Antibiotic use and impact on outcome from bacteraemic critical illness: the BActeraemia Study in Intensive Care (BASIC).

BACKGROUND: The lack of prospective, randomized, controlled trial data to guide optimal antibiotic use in bacteraemic critically ill patients has led to a wide variety of strategies and major issues with drug resistance. We therefore prospectively investigated the epidemiology of bacteraemia and fungaemia in intensive care units (ICUs); and the impact of timing, type and appropriateness of antibiotic intervention. METHODS: We conducted a multinational, multicentre, prospective observational study in 132 ICUs from 26 countries with no interventions. RESULTS: 1702 patients [European (69.6%), Australasian (12.2%), South American (8.3%) and Asian (9.9%)] developed 1942 bacteraemic episodes over the study period. Mortality rates were similar for those receiving empirical (40.5%), semi-targeted (37.6%) or fully targeted (33.3%) antibiotic therapy (P=0.40), and in those initially receiving broad- (39.3%) or restricted-spectrum (39.1%) therapy (P=0.94). First-line therapy was effective in terms of the antibiogram (where available) in 70.4% of cases. This in vitro susceptibility ranged from 76.3% for broad-spectrum antibiotics to 46.3% for restricted-spectrum antibiotics (P<0.0001). However, no antibiotic policy-associated variable, including in vitro susceptibility (odds ratio 0.89, 95% confidence interval 0.61-1.30), was a statistically significant predictor of mortality. CONCLUSIONS: We could not show an impact of antibiotics on mortality in critically ill patients, despite in vitro activity and early commencement. Randomized, multicentre trials are urgently needed to establish the appropriate duration, timing and combinations of antibiotics that will both optimally treat infection and minimize development of resistance and other complications.

La sedación y la analgesia en la unidad de cuidados intensivos / Sedation and analgesia in the intensive care unit

La excitación es la principal indicación para el uso de analgésicos y sedantes en la unidad de cuidados intensivos (UCI). Diversas enfermedades, entre las que se incluyen las enfermedades agudas del sistema nervioso central, la insuficiencia respiratoria aguda, la hipotensión y la hipoglucemia, pueden causar excitación. Estas deben ser investigadas antes de comenzar el tratamiento sintomático. En muchos pacientes en UCI la ansiedad, el temor y el dolor son causas reconocidas de excitación. En estos casos el uso de sedantes y analgésicos es muy importante para evitar la depresión y otros síndromes crónicos. No existe un nivel de sedación único ni tampoco un régimen de sedación que se adapte a todos los pacientes o a todas las situaciones. El uso de sedantes y analgésicos debe estar en sintonía con las necesidades del individuo. Los efectos colaterales de los sedantes pueden ser graves y comprometer la vida del paciente, como en el caso del síndrome por infusión de propofol. Los sistemas que otorgan puntaje, la evaluación clínica frecuente y la interrupción diaria de las infusiones de drogas por vía intravenosa pueden ser valiosas para encontrar el nivel de sedación óptimo y para evitar situaciones clínicas riesgosas.

Agitation is the commonest indication to use sedative and analgesic drugs in the intensive care unit (ICU). Several diseases, including acute central nervous system diseases, acute respiratory failure, hypotension, and hypoglycemia may cause agitation. These causes should be accurately sought before symptomatic treatments are started. In many ICU patients anxiety, fear and pain are well recognized causes of agitation. In such cases the use of sedatives and analgesics is of primary importance to avoid the development of depression and other chronic syndromes. There is no single level of sedation, nor single sedative regimen suitable for all patients and for all situations and for all patients, and the use of sedative and analgesics should be finely tuned on the patient's need. Side-effects of sedative drugs can be severe, or even life-threatening as in the so-called propofol-infusion syndrome. Appropriate scoring systems, frequent clinical evaluation and daily interruption of continuous intravenous drug infusions can be of great value to find the optimal level of sedation, and to avoid risky clinical situations. RiassuntoL'agitazione è la più comune indicazione all'uso di sedativi ed analgesici in Terapia Intensiva. Diverse malattie, incluse le malattie acute del sistema nervosa centrale, l'insufficienza respiratoria acuta, l'ipotensione e l'ipoglicemia, possono esserne la causa. In molti malati ricoverati in Terapia Intensiva sono l'ansia, la paura ed il dolore a causare agitazione. In questi casi l'uso di sedativi ed analgesici è di primaria importanza per evitare sindromi depressive ed altri disturbi cronici. Non vi è un singolo livello di sedazione o un regime sedativo per tutte le situazioni, perciò l'uso di tali farmaci dovrebbe essere basato sui bisogni del singolo paziente. Gli effetti collaterali dei farmaci sedativi possono essere gravi o addirittura letali come nella cosiddetta propofol infusion syndrome. Dei sistemi di valutazione appropriati, un esame clinico frequente e l'interruzione giornaliera delle infusioni endovenose continue possono essere di grande importanza per ottimizzare la sedazione e per evitare situazioni cliniche pericolose.