Role of source control in critically ill candidemic patients: a multicenter retrospective study.

PURPOSE: Candidemia is associated with high mortality especially in critically ill patients. Our aim was to identify predictors of mortality among critically ill patients with candidemia with a focus on early interventions that can improve prognosis. METHODS: Multicenter retrospective study. SETTING: This retrospective study was conducted in Intensive Care Units from three European university hospitals from 2015 to 2021. Adult patients with at least one positive blood culture for Candida spp. were included. Patients who did not require source control were excluded. Primary outcome was 14-day mortality. RESULTS: A total of 409 episodes of candidemia were included. Most candidemias were catheter related (173; 41%), followed by unknown origin (170; 40%). Septic shock developed in 43% episodes. Overall, 14-day mortality rate was 29%. In Cox proportional hazards regression model, septic shock (P 0.001; HR 2.20, CI 1.38-3.50), SOFA score ≥ 10 points (P 0.008; HR 1.83, CI 1.18-2.86), and prior SARS-CoV-2 infection (P 0.003; HR 1.87, CI 1.23-2.85) were associated with 14-day mortality, while combined early appropriate antifungal treatment and source control (P < 0.001; HR 0.15, CI 0.08-0.28), and early source control without appropriate antifungal treatment (P < 0.001; HR 0.23, CI 0.12-0.47) were associated with better survival compared to those without neither early appropriate antifungal treatment nor source control. CONCLUSION: Early source control was associated with better outcome among candidemic critically ill patients.

Multimodal analgesia protocol for pain management after total knee arthroplasty: comparison of three different regional analgesic techniques.

OBJECTIVES: To evaluate three different analgesic techniques, continuous epidural analgesia (EA), continuous intra-articular (IA) infusion analgesia and continuous femoral nerve block (FNB) in postoperative pain management, length of hospital stay (LOS), and time of patient mobilization after total knee arthroplasty (TKA). METHODS: Seventy-two patients undergoing TKA were randomly allocated into three groups according to the analgesic technique used for postoperative pain management. Group EA patients received epidural analgesia (control group), group IA received intra-articular infusion and group FNB received femoral nerve block. RESULTS: Upon analyzing the Numerical Rating Scale (NRS) scores at rest, at passive and active movement, up to 3 days postoperatively, we observed no statistically significant differences at any time point among the three groups. Similarly, no association among these analgesic techniques (EA, IA, FNB) was revealed regarding LOS. However, significant differences emerged concerning the time of mobilization. Patients who received IA achieved earlier mobilization compared to FNB and EA. CONCLUSIONS: Both IA and FNB generate similar analgesic effect with EA for postoperative pain management after TKA. However, IA appears to be significantly more effective in early mobilization compared to EA and FNB. Finally, no clinically important differences could be detected regarding LOS among the techniques studied.

Predictors of Operative Mortality of 928 Intact Aortoiliac Aneurysms.

BACKGROUND: The aim of this study is to identify preoperative and intraoperative factors associated with in-hospital mortality of intact abdominal aortoiliac aneurysm repair. METHODS: In this observational study, prospectively collected information included demographics, risk factors, comorbidities, aneurysm characteristics (including special aneurysm presentation, i.e., inflammatory, mycotic/infected, aortocaval fistula), investigations, and operative variables. Receiver operating characteristic) curve analysis of the Glasgow aneurysm score (GAS) and the Vascular Study Group of New England (VSGNE) score was performed in the subgroup of bland aneurysms undergoing isolated elective repair. RESULTS: A total of 928 cases with intact aortoiliac aneurysms had an elective (n = 882) or urgent (n = 46) repair, associated with an in-hospital mortality of 1.7% and 8.7%, respectively (P = 0.01). Open repair (n = 514) was a predictor of higher mortality (3.3% vs. 0.5% for endovascular aneurysm repair [EVAR], n = 414, odds ratio [OR] 7.1, P = 0.003), and so was the pre-EVAR era (4.8% vs. 1.3% in the EVAR era, OR 4.0, P = 0.004). Other significant predictors included the presence of abdominal/back pain (7.5% vs. 1.3%, OR = 6.0, P = 0.001), preoperative angiography (7% vs. 1.6%, OR = 4.5, P = 0.01), special aneurysm presentation (10.9% vs. 1.5%, OR = 8.1, P < 0.001), concomitant major procedures (19% vs. 1.7%, OR = 14.0, P < 0.001), serious intraoperative complications (9.1% vs. 1.5%, OR = 6.6, P = 0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, P < 0.001), and procedure duration (270 and 150 min for cases with and without mortality, respectively, P < 0.001). Open repair (OR = 4.5, P = 0.05), special aneurysm presentation (OR = 6.58, P = 0.001), and concomitant major procedures (OR = 14.3, P < 0.001) were independent predictors of higher mortality. ROC curve analysis for the GAS (P = 0.87) and VSGNE score (P = 0.10) failed to demonstrate statistical significance in the subgroup of bland aneurysms undergoing isolated elective repair. CONCLUSIONS: Our study has demonstrated independent risk factors for mortality, which should be considered when contemplating aortoiliac aneurysm repair. We failed to externally validate the GAS and VSGNE score.

Missed Nursing Care in the Postanesthesia Care Unit: A Cross-Sectional Study.

PURPOSE: This study aimed to investigate the prevalence, activities, and reasons for missed nursing care in the postanesthesia care unit (PACU) and the effect of intensive care unit (ICU) overflow patients. DESIGN: This is a single-center, cross-sectional survey. METHODS: Nineteen PACU-registered nurses of a tertiary care hospital participated. Over a 7-month period, participants were asked to complete a validated questionnaire, which included 19 items related to missed nursing care activities and 10 items related to reasons for missed nursing care. χ2 test and 1-way analysis of variance were used for data analysis. FINDINGS: Questionnaires (N = 397) were completed. Prevalence of missed nursing care activities was 78.1% and was significantly higher in cases of ICU overflow patients (P < .001). The three most reported missed nursing care activities were "drug preparation, administration, and assessment of effectiveness," "patient surveillance and assessment," and "care associated with pain"; prevalence was significantly higher in cases of ICU overflow patients (P = .036, P = .003, and P = .004, respectively). The three most reported reasons for missed nursing care were "inadequate number of nursing personnel," "unexpected rise in patient volume or acuity," and "heavy admission or discharge activity". CONCLUSIONS: The findings indicated missed nursing care was common in the PACU and increased in case of ICU overflow patients. Therefore, missed nursing care needs to be identified and minimized, while the number and length of stay of critically ill patients admitted to the PACU should be limited.

Molecular characteristics and predictors of mortality among Gram-positive bacteria isolated from bloodstream infections in critically ill patients during a 5-year period (2012-2016).

To identify the molecular characteristics of Gram-positive cocci isolated from blood cultures and clinical outcome among critically ill patients. This retrospective study was conducted in the general intensive care unit of the University General Hospital of Patras, Greece, during a 5-year period (2012-2016). All adult patients with a Gram-positive BSI were included. PCR was applied to identify mecA gene (staphylococci); vanA, vanB, and vanC genes (enterococci). Linezolid-resistant S. epidermidis, MRSA, and VRE were further typed by multilocus sequence typing. Mutations in region V of 23S rDNA and ribosomal protein L4were investigated by PCR and sequencing analysis. The presence of the cfr gene was tested by PCR. In total, 141 Gram-positive BSIs were included. Coagulase-negative staphylococci predominated (n = 69; 65 methicillin-resistant, 23 linezolid-resistant carrying both C2534T and T2504A mutations and belonging to the ST22 clone), followed by enterococci (n = 46; 11 vancomycin-resistant carrying vanA gene, classified into four clones), S. aureus (n = 22; 10 methicillin-resistant, classified into three clones) and streptococci (n = 4). The most common type of infection was catheter-related (66; 46.8%), followed by primary BSI (28; 19.9%). Overall 14-day fatality was 24.8%. Multivariate analysis revealed septic shock as independent predictor of fatality, while appropriate empiric antimicrobial treatment and catheter-related BSI were identified as a predictor of good prognosis. Even though most of Gram-positive cocci were multidrug-resistant, fatality rate was low, associated with catheter-related BSIs. Among CNS, LR isolates represented one-third of BSIs due to the dissemination of ST22 S. epidermidis propagated by utilization of linezolid.

High flow nasal cannula oxygen therapy in adults with COVID-19 respiratory failure. A case report.

The novel corona virus (SARS-CoV-2) continuous to spread around the globe causing high mortality, tremendous stress on healthcare systems and an unprecedented disruption of everyday life with unpredictable socioeconomic ramifications. The diseaseis typically affecting the respiratory system and some patients will develop refractory hypoxemic respiratory insufficiency requiring mechanical ventilation. The role of non-invasive ventilation (NIV), high flow nasal cannula (HFNC) or continuous positive airway pressure devices (C-PAP) in the treatment of the 2019 corona virus disease (COVID-19) is not yet clear. We hereby report a case of a 44-year-old COVID-19 positive male patient suffering from hypoxic respiratory failure that was successfully treated with high flow nasal cannula oxygen therapy in a negative pressure intensive care room. Although specific criteria for the use of high flow nasal canula devices COVID-19 are not available at this time, clinicians could use this non-invasive modality as analternative method of respiratory support in selected patients presenting with respiratory failure.

Reversal of carbapenemase-producing Klebsiella pneumoniae epidemiology from blaKPC- to blaVIM-harbouring isolates in a Greek ICU after introduction of ceftazidime/avibactam.

OBJECTIVES: Our aim was to determine the epidemiology of bloodstream infections (BSIs) by carbapenemase-producing Klebsiella pneumoniae (CP-Kp) after the introduction of ceftazidime/avibactam in January 2018 among ICU patients. PATIENTS AND METHODS: All patients hospitalized at the ICU of the University General Hospital of Patras, Greece with CP-Kp BSI during 2015-18 were included. MICs of meropenem, fosfomycin, tigecycline and ceftazidime/avibactam (only for isolates from 2018) were determined by Etest, whereas for colistin, the broth microdilution method was applied. All isolates were tested by PCR for the presence of blaKPC, blaVIM, blaNDM and blaOXA-48 genes. RESULTS: Among 170 BSIs due to CP-Kp (2015-18), 132 (78%) were caused by isolates carrying blaKPC (4 ceftazidime/avibactam-resistant), 17 blaVIM (10%), 16 blaNDM (9%) and 5 carrying both blaKPC and blaVIM (3%). From 2015 to 2017 (125 BSIs), KPC-producing strains (110; 88%) predominated, followed by NDM-producing strains (15; 12%), whereas no VIM-producing strain was isolated. Among the 45 BSIs in 2018, 22 (49%) were due to isolates carrying blaKPC (4 ceftazidime/avibactam resistant), followed by 17 (38%) carrying blaVIM, 5 (11%) carrying both blaKPC and blaVIM, and 1 isolate carrying blaNDM (2%). MBLs were more frequent in 2018 compared with 2015-17 (51% versus 12%; P < 0.001). Multivariate analysis found that prior administration of ceftazidime/avibactam (P = 0.014; OR 16.7, 95% CI 1.8-158.6) was independently associated with the development of BSI due to ceftazidime/avibactam-resistant isolates. CONCLUSIONS: Widespread ceftazidime/avibactam use may lead to a change in the palette of carbapenemases by replacing KPC with MBL-producing isolates.

Nurse understaffing is associated with adverse events in postanaesthesia care unit patients.

AIMS AND OBJECTIVES: To investigate the associations between nurse staffing and the incidence and severity of hypoxaemia, arterial hypotension and bradycardia of postoperative patients during their postanaesthesia care unit stay. BACKGROUND: Nurse understaffing has been associated with adverse patient outcomes in a variety of hospital settings. In the postanaesthesia care unit, nursing shortage is common and can be related to compromised prevention, detection and treatment of adverse events. DESIGN: Observational, single-centre, prospective study that adhered to Strengthening the Reporting of Observational studies in Epidemiology checklist (see Supporting information Appendix S1); 2,207 patients admitted to the postanaesthesia care unit of a tertiary care hospital over a 5-month period were enrolled. METHODS: Incidence of hypoxaemia (arterial oxygen saturation <95%), arterial hypotension (systolic blood pressure <90 mmHg) and bradycardia (heart rate <50 beats per minute), along with episode severity, was recorded. Patients were classified into three groups as follows: sufficient staffing, low and high understaffing. Risk for hypoxaemia, arterial hypotension and bradycardia was adjusted according to patient, anaesthesia and operation characteristics. RESULTS: The incidence of hypoxaemia was significantly higher in the high understaffing group patients, while the incidence of arterial hypotension was significantly higher in both low and high understaffing group patients, compared to sufficient staffing group ones. In the high understaffing group patients, hypoxaemia and arterial hypotension episodes were of significantly higher severity. CONCLUSIONS: These associations between hypoxaemia and arterial hypotension and postanaesthesia care unit understaffing indicate that care quality and patient safety can be compromised in case patient acuity is not matched with sufficient nursing resources. RELEVANCE TO CLINICAL PRACTICE: Higher incidence of hypoxaemia and arterial hypotension advocates for the prevention of imbalances between patient number and care demands and the number of available nurses.

Gut-origin sepsis in the critically ill patient: pathophysiology and treatment.

INTRODUCTION: Gut permeability is increased in critically ill patients, and associated with the development of the systemic inflammatory response syndrome and multiple organ dysfunction syndrome (MODS). The pathogenetic link(s) and potential therapies are an area of intense research over the last decades. METHODS: We thoroughly reviewed the literature on gut-origin sepsis and MODS in critically ill patients, with emphasis on the implicated pathophysiological mechanisms and therapeutic interventions. FINDINGS: Intestinal barrier failure leading to systemic bacterial translocation associated with MODS was the predominant pathophysiological theory for several years. However, clinical studies with critically ill patients failed to provide the evidence of systemic spread of gut-derived bacteria and/or their products as a cause of MODS. Newer experimental data highlight the role of the mesenteric lymph as a carrier of gut-derived danger-associated molecular patterns (DAMPs) to the lung and the systemic circulation. These substances are recognized by pattern recognition receptor-bearing cells in diverse tissues and promote proinflammatory pathways and the development MODS. Therefore, the gut becomes a pivotal proinflammatory organ, driving the systemic inflammatory response through DAMPs release in mesenteric lymph, without the need for systemic bacterial translocation. CONCLUSIONS: There is an emerging need for application of sensitive non-invasive and easily measured biomarkers of early intestinal injury (e.g., citrulline, intestinal fatty acid protein, and zonulin) in our everyday clinical practice, guiding the early pharmacological intervention in critically ill patients to restore or prevent intestinal injury and improve their outcomes.

Inadvertent hypothermia and mortality in critically ill adults: Systematic review and meta-analysis.

OBJECTIVE: Considering that inadvertent hypothermia (IH) is common in Intensive Care Unit (ICU) patients and can be followed by severe complications, this systematic review identified, appraised and synthesised the published literature about the association between IH and mortality in adults admitted to the ICU. DATA SOURCES: By using key terms, literature searches were conducted in Pubmed, CINAHL, Cochrane Library, Web of Science and EMBASE. REVIEW METHODS: According to PRISMA guidelines, articles published between 1980-2016 in English-language, peer-reviewed journals were considered. IH was defined as core temperature of <36.5°C or lower, present on ICU admission or manifested during ICU stay. Outcome measure included ICU, hospital or 28-day mortality. Selected cohort studies were evaluated with the Newcastle-Ottawa Scale. Extracted data were summarised in tables and synthesised qualitatively and quantitatively, with adjusted odds ratios (ORs) for mortality being combined in meta-analyses. RESULTS: Eighteen observational studies met inclusion criteria. All of them had high methodological quality. In twelve out of fifteen studies, unadjusted mortality was significantly higher in hypothermic patients compared to non-hypothermic ones. Likewise, in thirteen out of sixteen studies, IH or lowest core temperature was independently associated with significantly higher mortality. High severity and long duration of IH were also associated with higher mortality. Mortality was significantly higher in patients with core temperature <36.0°C (pooled OR 2.093, 95% CI 1.704-2.570), and in those with core temperature <35.0°C (pooled OR 2.945, 95% CI 2.166-4.004). CONCLUSIONS: These findings indicate that IH predicts mortality in critically ill adults and pose suspicion that this may contribute to adverse patient outcome.

Risk factors and predictors of mortality of candidaemia among critically ill patients: role of antifungal prophylaxis in its development and in selection of non-albicans species.

PURPOSE: The aim of the present study is to identify risk factors for development and predictors of mortality of candidaemia among critically ill patients. METHODS: A 1:7 case-control study was conducted during a 4-year period (2012-2015) in a Greek Intensive Care Unit (ICU). Candidaemia was confirmed by positive blood cultures. All yeasts were identified using API 20C AUX System or Vitek 2 Advanced Expert System. Epidemiologic data were collected from the ICU computerized database and patients' chart reviews. RESULTS: Fifty-three patients developed candidaemia with non-albicans species being the predominant ones (33 patients, 62.3%). Multivariate analysis found that prior emergency surgery, malignancy, hospitalization during summer months, prior septic shock by KPC-producing Klebsiella pneumoniae and number of antibiotics administered were independently associated with candidaemia, while, prior administration of azole was a protective factor. Non-albicans candidaemia was associated with number of antibiotics administered and prior administration of echinocandin. Mortality of 14 days was 28.3% (15 patients) and was associated with SOFA score upon infection onset and septic shock, while, appropriate empirical antifungal treatment was associated with better survival. CONCLUSIONS: Prophylactic azole administration prevents development of candidaemia, while, echinocandin administration predisposes to non-albicans candidaemia. Empirical administration of an appropriate antifungal agent is associated with better survival.

Early KPC-Producing Klebsiella pneumoniae Bacteremia among Intensive Care Unit Patients Non-Colonized upon Admission.

Among 140 patients colonized by KPC-producing Klebsiella pneumoniae (KPC-Kp) between fourth and seventh day of Intensive Care Unit stay, 24 developed bacteraemia immediately after colonization. Colistin-resistance of the colonizing isolate was the factor significantly associated with early KPC-Kp bacteraemia (P < 0.001; OR 6.6, 95% CI 2.4-18.4), a worrisome finding since infections by colistin-resistant isolates is associated with increased mortality due to limited remaining therapeutic options.

Risk factors for infection and predictors of mortality among patients with KPC-producing Klebsiella pneumoniae bloodstream infections in the intensive care unit.

BACKGROUND: Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae (KPC-Kp) infections in intensive care units (ICUs) are associated with increased mortality. We aimed to determine risk factors for infection and predictors of 30-day mortality in ICU patients with KPC-Kp bloodstream infections (BSI). METHODS: During a 26-month period, patients (n = 273) who stayed more than 6 days in the ICU of the University Hospital of Patras, Greece, were divided into 2 groups, those who developed KPC-Kp BSI and those who did not. K. pneumoniae was identified by Vitek 2 technology. Antibiotic susceptibility testing was performed by agar disk diffusion method. Minimum inhibitory concentrations were determined by Etest. The presence of the blaKPC gene was confirmed by PCR. Molecular typing was performed by pulsed-field gel electrophoresis of XbaI-restricted genomic DNA. Epidemiological data were collected by patient chart review. RESULTS: Five patients had bacteraemia upon admission, while in 48 (17.6%) the BSI developed after 6 days of hospitalization. Risk factors for KPC-Kp BSI in the latter group were the administration of aminoglycosides, number of invasive catheters inserted after the third day, and tracheostomy. The 30-day mortality was 43.4% (23/53 patients). Multivariate analysis revealed that age, SAPS II score at onset of BSI, resistance to colistin, gentamicin, or tigecycline, and septic shock were independently associated with mortality. Treatment with at least 2 appropriate antibiotics was identified as a predictor of a good prognosis. CONCLUSIONS: Many risk factors are involved in KPC-Kp BSI among ICU patients. The high mortality in patients with KPC-KP BSI in the ICU requires the implementation of appropriate infection control measures.

Incidence of Carbapenem-Resistant Gram-Negative Bacterial Infections in Critically Ill Patients with COVID-19 as Compared to Non-COVID-19 Patients: A Prospective Case-Control Study.

Introduction: Critically ill COVID-19 patients hospitalized in intensive care units (ICU) are immunosuppressed due to SARSCoV-2-related immunological effects and are administered immunomodulatory drugs. This study aimed to determine whether these patients carry an increased risk of multi-drug resistant (MDR) and especially carbapenem-resistant Gram-negative (CRGN) bacterial infections compared to other critically ill patients without COVID-19. Materials and Methods: A prospective case-control study was conducted between January 2022 and August 2023. The ICU patients were divided into two groups (COVID-19 and non-COVID-19). Differences in the incidence of CRGN infections from Klebsiella pneumoniae, Acinetobacter spp., and Pseudomonas aeruginosa were investigated. In addition, an indicator of the infection rate of the patients during their ICU stay was calculated. Factors independently related to mortality risk were studied. Results: Forty-two COVID-19 and 36 non-COVID-19 patients were analyzed. There was no statistically significant difference in the incidence of CRGN between COVID-19 and non-COVID-19 patients. The infection rate was similar in the two groups. Regarding the aetiological agents of CRGN infections, Pseudomonas aeruginosa was significantly more common in non-COVID-19 patients (p=0.007). COVID-19 patients had longer hospitalisation before ICU admission (p=0.003) and shorter ICU length of stay (LOS) (p=0.005). ICU COVID-19 patients had significantly higher mortality (p < 0.001) and sequential organ failure assessment (SOFA) score (p < 0.001) compared to non-COVID-19 patients. Μortality secondary to CRGN infections was also higher in COVID-19 patients compared to non-COVID-19 patients (p=0.033). Male gender, age, ICU LOS, and hospital LOS before ICU admission were independent risk factors for developing CRGN infections. Independent risk factors for patients' mortality were COVID-19 infection, obesity, SOFA score, total number of comorbidities, WBC count, and CRP, but not infection from CRGN pathogens. Conclusions: The incidence of CRGN infections in critically ill COVID-19 patients is not different from that of non-COVID-19 ICU patients. The higher mortality of COVID-19 patients in the ICU is associated with higher disease severity scores, a higher incidence of obesity, and multiple underlying comorbidities, but not with CRGN infections.

Intubation Time, Lung Mechanics and Outcome in COVID-19 Patients Suffering Acute Respiratory Distress Syndrome: A Single-Center Study.

Background: We examined the effect of intubation time and the lung mechanics on clinical outcomes in coronavirus disease 2019 (COVID-19) patients. Methods: Based on the patient's hospital admission, intubation time was defined as early (≤ 2 days) or late (> 2 days). Patients were further divided into three groups; early (≤ 3 days), late (4 - 6 days), and very late (> 6 days) intubated. Results: A total of 194 patients were included; 66.5% male, median age 65 years. Fifty-eight patients (29.9%) were intubated early and 136 (70.1%) late. Early intubated patients revealed lower mortality (44.8% vs. 72%, P < 0.001), were younger (60 vs. 67, P = 0.002), had lower sequential organ failure assessment (SOFA) scores (6 vs. 8, P = 0.002) and higher lung compliance on admission days 1, 6 and 12 (42 vs. 36, P = 0.006; 40 vs. 33, P < 0.001; and 37.5 vs. 32, P < 0.001, respectively). Older age (adjusted odds ratio (aOR) = 1.15, P < 0.001), intubation time (aOR = 1.15, P = 0.004), high SOFA scores (aOR = 1.81, P < 0.001), low partial pressure of oxygen (PaO2)/fractional inspired oxygen tension (FiO2) ratio (aOR = 0.96, P = 0.001), and low lung compliance on admission days 1 and 12 (aOR = 1.12, P = 0.012 and aOR = 1.14, P < 0.001, respectively) were associated with higher mortality. Very late and late intubated patients had higher mortality rates than patients intubated early (78.4% vs. 63.4% vs. 44.6%, respectively, P < 0.001). Conclusions: Among COVID-19 intubated patients, age, late intubation, high SOFA scores, low PaO2/FiO2 ratio, and low lung compliance are associated with higher intensive care unit (ICU) mortality.

Intensive Care Unit Mortality Trends during the First Two Years of the COVID-19 Pandemic in Greece: A Multi-Center Retrospective Study.

Data on COVID-19 mortality among patients in intensive care units (ICUs) from Eastern and/or Southern European countries, including Greece, are limited. The purpose of this study was to evaluate the ICU mortality trends among critically ill COVID-19 patients during the first two years of the pandemic in Greece and to further investigate if certain patients' clinical characteristics contributed to this outcome. We conducted a multi-center retrospective observational study among five large university hospitals in Greece, between February 2020 and January 2022. All adult critically ill patients with confirmed COVID-19 disease who required ICU admission for at least 24 h were eligible. In total, 1462 patients (66.35% males) were included in this study. The mean age of this cohort was 64.9 (±13.27) years old. The 28-day mortality rate was 35.99% (n = 528), while the overall in-hospital mortality was 50.96% (n = 745). Cox regression analysis demonstrated that older age (≥65 years old), a body mass index within the normal range, and a delay in ICU admission from symptom onset, as well as worse baseline clinical severity scores upon ICU admission, were associated with a greater risk of death. Mortality of critically ill COVID-19 patients was high during the first two years of the pandemic in Greece but comparable to other countries. Risk factors for death presented in this study are not different from those that have already been described for COVID-19 in other studies.

Factors influencing linezolid-nonsusceptible coagulase-negative staphylococci dissemination among patients in the intensive care unit: a retrospective cohort study.

BACKGROUND: The aim of the present study was to identify risk factors for linezolid-nonsusceptible coagulase-negative staphylococci (CNS) dissemination in the intensive care unit. METHODS: Among the 246 patients included, 33 revealed a linezolid-nonsusceptible CNS-positive culture specimen, 68 were positive for linezolid-susceptible CNS and 145 served as controls. Isolates were characterized by phenotypic and genotypic methods to species level, susceptibility to antistaphylococcal agents and clones. RESULTS: Among the 33 linezolid-nonsusceptible CNS patients, 29 revealed Staphylococcus epidermidis and 4 Staphylococcus capitis. All S. epidermidis strains belonged to the ST22 clone (by multilocus sequence typing), 26 carried both C2534T and T2504A and 3 strains were C2543T mutations. S. capitis strains were stratified as a common pulsed-field gel electrophoresis type and carried the G2576T mutation. Risk factors for linezolid-nonsusceptible CNS isolation were linezolid administration and mean number of linezolid-nonsusceptible CNS-positive patients in nearby beds per day. CONCLUSIONS: These results reinforce the aspect of rational antibiotic usage, but also highlight the need for strict infection control measures to prevent the dissemination of linezolid-nonsusceptible CNS.

Efficacy of Fosfomycin-Containing Regimens for Treatment of Bacteremia Due to Pan-Drug Resistant Acinetobacter baumannii in Critically Ill Patients: A Case Series Study.

Acinetobacter baumannii (AB) has evolved over the last decades as a major problem in carbapenem-resistant gram-negative nosocomial infections, associated with high mortality rates especially in the intensive care unit (ICU). Recent reports highlight the increasing prevalence of resistance to colistin, a last resort therapeutic option for carbapenem-resistant AB. We retrospectively evaluated the characteristics, treatment regimens and outcomes of twenty patients with pan-drug resistant (PDR) AB primary bacteremia hospitalized in the ICU of the University General Hospital of Patras, during a two-year period (October 2020-September 2022). The 28-day mortality reached 50%. Between survivors and non-survivors, no differences were found regarding age, gender, and Charlson comorbidity index (CCI). However, non-survivors had higher APACHE II scores and higher prevalence of septic shock and COVID-19 infection. A significantly higher percentage in the survivor group received Fosfomycin as part of the combination regimen. Inclusion of fosfomycin in the combination therapeutic regimen was associated with significantly better survival as compared to non-fosfomycin-containing regimens. In view of the increasing prevalence of PDR-AB infections in ICUs, its associated high rates of mortality and the lack of effective treatment options, the observed survival benefit with fosfomycin inclusion in the therapeutic regimen merits further validation in larger prospective studies.

Risk factors for KPC-producing Klebsiella pneumoniae enteric colonization upon ICU admission.

OBJECTIVES: To identify risk factors for KPC-producing Klebsiella pneumoniae (KPC-Kp) enteric colonization at intensive care unit (ICU) admission. Recently, the emergence and spread of KPC-producing Enterobacteriaceae in healthcare facilities has become an important issue. Understanding the extent of the reservoir in ICUs may be important for targeted intervention. METHODS: A prospective observational study of all patients (n = 405) admitted to an ICU was conducted during a 22 month period. Rectal samples were taken from each patient within 12-48 h of admission and were inoculated in selective chromogenic agar. K. pneumoniae isolates were characterized by standard methodology. Antibiotic susceptibility testing (agar disc diffusion method), MIC determination (Etest), identification of carbapenemase-producing isolates (Hodge test) and determination of KPC production (boronic acid-imipenem disc test) were performed. The presence of the bla(KPC) gene was confirmed by PCR. Epidemiological data were collected from the ICU computerized database and patient chart reviews. RESULTS: Upon ICU admission, 52/405 (12.8%) patients were colonized with KPC-Kp that was associated with the following risk factors: previous ICU stay (OR 12.5; 95% CI 1.8-86.8), chronic obstructive pulmonary disease (OR 6.3; 95% CI 1.2-31.9), duration of previous hospitalization (OR 1.3; 95% CI 1.1-1.4), previous use of carbapenems (OR 5.2; 95% CI 1.0-26.2) and previous use of ß-lactams/ß-lactamase inhibitors (OR 6.7; 95% CI 1.4-32.9). For patients previously hospitalized on peripheral wards the following risk factors were identified: duration of hospitalization prior to ICU admission (OR 1.1; 95% CI 1.1-1.3), number of comorbidities (OR 1.9; 95% CI 1.1-3.5) and number of antimicrobials administered (OR 2.1; 95% CI 1.3-3.3). CONCLUSIONS: The high prevalence of KPC-Kp enteric carriage in ICU patients at admission dictates the importance of implementation of infection control measures and strict antibiotic policies prior to ICU transfer.

Quantification of superoxide radical production in 4 vital organs of rats subjected to hemorrhagic shock.

OBJECTIVE: The aim of this study was to measure the production of superoxide radical (O2-), a direct indicator of oxidative stress, in 4 vital organs of rats subjected to hemorrhagic shock. For this purpose, and for the first time, a new quantitative assay for the ex vivo measurement of O2- via an established 1:1 molar relationship between O2- and 2-OH-ethidium was used. The production of lipid hydroperoxides (LOOHs), a standard method of evaluation of oxidative stress, was also used for reasons of comparison. METHODS: Sixteen male Wistar rats were divided into 2 groups: sham and hemorrhagic shock, targeting to a mean arterial pressure of 30 to 40 mm Hg for 60 minutes. Three hours after resuscitation, tissues were collected for measurement of LOOHs and O2- production. RESULTS: Hemorrhagic shock induced increased production of LOOHs in the gut, liver, and lungs (P<.001), whereas the production of O2- was also increased in the gut (P<.001), liver (P<.001), and, to a lesser extent, in the lungs (P<.05). The oxidative load of the kidneys, as estimated by both techniques, remained unaffected. CONCLUSION: The results of this new O2- assay were comparable with the results of the established LOOHs method, and this assay proved to be accurate and sensitive in the detection and quantification of O2- production in all organs tested. Thus, the proposed direct measurement of O2- in critically ill patients often facing in extremis situations could be used as a prognostic tool and as a method to evaluate therapeutic interventions in the setting of emergency medicine.