Predictors of inappropriate antimicrobial prescription: Eight-year point prevalence surveys experience in a third level hospital in Spain.

Antibiotic stewardship programs (ASP) have already demonstrated clinical benefits. We aimed to describe the Point Prevalence Surveys (PPS) methodology implemented in our hospital as an efficient tool to guide ASP strategies. Annually repeated PPS were conducted from 2012 to 2019 at a 750-bed university hospital in South Spain. Key quality indicators and inappropriateness of antimicrobial treatment, defined strictly according to local guidelines, were described. Variables associated with inappropriate treatment were identified by bi/multivariable analysis. A total of 1,600 patients were included. We found that 49% of the prescriptions were inappropriate due to unnecessary treatment (14%), not first line drug recommended (14%), inadequate drug according to microbiological results (9%), unsuitable doses (8%), route (3%) or duration (7%). Samples collection presented a significant protective effect together with sepsis presentation at onset and intensive care unit admission. However, age, receiving an empirical treatment and an unknown or urinary source of the infections treated were independent risk factors for inappropriateness. Site and severity of infection were documented in medical charts by prescribers (75 and 61% respectively). PPS may allow identifying the main risk factors for inappropriateness. This simple methodology may be useful for ASP to select modifiable factors to be prioritized for targeted interventions.

Estudio caso-control del impacto clínico de la traqueobronquitis asociada a la ventilación mecánica en pacientes adultos, que no desarrollan neumonía asociada a ventilación mecánica / A case-control study on the clinical impact of ventilator associated tracheobronchitis in adult patients who did not develop ventilator associated pneumonia

Objetivos: El objetivo primario fue determinar si la traqueobronquitis asociada a ventilación mecánica (TAV) está asociada con un aumento de estancia en UCI. Los objetivos secundarios incluyeron prolongación de estancia hospitalaria, así como mortalidad en UCI y hospitalaria. Diseño: Estudio retrospectivo caso-control. Apareamos cada caso con un control en base a los siguientes criterios: periodo de VM al menos tan extenso, como el tiempo en que el caso desarrolla la TAV ± 2 días, gravedad evaluada por la escala APACHE II al ingreso en UCI, igual ± 3, igual motivo de ingreso del paciente, igual edad ± 10 años. Pacientes: Pacientes adultos ingresados en una UCI polivalente de 30 camas, con el diagnóstico de TAV en el periodo 2013-2016. Resultados: Identificamos 76 pacientes con TAV que ingresaron en UCI en el periodo de estudio. No se encontraron controles adecuados para 3 pacientes con TAV. No se encontraron diferencias significativas entre ambos grupos en cuanto a características demográficas, motivo de ingreso y comorbilidades. La estancia media en UCI de los pacientes con traqueobronquitis asociada a ventilación mecánica fue más prolongada en los casos que en los controles, mediana 22d (14-35), comparada con los controles mediana 15d (8-27), p=0,02. Los casos presentaron mayor número de días de VM respecto a los controles, mediana 18 días (9-28) vs. 9 días (5-16) p = 0,03. No encontramos diferencias significativas respecto a la estancia hospitalaria 40d (28-61) vs. 35d (23-54), p= 0,32; mortalidad en UCI (20,5 vs. 31,5% p=0,13) y mortalidad hospitalaria (30,1 vs. 43,8% p= 0,09). Realizamos un análisis del subgrupo de pacientes con TAV con documentación microbiológica y tratamiento empírico adecuado sin encontrar diferencias significativas en ninguno de los aspectos analizados. Conclusiones: La TAV, prolonga los días de estancia en UCI y de ventilación mecánica. Este efecto desaparece cuando los pacientes reciben tratamiento empírico adecuado

Objectives: The main objective was to determine whether ventilator-associated tracheobronchitis (VAT) is related to increased length of ICU stay. Secondary endpoints included prolongation of hospital stay, as well as, ICU and hospital mortality. Design: A retrospective matched case-control study. Each case was matched with a control for duration of ventilation (± 2 days until development of ventilator-associated tracheobronchitis), disease severity (Acute Physiology and Chronic Health Evaluation II) at admission ± 3, diagnostic category and age ±10 years. Patients: Critically ill adults admitted to a polyvalent 30-beds ICU with the diagnosis of VAT in the period 2013-2016. Main results: We identified 76 cases of VAT admitted to our ICU during the study period. No adequate controls were found for 3 patients with VAT. There were no significant differences in demographic characteristics, reasons for admission and comorbidities. Patients with VAT had a longer ICU length of stay, median 22 days (14-35), compared to controls, median 15 days (8-27), p=.02. Ventilator days were also significantly increased in VAT patients, median 18 (9-28) versus 9 days (5-16), p=.03. There was no significant difference in total hospital length of stay 40 (28-61) vs. 35days (23-54), p=.32; ICU mortality (20.5 vs. 31.5% p=.13) and hospital mortality (30.1 vs. 43.8% p=.09). We performed a subanalysis of patients with microbiologically proven VAT receiving adequate antimicrobial treatment and did not observe significant differences between cases and the corresponding controls. Conclusions: VAT is associated with increased length of intensive care unit stay and longer duration of mechanical ventilation. This effect disappears when patients receive appropriate empirical treatment

A case-control study on the clinical impact of ventilator associated tracheobronchitis in adult patients who did not develop ventilator associated pneumonia. / Estudio caso-control del impacto clínico de la traqueobronquitis asociada a la ventilación mecánica en pacientes adultos, que no desarrollan neumonía asociada a ventilación mecánica.

OBJECTIVES: The main objective was to determine whether ventilator-associated tracheobronchitis (VAT) is related to increased length of ICU stay. Secondary endpoints included prolongation of hospital stay, as well as, ICU and hospital mortality. DESIGN: A retrospective matched case-control study. Each case was matched with a control for duration of ventilation (± 2 days until development of ventilator-associated tracheobronchitis), disease severity (Acute Physiology and Chronic Health Evaluation II) at admission ± 3, diagnostic category and age ±10 years. PATIENTS: Critically ill adults admitted to a polyvalent 30-beds ICU with the diagnosis of VAT in the period 2013-2016. MAIN RESULTS: We identified 76 cases of VAT admitted to our ICU during the study period. No adequate controls were found for 3 patients with VAT. There were no significant differences in demographic characteristics, reasons for admission and comorbidities. Patients with VAT had a longer ICU length of stay, median 22 days (14-35), compared to controls, median 15 days (8-27), p=.02. Ventilator days were also significantly increased in VAT patients, median 18 (9-28) versus 9 days (5-16), p=.03. There was no significant difference in total hospital length of stay 40 (28-61) vs. 35days (23-54), p=.32; ICU mortality (20.5 vs. 31.5% p=.13) and hospital mortality (30.1 vs. 43.8% p=.09). We performed a subanalysis of patients with microbiologically proven VAT receiving adequate antimicrobial treatment and did not observe significant differences between cases and the corresponding controls. CONCLUSIONS: VAT is associated with increased length of intensive care unit stay and longer duration of mechanical ventilation. This effect disappears when patients receive appropriate empirical treatment.

A case of pan-resistant Burkholderia cepacia complex bacteremic pneumonia, after lung transplantation treated with a targeted combination therapy.

We describe a case of one patient with cystic fibrosis who developed a pan-resistant Burkholderia cepacia complex rapidly progressive bacteraemic pneunonia, following bilateral lung transplantation. The patient was treated with a targeted combination antibiotic therapy (meropenem plus ceftazidime/avibactam plus high doses of nebulized colistimethate sodium). Evolution of the disease was complicated by multiple organ system dysfunction. Finally, clinical improvement and microbiological cure was achieved.

Clinical characteristics, evolution, and treatment-related risk factors for mortality among immunosuppressed patients with influenza A (H1N1) virus admitted to the intensive care unit.

PURPOSE: Information about immunocompromised patients infected with influenza A (H1N1) virus and requiring admission to the ICU is lacking. Our objective was to know the clinical characteristics of these patients and to identify treatment-related variables associated with mortality. MATERIAL AND METHODS: A prospective multicenter observational cohort study was based on data from a Spanish registry (2009-2015) collected by 148 Spanish ICUs. All patients admitted to the ICU with the diagnosis of influenza A (H1N1) virus infection were included. Immunosuppression was clearly defined. Factors associated with mortality in immunocompromised patients were assessed by conventional logistic regression analysis and by a propensity score (PS) adjusted-multivariable analysis. RESULTS: Of 1899 patients with influenza A (H1N1) infection, 238 (12.5%) were classified as immunocompromised. Mortality was significantly higher in immunosuppressed patients. Four variables independently associated with mortality were identified: SOFA score, need of vasopressor, use of corticosteroids, and acute renal failure, AKIN 3 stage. In the PS-adjusted model, corticosteroid therapy remained as an independent factor associated with increased mortality (OR 2.25;95%CI, 1.15-4.38;p = 0.017). In the subgroup of hematological patients (n = 141), corticosteroid therapy was also associated with increased mortality (OR 3.12; 95%CI, 1.32-7.41; p = 0.010). CONCLUSION: Immunocompromised individuals with influenza A (H1N1) admitted to the ICU have a poor outcome. In this population, the use of corticosteroids is strongly discouraged.

To which extent can we decrease antibiotic duration in critically ill patients?

INTRODUCTION: Inadequate empirical antibiotic therapy is associated with higher mortality in critically ill patients with severe infections. Nevertheless, prolonged duration of antibiotic treatment is also potentially harmful. Development of new infections with more resistant pathogens is one of the arguments against the administration of prolonged courses of antibiotics. Areas covered: We aim to describe the optimal duration of antimicrobial therapy in the most common infections affecting critically ill patients. A literature search was performed to identify all clinical trials, observational studies, meta-analysis, and reviews about this topic from PubMed. Expert commentary: Diverse observational studies have reported a poor outcome in critically ill patients without a documented infection who receive prolonged antibiotic therapy. We summarize the available information about the optimal duration of antimicrobial therapy in critically ill patients with severe infections including community-acquired pneumonia, intra-abdominal infections, bacteremia, meningitis and urinary-tract infections as well as the clinical consequences of short antimicrobial courses in certain severe infections. The utility of procalcitonin to reduce the duration of antibiotics is also discussed. Finally, we give clear recommendations about the length of treatment for the most common infections in critically ill patients.