: 0.85, 0.84, and 0.83 for the 30-, 90-, and 180-d models, respectively), and good calibration (standardized mortality ratio: 0.99, 0.99, and 1.00; Hosmer-Lemeshow goodness of fit H-statistic: 66.4, 63.7, and 81.4 for the 30-, 90-, and 180-d models, respectively). There were modest changes in an ICU's standardized mortality ratio grouping (< 1.00, not significant, > 1.00) when follow-up was extended from 30 to 90 days and 180 days, respectively; about 11-13% of all ICUs. CONCLUSIONS: The recalibrated Simplified Acute Physiology Score 3 hospital outcome prediction model performed well on long-term outcomes. Evaluation of ICU performance using standardized mortality ratio was only modestly sensitive to the follow-up time. Our results suggest that 30-day mortality may be a good benchmark of ICU performance. However, the duration of follow-up must balance between what is most relevant for patients, most affected by ICU care, least affected by administrative policies and practically feasible for caregivers.

Evolution of chronic renal impairment and long-term mortality after de novo acute kidney injury in the critically ill; a Swedish multi-centre cohort study.

INTRODUCTION: Acute Kidney Injury (AKI) is common in critical ill populations and its association with high short-term mortality is well established. However, long-term risks of death and renal dysfunction are poorly understood and few studies exclude patients with pre-existing renal disease, meaning outcome for de novo AKI has been difficult to elicit. We aimed to compare the long-term risk of Chronic Kidney Disease (CKD), End Stage Renal Disease (ESRD) and mortality in critically ill patients with and without severe de novo AKI. METHOD: This cohort study was conducted between 2005 and 2011 in Swedish intensive care units (ICU). Data from 130134 adult patients listed on the Swedish intensive care register-database was linked with other national registries. Patients with pre-existing CKD (4192) and ESRD (1389) were excluded, as were cases (26771) with incomplete data. Patients were classified according to AKI exposure during ICU admission. Outcome in the de novo AKI group was compared to the non-exposed (no-AKI) intensive care control group. Primary outcome was all-cause mortality. Follow-up ranged from one to seven years (median 2.1 years). Secondary outcomes were incidence of CKD and ESRD and median follow-up was 1.3 years. RESULTS: Of 97 782 patients, 5273 (5.4%) had de novo AKI. These patients had significantly higher crude mortality at one (48.4% vs. 24.6%) and five years (61.8% vs. 39.1%) compared to the control group. The first 30% of deaths in AKI patients occurred within 11 days of ICU admission whilst the 30-centile in the no-AKI group died by 748 days. CKD was significantly more common in AKI survivors at one year (6.0% vs. 0.44%) than in no-AKI group (adjusted incidence rate ratio (IRR) 7.6). AKI patients also had significantly higher rates of ESRD at one (2.0% vs. 0.08%) and at five years (3.9% vs. 0.3%) than those in the comparison group (adjusted IRR 22.5). CONCLUSION: This large cohort study demonstrated that de novo AKI is associated with increased short and long-term risk of death. AKI is independently associated with increased risk of CKD and ESRD as compared to an ICU control population. Severe de novo AKI survivors should be routinely followed-up and their renal function monitored.

Gender differences in outcome and use of resources do exist in Swedish intensive care, but to no advantage for women of premenopausal age.

INTRODUCTION: Preclinical data indicate that oestrogen appears to play a beneficial role in the pathophysiology of and recovery from critical illness. In few previous epidemiologic studies, however, have researchers analysed premenopausal women as a separate group when addressing potential gender differences in critical care outcome. Our aim was to see if women of premenopausal age have a better outcome following critical care and to investigate the association between gender and use of intensive care unit (ICU) resources. METHODS: On the basis of our analysis of 127,254 consecutive Simplified Acute Physiology Score III-scored Swedish Intensive Care Registry ICU admissions from 2008 through 2012, we determined the risk-adjusted 30-day mortality, accumulated nurse workload score and ICU length of stay. To investigate associations with sex, we used logistic regression and multivariate analyses on the entire cohort as well as on two subgroups stratified by median age for menopause (up to and including 45 years and older than 45 years) and six selected diagnostic subgroups (sepsis, multiple trauma, chronic obstructive pulmonary disease, acute respiratory distress syndrome, pneumonia and cardiac arrest). RESULTS: There was no sex difference in risk-adjusted mortality for the cohort as a whole, and there was no sex difference in risk-adjusted mortality in the group 45 years of age and younger. For the group of patients older than 45 years of age, we found a reduced risk-adjusted mortality in men admitted for cardiac arrest. For the cohort as a whole, and for those admitted with multiple trauma, male sex was associated with a higher nurse workload score and a longer ICU stay. CONCLUSIONS: Using information derived from a large multiple ICU register database, we found that premenopausal female sex was not associated with a survival advantage following intensive care in Sweden. When the data were adjusted for age and severity of illness, we found that men used more ICU resources per admission than women did.

Infections, antibiotic treatment and mortality in patients admitted to ICUs in countries considered to have high levels of antibiotic resistance compared to those with low levels.

BACKGROUND: Antimicrobial resistance is an increasing concern in ICUs worldwide. Infection with an antibiotic resistant (ABR) strain of an organism is associated with greater mortality than infection with the non-resistant strain, but there are few data assessing whether being admitted to an intensive care unit (ICU) with high levels of antimicrobial resistance is associated with a worse outcome than being admitted to an ICU with low rates of resistance. The aim of this study was, therefore, to compare the characteristics of infections and antibiotic treatments and patient outcomes in patients admitted to ICUs in countries considered as having high levels of antibiotic resistance and those admitted to ICUs in countries considered as having low levels of antibiotic resistance. METHODS: Data from the large, international EPIC II one-day point prevalence study on infections in patients hospitalized in ICUs were used. For the current study, we compared the data obtained from patients from two groups of countries: countries with reported MRSA rates of ≥ 25% (highABR: Greece, Israel, Italy, Malta, Portugal, Spain, and Turkey) and countries with MRSA rates of < 5% (lowABR: Denmark, Finland, Netherlands, Norway, and Sweden). RESULTS: On the study day, 1187/2204 (53.9%) patients in the HighABR ICUs were infected and 255/558 (45.7%) in the LowABR ICUs (P < 0.01). Patients in the HighABR ICUs were more severely ill than those in the LowABR ICUs, as reflected by a higher SAPS II score (35.6 vs 32.7, P < 0.05) and had longer median ICU (12 days vs 5 days) and hospital (24 days vs 16 days) lengths of stay. They also had higher crude ICU (20.0% vs 15.4%) and hospital (27.0% vs 21.5%) mortality rates (both P < 0.05). However, after multivariable adjustment and matched pair analysis there were no differences in ICU or hospital mortality rates between High or LowABR ICU patients overall or among those with infections. CONCLUSIONS: Being hospitalized in an ICU in a region with high levels of antimicrobial resistance is not associated per se with a worse outcome.

A prospective longitudinal multicentre study of health related quality of life in ICU survivors with COPD.

INTRODUCTION: Mortality amongst COPD patients treated on the ICU is high. Health-related quality of life (HRQL) after intensive care is a relevant concern for COPD patients, their families and providers of health care. Still, there are few HRQL studies after intensive care of this patient group. Our hypothesis was that HRQL of COPD patients treated on the ICU declines rapidly with time. METHODS: Fifty-one COPD patients (COPD-ICU group) with an ICU stay longer than 24 hours received a questionnaire at 6, 12 and 24 months after discharge from ICU. HRQL was measured using two generic instruments: the EuroQoL instrument (EQ-5D and EQ-VAS) and the Short Form 36 Health Survey (SF-36). The results were compared to HRQL of two reference groups from the general population; an age- and sex-adjusted reference population (Non-COPD reference) and a reference group with COPD (COPD reference). RESULTS: HRQL of the COPD-ICU group at 6 months after discharge from ICU was lower compared to the COPD reference group: Median EQ-5D was 0.66 vs. 0.73, P = 0.08 and median EQ-VAS was 50 vs.55, P < 0.05. There were no significant differences in the SF-36 dimensions between the COPD-ICU and COPD-reference groups, although the difference in physical functioning (PF) approached statistical significance (P = 0.059). Patients in the COPD-ICU group who were lost to follow-up after 6 months had low HRQL scores at 6 months. Scores for patients who died were generally lower compared to patients who failed to respond to the questionnaire. The PF and social functioning (SF) scores in those who died were significantly lower compared to patients with a complete follow up. HRQL of patients in the COPD-ICU group that survived a complete 24 months follow up was low but stable with no statistically significant decline from 6 to 24 months after ICU discharge. Their HRQL at 24 months was not significantly different from HRQL in the COPD reference group. CONCLUSIONS: HRQL in COPD survivors after intensive care was low but did not decline from 6 to 24 months after discharge from ICU. Furthermore, HRQL at 24 months was similar to patients with COPD who had not received ICU treatment.

Inter-rater reliability of the early functional abilities scale.

OBJECTIVE: To investigate the inter-rater reliability of the Early Functional Abilities (EFA) scale. DESIGN: An observational study of inter-rater reliability in an open cohort. PATIENTS: Twenty-four patients with traumatic brain injury in need of medical or surgical intervention in the early rehabilitation section of the intensive care unit. METHODS: The EFA was assessed by 4 different professions in the rehabilitation team. Inter-rater reliability was assessed using linear weighted kappa statistics. RESULTS: The overall weighted kappa values of the different EFA items varied from 0.27 to 0.60. The items in the sensorimotor functional area had the highest pairwise agreement,with a mean kappa range of 0.68­0.76. The vegetativest ability, position tolerance and wakefulness items had the lowest mean kappa values (0.49, 0.33 and 0.49, respectively). Agreement was good to excellent between the occupational therapist and physiotherapist across the majority of the items, whereas the physician and nurse agreed less with one another. CONCLUSION: The inter-rater reliability of the EFA scale was good for most items among all the raters. The scale maybe used by all members of the interdisciplinary team after training in administration and scoring. A reduction in the number of items in the vegetative functional domain is recommended.

Variations in the length of stay of intensive care unit nonsurvivors in three Scandinavian countries.

INTRODUCTION: The length of stay (LOS) in intensive care unit (ICU) nonsurvivors is not often reported, but represents an important indicator of the use of resources. LOS in ICU nonsurvivors may also be a marker of cultural and organizational differences between units. In this study based on the national intensive care registries in Finland, Sweden, and Norway, we aimed to report intensive care mortality and to document resource use as measured by LOS in ICU nonsurvivors. METHODS: Registry data from 53,305 ICU patients in 2006 were merged into a single database. ICU nonsurvivors were analyzed with regard to LOS within subgroups by univariate and multivariate analysis (Cox proportional hazards regression). RESULTS: Vital status at ICU discharge was available for 52,255 patients. Overall ICU mortality was 9.1%. Median LOS of the nonsurvivors was 1.3 days in Finland and Sweden, and 1.9 days in Norway. The shortest LOS of the nonsurvivors was found in patients older than 80 years, emergency medical admissions, and the patients with the highest severity of illness. Multivariate analysis confirmed the longer LOS in Norway when corrected for age group, admission category, sex, and type of hospital. LOS in nonsurvivors was found to be inversely related to the severity of illness, as measured by APACHE II and SAPS II. CONCLUSIONS: Despite cultural, religious, and educational similarities, significant variations occur in the LOS of ICU nonsurvivors among Finland, Norway, and Sweden. Overall, ICU mortality is low in the Scandinavian countries.

Long-term survival according to ventilation mode in acute respiratory failure secondary to chronic obstructive pulmonary disease: a multicenter, inception cohort study.

PURPOSE: The aim of the study was to investigate 5-year survival stratified by mechanical ventilation modality in chronic obstructive pulmonary disease (COPD) patients treated in the ICU. MATERIALS AND METHODS: Prospective, observational study of COPD patients with acute respiratory failure admitted to 9 multidisciplinary ICUs in Sweden. Characteristics on admission, including illness severity scores and the first blood gas, and survival were analyzed stratified by ventilation modality (noninvasive [NIV] vs invasive mechanical ventilation). RESULTS: Ninety-three patients, mean age of 70.6 (SD, 9.6) years, were included. Sixteen patients were intubated immediately, whereas 77 were started on NIV. Patients who were started on NIV had a lower median body mass index (BMI) (21.9 vs 27.0; P < .01) and were younger compared to those who were intubated immediately (median age, 70 vs 74.5 years; P < .05). There were no differences in the initial blood gas results between the groups. Long-term survival was greater in patients with NIV (P < .05, log rank). The effect of NIV on survival remained after including age, Acute Physiology and Chronic Health Evaluation II score, and BMI in a multivariate Cox regression model (NIV hazard ratio, 0.44; 95% confidence interval, 0.21-0.92). Fifteen patients with failed NIV were intubated and mechanically ventilated. Long-term survival in patients with failed NIV was not significantly different from patients who were intubated immediately. CONCLUSION: The short-term survival benefit of NIV previously found in randomized controlled trials still applies after 5 years of observation.

Surveillance of microbial resistance in European Intensive Care Units: a first report from the Care-ICU programme for improved infection control.

PURPOSE: To report initial results from a European ICU surveillance programme focussing on antibiotic consumption, microbial resistance and infection control. METHODS: Thirty-five ICUs participated during 2005. Microbial resistance, antibiotic consumption and infection control stewardship measures were entered locally into a web-application. Results were validated locally, aggregated by project leaders and fed back to support local audit and benchmarking. RESULTS: Median (range) antibiotic consumption was 1,254 (range 348-4,992) DDD per 1,000 occupied bed days. The proportion of MRSA was median 11.6% (range 0-100), for ESBL phenotype of E. coli and K. pneumoniae 3.9% (0-80) and 14.3% (0-77.8) respectively, and for carbapenem-resistant P. aeruginosa 22.5% (0-100). Screening on admission for alert pathogens was commonly omitted, and there was a lack of single rooms for isolation. CONCLUSIONS: The surveillance programme demonstrated wide variation in antibiotic consumption, microbial resistance and infection control measures. The programme may, by providing rapid access to aggregated results, promote local and regional audit and benchmarking of antibiotic use and infection control practices.

Prescription of antibiotic agents in Swedish intensive care units is empiric and precise.

Since the prescription of antibiotics in the hospital setting is often empiric, particularly in the critically ill, and therefore fraught with potential error, we analysed the use of antibiotic agents in Swedish intensive care units (ICUs). We examined indications for antibiotic treatment, agents and dosage prescribed among 393 patients admitted to 23 ICUs at 7 tertiary care centres, 11 secondary hospitals and 5 primary hospitals over a 2-week period in November 2000. Antibiotic consumption was higher among ICU patients in tertiary care centres with a median of 84% (range 58-87%) of patients on antibiotics compared to patients in secondary hospitals (67%, range 35-93%) and in primary hospitals (38%, range 24-80%). Altogether 68% of the patients received antibiotics during the ICU stay compared to 65% on admission. Cefuroxime was the most commonly prescribed antibiotic before and during admission (28% and 24% of prescriptions, respectively). A date for decision to continue or discontinue antibiotic therapy was set in 21% (6/29) of patients receiving prophylaxis, in 8% (16/205) receiving empirical treatment and in 3% (3/88) when culture-based therapy was given. No correlation between antibiotic prescription and laboratory parameters such as CRP levels, leukocyte and thrombocyte counts, was found. The treatment was empirical in 64% and prophylactic in 9% of cases. Microbiological data guided prescription more often in severe sepsis (median 50%, range 40-60% of prescriptions) than in other specified forms of infection (median 32%, range 21-50%). The empirically chosen antibiotic was found to be active in vitro against the pathogens found in 55 of 58 patients (95%) with a positive blood culture. This study showed that a high proportion of ICU patients receive antimicrobial agents and, as expected, empirical-based therapy is more common than culture-based therapy. Antibiotics given were usually active in vitro against the pathogen found in blood cultures. We ascribe this to a relatively modest antibiotic resistance problem in Swedish hospitals.