Rotation of antimicrobial therapy in the intensive care unit: impact on incidence of ventilator-associated pneumonia caused by antibiotic-resistant Gram-negative bacteria.

The development of antibiotic resistance is associated with high morbidity and mortality, particularly in the intensive care unit (ICU) setting. We evaluated the effect of an antibiotic rotation programme on the incidence of ventilator-associated pneumonia (VAP) caused by antibiotic-resistant Gram-negative bacteria. We conducted a 2-year before-and-after study at two medical-surgical ICUs at two different tertiary referral hospitals. We included all mechanically ventilated patients admitted for > or =48 h who developed VAP. From 1 January through 31 December 2007, a quarterly rotation of antibiotics (piperacillin/tazobactam, fluoroquinolones, carbapenems and cefepime/ceftazidime) for the empirical treatment of VAP was implemented. We analysed the incidence of VAP and the antibiotic resistance patterns of the responsible pathogens in 2006, before (P1) and, in 2007, after (P2) the introduction of the scheduled rotation programme. Overall, there were 79 VAP episodes in P1 and 44 in P2; the mean incidence of VAP was 20.96 cases per 1,000 days of mechanical ventilation (MV) during P1 and 14.97 in P2, with no significant difference between periods on segmented regression analysis. We observed a non-significant reduction of the number of both the poly-microbial (14 [17.7%] in P1 and 5 [10.6%] in P2 [p = 0.32]) and of the antibiotic-resistant Gram-negative bacteria-related VAP (42 [45.2%] in P1 and 16 [34%] in P2 [p = 0.21]). Conversely, the number of VAP caused by Pseudomonas aeruginosa passed from 8.35 per 1,000 days of MV in P1 to 2.33 per 1,000 days of MV in P2 (p = 0.02). No difference in ICU mortality and crude in-hospital mortality between P1 and P2 was noted. Moreover, no significant change of microbial flora isolated through clinical cultures was observed. We were able to conclude that, despite global microbial flora not being affected by such a programme, antibiotic therapy rotation may reduce the incidence of VAP caused by antibiotic-resistant Gram-negative bacteria in the ICU, such as Pseudomonas aeruginosa. The application of this programme may also improve antibiotic susceptibility. However, further studies are needed to confirm our results.

Meticillin-resistant Staphylococcus aureus control in an intensive care unit: a 10 year analysis.

Data regarding the efficacy of programmes to control meticillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs) are limited. We performed an observational 'before-and-after' study to evaluate the search-and-destroy (S&D) strategy as compared with S&D and isolation (SDI), to control MRSA in a general ICU. S&D included active surveillance, contact precautions and treatment of carriers; in SDI, isolation or cohorting were added. Three phases were identified: period 1 (p1), 1996-1997, before the introduction of programme; period 2 (p2), 1998-2002, with S&D programme; period 3 (p3), 2003-2005, with SDI in a new ICU. During the 10 years of the study we observed 3978 patients; 667, 1995 and 1316 patients in p1, p2 and p3 respectively. The numbers of MRSA-infected patients were 19 in p1, 23 in p2, and 6 in p3. The infection rate was 3.5, 1.7 and 0.7 cases per 1000 patient-days in p1, p2 and p3, respectively; a significant reduction was observed between p1 vs p2 (P=0.024) and p2 vs p3 (P=0.048), although the latter was not confirmed by a segmented regression analysis. The proportion of ICU-acquired MRSA cases was 80%, 77% and 52% during p1, p2 and p3, respectively (P=0.0001 for trend). The proportion of S. aureus isolates resistant to meticillin was 51%, 32% and 23% during p1, p2 and p3, respectively (P<0.0001 for trend). S&D strategy was effective in significantly reducing MRSA infection, transmission rates and proportion of meticillin resistance in an ICU with endemic MRSA. SDI may further enhance S&D efficacy.

Considerations on 200 cases of percutaneous cricothyroidotomy (minitracheotomy).

More than 10 yrs ago, minitracheotomy was suggested as an elective method in the treatment of sputum retention, resulting from impaired ability to cough, in many medical and surgical diseases. We report our experience of 200 cases of percutaneous cricothyroidotomy in our Intensive Care Unit (145 patients), and in other wards (55 patients). The results confirm that minitracheotomy is easy and quick to perform, well-accepted by patients, and free of relevant complications when the technique is performed correctly and sufficient care is adopted. About 60-70% of treated patients benefited by minitracheotomy and did not require more invasive interventions. A better control of technique, moreover, allowed other possible applications to be discovered.

Fibrinolytic (rt-PA) therapy for superior vena cava thrombosis in a multiple trauma patient.

An adult multiple trauma patient (head injury with coma, blunt chest trauma, bone and pelvis fractures) developed superior vena cava thrombosis which extended to the right atrium as a complication of central venous catheterism. Since a four day heparin therapy was unsuccessful, the patient was treated with recombinant tissue-type plasminogen activator (rt-PA), 100 mg over three hours. Thrombolysis with rt-PA was not associated with cutaneous or internal bleeding and was partially effective (improvement of the clinical picture, disappearance of the right atrium thrombus, superior vena cava still occluded). Although our patient could have benefited from an additional administration of rt-PA, we did not start a second course because the risk of major hemorrhage increases over 100 mg. For its relative clot-selectivity rt-PA could be indicated when fibrinolytic treatment is required in multiple trauma patient, but safe and more efficacious regimens have still to be defined.

[The preventive minitracheotomy as support in difficult intubations: a proposition. Description of a clinical case]. / La minitracheotomia preventiva quale supporto nella intubazione difficile: una proposta. Descrizione di un caso clinico.

The authors suggest preventive minitracheotomy as a support technique in difficult endotracheal intubation, and report their experience in a case of surgical operation to remove a bony neoformation of C1 and C2 posterior arcs. Endotracheal intubation, difficult because no part of the glottis could be seen, was made possible by preventive minitracheotomy. In this way sedation, myorelaxation and excellent oxygenation during following manoeuvre that resulted atraumatic, were obtained. The small cannula of minitracheotomy was maintained closed during the operation and open for 24 hours thereafter to prevent obstructive complications. It was then removed.

[Use of atracurium for the prevention of fasciculations and succinylcholine myalgia in athletes undergoing orthopedic surgery]. / Impiego dell'atracurium nella prevenzione delle fascicolazioni e delle mialgie da succinilcolina in atleti sottoposti a chirurgia ortopedica.

The Authors report their clinical experience about the use of atracurium besylate in preventing succinylcholine-induced fasciculations and postoperative myalgias in fifty athletes (ASA class 1), submitted to arthroscopic meniscectomy. The patients were pretreated with atracurium 5 mg i.v. or saline solution in a double-blind fashion. After 2.5 minutes, succinylcholine 1.3 mg/kg was administered, and fasciculations were recorded on a scale ranging from 0 to 3. Twenty-four hours after surgery all subjects were questioned about myalgias occurrence, scored by a 0-3 scale. Fasciculations occurred in all patients who received saline and in 44% of those treated with atracurium. Myalgias on the postoperative day were observed in 80% of patients treated with saline solution, but only in 36% of patients who received atracurium. The difference between atracurium and saline solution was statistically significant (p less than 0.001) either for fasciculations or myalgias incidence. These findings show that atracurium 5 mg i.v. is effective in preventing succinylcholine-induced fasciculations and postoperative myalgias, and suggest atracurium as the drug of choice for this purpose, particularly in muscular subjects.

[Hypokalemic myopathy. Our experience at an intensive care unit]. / Miopatia ipokaliemica. Nostra esperienza in un reparto di terapia intensiva.

Disturbances of potassium homeostasis are frequently iatrogenic: some drugs, especially diuretics, are sometimes taken without proper electrolyte control and replacement; this can lead to more or less severe hypokalemic states. After some physiopathologic remarks, the Authors report their experience with four patients admitted for severe hypokalemia; the clinical picture was always quite typical: severe muscle weakness (even quadriparesis), cardiac rhythm abnormalities, metabolic alkalosis. A reliable diagnostic tool is muscle biopsy that shows aspects of vacuolar myopathy.