Effect of an acrylic terpolymer barrier film beneath transparent catheter dressings on skin integrity, risk of dressing disruption, catheter colonisation and infection.

OBJECTIVES: We assessed the effect of a skin-protective terpolymer barrier film around the catheter insertion site on frequency of dressing disruptions and skin integrity issues (hyperaemia, skin irritation, residues of adhesives and moisture under the dressing). Secondary outcomes included colonisation of the central venous catheter (CVC) and rates of central line-associated bloodstream infection. RESEARCH METHODOLOGY: A monocentric, open-label, randomised controlled trial was performed comparing a control group receiving standard transparent catheter dressings without the skin-protecting barrier film and an intervention group receiving a transparent chlorhexidine-impregnated dressing with use of the skin-protective acrylic terpolymer barrier film (3M™ Cavilon™ No - Sting Barrier Film, 3 M Health Care, St. Paul, MN, USA). RESULTS: Sixty patients were enrolled and randomised in the study accounting for 60 central venous catheters and a total of 533 catheter days. Dressing disruptions occurred more frequently and at sooner time point in the control group. Skin integrity issues were significantly less observed in the intervention group. No differences in CVC colonisation or central line-associated bloodstream infection were observed. CONCLUSIONS: The application of a barrier film creating a skin-protective polymer layer beneath transparent catheter dressings is associated with less dressing disruptions and skin integrity issues without altering the risk of infectious complications if used in combination with a chlorhexidine-impregnated catheter dressing.

Costs and length of stay associated with antimicrobial resistance in acute kidney injury patients with bloodstream infection.

INTRODUCTION: Antimicrobial resistance negatively impacts on prognosis. Intensive care unit (ICU) patients, and particularly those with acute kidney injury (AKI), are at high risk for developing nosocomial bloodstream infections (BSI) due to multi-drug-resistant strains. Economic implications in terms of costs and length of stay (LOS) attributable to antimicrobial resistance are underevaluated. This study aimed to assess whether microbial susceptibility patterns affect costs and LOS in a well-defined cohort of ICU patients with AKI undergoing renal replacement therapy (RRT) who developed nosocomial BSI. METHODS: Historical study (1995-2004) enrolling all adult RRT-dependent ICU patients with AKI and nosocomial BSI. Costs were considered as invoiced in the Belgian reimbursement system, and LOS was used as a surrogate marker for hospital resource allocation. RESULTS: Of the 1330 patients with AKI undergoing RRT, 92 had microbiologic evidence of nosocomial BSI (57/92, 62% due to a multi-drug-resistant microorganism). Main patient characteristics were equal in both groups. As compared to patients with antimicro-4 bial-susceptible BSI, patients with antimicrobial-resistant BSI were more likely to acquire Gram-positive infection (72.6% vs 25.5%, P<0.001). No differences were found neither in LOS (ICU before BSI, ICU, hospital before BSI, hospital, hospital after BSI, and time on RRT; all P>0.05) or hospital costs (all P>0.05) when comparing patients with antimicrobial-resistant vs antimicrobial-susceptible BSI. However, although not statistically significant, patients with BSI caused by resistant Gram-negative-, Candida-, or anaerobic bacteria incurred substantial higher costs than those without. CONCLUSION: In a cohort of ICU patients with AKI and nosocomial BSI undergoing RRT, patients with antimicrobial-resistant vs antimicrobial-susceptible Gram-positive BSI did not have longer hospital stays, or higher hospital costs. Patients with resistant "other" (i.e. Gram-negative, Candida, or anaerobic) BSI were found to have a distinct trend towards increased resources use as compared to patients with susceptible "other" BSI, respectively.

Hyperglycaemia upon onset of ICU-acquired bloodstream infection is associated with adverse outcome in a mixed ICU population.

This study aimed to assess whether a relationship exists between hyperglycaemia and outcome in a mixed cohort of critically ill patients with nosocomial bloodstream infection (BSI), and to evaluate patterns of blood glucose levels between survivors and non-survivors. A historical observational cohort study was conducted in the intensive care unit (ICU) of a tertiary care referral centre. One-hundred-and-thirty patients with a microbiologically documented ICU-acquired BSI (period 2003 to 2004) were included. For the study, morning blood glucose levels were evaluated from one day prior until five days after onset of BSI. The contribution of hyperglycaemia, divided in three subgroups (> or = 150 mg/dl, > or = 175 mg/dl and > or = 200 mg/dl), to in-hospital mortality was estimated by logistic regression. In-hospital mortality was 36.2%. Over the seven study days, no differences were found in daily morning blood glucose levels between survivors (n = 83) and non-survivors (n = 47). Nevertheless, the trend of blood glucose levels upon onset of BSI showed a remarkable increase in the non-survivors, whereas it decreased in the survivors. Hyperglycaemia (> or = 175 mg/dl and > or = 200 mg/dl) was observed more often among the non-survivors. Multivariate logistic regression showed that APACHE II (P = 0.002), antibiotic resistance (P = 0.004) and hyperglycaemia (> or = 175 mg/dl) upon onset of BSI (P = 0.017) were independently associated with in-hospital mortality, whereas a history of diabetes (P = 0.041) was associated with better outcome. Hyperglycaemia (> or = 175 mg/dl) upon onset of ICU-acquired BSI is associated with worse outcome in a heterogeneous ICU population. Patterns of morning blood glucose levels have only limited value in the prediction of the individual course.

Critical care nurses' knowledge of evidence-based guidelines for preventing infections associated with central venous catheters: an evaluation questionnaire.

BACKGROUND: Lack of adherence to recommended evidence-based guidelines for preventing infections associated with use of central venous catheters may be due to nurses' lack of knowledge of the guidelines. OBJECTIVE: To develop a reliable and valid questionnaire for evaluating critical care nurses' knowledge of evidence-based guidelines for preventing infections associated with central venous catheters. METHODS: A total of 10 nursing-related strategies were identified from current evidence-based guidelines for preventing infections associated with use of central venous catheters. Face and content validation were determined for selected interventions and multiple-choice questions (1 question per intervention). The test results of 762 critical care nurses were evaluated for item difficulty, item discrimination, and quality of the response alternatives or options for answers (possible responses). RESULTS: All 10 items had face and content validity. Values for item difficulty ranged from 0.1 to 0.9. Values for item discrimination ranged from 0.05 to 0.41. The quality of the response alternatives (0.0-0.8) indicated widespread misconceptions among the critical care nurses in the sample. CONCLUSION: The questionnaire is reliable and has face and content validity. Findings from surveys in which this questionnaire is used can lead to better educational programs for critical care nurses on infections associated with use of central venous catheters.

Critical care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia: an evaluation questionnaire.

BACKGROUND: Nurses' lack of knowledge may be a barrier to adherence to evidence-based guidelines for preventing ventilator-associated pneumonia. OBJECTIVE: To develop a reliable and valid questionnaire for evaluating critical care nurses' knowledge of evidence-based guidelines for preventing ventilator-associated pneumonia. METHODS: Ten nursing-related interventions were identified from a review of evidence-based guidelines for preventing ventilator-associated pneumonia. Selected interventions and multiple-choice questions (1 question per intervention) were subjected to face and content validation. Item difficulty, item discrimination, and the quality of the response alternatives or options for answers (possible responses) were evaluated on the test results of 638 critical care nurses. RESULTS: Face and content validity were achieved for 9 items. Values for item difficulty ranged from 0.1 to 0.9. Values for item discrimination ranged from 0.10 to 0.65. The quality of the response alternatives led to the detection of widespread misconceptions among critical care nurses. CONCLUSION: The questionnaire is reliable and has face and content validity. Results of surveys with this questionnaire can be used to focus educational programs on preventing ventilator-associated pneumonia.

Severe infection, sepsis and acute kidney injury.

Both severe infection and acute kidney injury (AKI) have a high, and rising incidence in critically ill patients admitted to the intensive care unit (ICU), and are associated with increased in-hospital mortality. Septic AKI patients are more severely ill compared to non-septic AKI patients and have worse outcome. Severe infection is a major cause of AKI in ICU patients, while conversely, AKI patients are at increased risk for infection. The dogma from the past relates the development of AKI in sepsis patients to decreased renal blood flow. However, current data suggest that there is no impairment of renal blood flow in patients with sepsis. The pathogenesis of AKI in sepsis is probably related to cytotoxic effects of inflammation, and impaired microcirculation. In addition, hyperglycaemia, and antimicrobial agent-induced drug nephrotoxicity may contribute to the development of AKI. On the other hand, AKI patients are at greater risk for infection as a result of volume overload, dialysis catheter insertion and secondary manipulation, inflammation of the kidneys leading to'organ cross talk', and impaired host immunity.

The value of sepsis definitions in daily ICU-practice.

Sepsis is a major disease entity with important clinical and economic implications. Sepsis is the hosts' reaction to infection and is characterized by a systemic inflammatory response. Because of difficulties in defining sepsis, the SIRS was introduced trying to summarize the inflammatory response in a limited set of elementary characteristics (fever or hypothermia, leucocytosis or leucopenia, tachycardia, hyperventilation). In daily practice it is essential to identify septic patients as soon as possible because early recognition results in better survival rates. However, in order to allow early detection, a more stringent description of "the septic profile" is needed. From the start, even after revision of the primary sepsis description, these definitions have caused much controversy and debate because they lack sensitivity and specificity. Conclusively, almost all patients admitted to the intensive care unit meet or develop the systemic inflammatory response syndrome. Therefore, it is difficult to distinguish patients with true sepsis from those with severe inflammation due to non-infectious causes. This review highlights the current sepsis definitions, and discusses their strengths as well as their shortcomings for daily intensive care unit practice.

Invasive aspergillosis in critically ill patients: attributable mortality and excesses in length of ICU stay and ventilator dependence.

Invasive aspergillosis is a rare disease in intensive care unit (ICU) patients and carries a poor prognosis. The aim of the present study was to determine the attributable mortality due to invasive aspergillosis in critically ill patients. In a retrospective, matched cohort study (July 1997-December 1999), 37 ICU patients with invasive aspergillosis were identified together with 74 control patients. Matching of control (1:2) patients was based on the acute physiology and chronic health evaluation (APACHE) II classification: an equal APACHE II score (+/-1 point) and diagnostic category. This matching procedure results in an equal expected in-hospital mortality for cases and controls. Additionally, control patients were required to have an ICU stay equivalent to or longer than the case before the first culture positive for Aspergillus spp. Patients with invasive aspergillosis were more likely to experience acute renal failure (43.2% versus 20.5%; P = 0.020). They also had a longer ICU stay (median: 13 days versus seven days; P < 0.001) as well as a more extended period of mechanical ventilator dependency (median: 13 days versus four days; P < 0.001). Hospital mortalities for cases and controls were 75.7% versus 56.8%, respectively (P=0.051). The attributable mortality was 18.9% (95% CI: 1.1-36.7). A multivariate survival analysis showed invasive aspergillosis [hazard ratio (HR): 1.9, 95% CI: 1.2-3.0; P = 0.004] and acute respiratory failure (HR: 6.5, 95%: 1.4-29.3; P < 0.016) to be independently associated with in-hospital mortality. In conclusion, it was found that invasive aspergillosis in ICU patients carries a significant attributable mortality of 18.9%. In a multivariate analysis, adjusting for other co-morbidity factors, invasive aspergillosis was recognized as an independent predictor of mortality.

Clinical impact of nosocomial Klebsiella bacteremia in critically ill patients.

In order to determine the clinical impact of Klebsiella bacteremia on critically ill patients, a matched cohort study was conducted between January 1992 and December 2000. During the study period, all intensive care unit (ICU) patients with nosocomial Klebsiella bacteremia were defined as cases (n=52), but two of these patients were excluded from the matched cohort due to incomplete medical records. The remaining 50 patients were matched at a ratio of 1:2 with control patients (n=100) on the basis of the APACHE II severity of disease classification system. Patients with Klebsiella bacteremia experienced acute renal failure and hemodynamic instability more often than controls. They also had a longer ICU stay and longer ventilator dependence. In-hospital mortality rates for cases and controls were nearly equal (36% vs. 37%, respectively; P=0.905). In conclusion, after adjusting accurately for severity of underlying disease and acute illness, no difference in mortality was found between ICU patients with Klebsiella bacteremia and their matched control subjects.