Invasive fungal infection in crtically ill patients: hurdles and next challenges.

A narrative review from a multidisciplinary task force of experts in critical care medicine and clinical mycology was carried out. The multi drug-resistant species Candida auris has emerged simultaneously on several continents, causing hospital outbreaks, especially in critically ill patients. Although there are not enough data to support the routine use of continuous antibiotic prophylaxis in patients subjected to extracorporeal membrane oxygenator, a clear increase of invasive fungal infection (IFI) has been described with the use of this device. Possible IFI treatment failures could be related with suboptimal antifungal concentrations despite dose adjustment. Invasive aspergillosis has become an important life-threating infection in intensive care unit related with new risk factors described. IFI remain important problem in critical patients due to the appearance of new risk factors, new species, and resistance increase. Multidisciplinary packages of measures designed to reduce IFI incidence and improve diagnostics tools may reduce the high mortality associated.

Epidemiology, antibiotic therapy and clinical outcomes of healthcare-associated pneumonia in critically ill patients: a Spanish cohort study.

PURPOSE: Information about healthcare-associated pneumonia (HCAP) in critically ill patients is scarce. METHODS: This prospective study compared clinical presentation, outcomes, microbial etiology, and treatment of HCAP, community-acquired pneumonia (CAP), and immunocompromised patients (ICP) with severe pneumonia admitted to 34 Spanish ICUs. RESULTS: A total of 726 patients with pneumonia (449 CAP, 133 HCAP, and 144 ICP) were recruited during 1 year from April 2011. HCAP patients had more comorbidities and worse clinical status (Barthel score). HCAP and ICP patients needed mechanical ventilation and tracheotomy more frequently than CAP patients. Streptococcus pneumoniae was the most frequent pathogen in all three groups (CAP, 34.2 %; HCAP, 19.5 %; ICP, 23.4 %; p = 0.001). The overall incidence of Gram-negative pathogens, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa was low, but higher in HCAP and ICP patients than CAP. Empirical treatment was in line with CAP guidelines in 73.5 % of patients with CAP, in 45.5 % of those with HCAP, and in 40 % of those with ICP. The incidence of inappropriate empirical antibiotic therapy was 6.5 % in CAP, 14.4 % in HCAP, and 21.8 % in ICP (p < 0.001). Mortality was highest in ICP (38.6 %) and did not differ between CAP (18.4 %) and HCAP (21.2 %). CONCLUSIONS: HCAP accounts for one-fifth of cases of severe pneumonia in patients admitted to Spanish ICUs. The empirical antibiotic therapy recommended for CAP would be appropriate for 90 % of patients with HCAP in our population, and consequently the decision to include coverage of multidrug-resistant pathogens for HCAP should be cautiously judged in order to prevent the overuse of antimicrobials.

Epidemiology, diagnosis and treatment of fungal respiratory infections in the critically ill patient.

OBJECTIVE: To elaborate practical recommendations based on scientific evidence, when available, or on expert opinions for the diagnosis, treatment and prevention of fungal respiratory infections in the critically ill patient, including solid organ transplant recipients. METHODS: Twelve experts from two scientific societies (The Spanish Society for Chemotherapy and The Spanish Society of Intensive Care and Coronary Units) reviewed in a meeting held in March 2012 epidemiological issues and risk factors as basis for a document about prevention, diagnosis and treatment of respiratory fungal infections caused by Candida spp., Aspergillus spp or Zygomycetes. RESULTS: Despite the frequent isolation of Candida spp. from respiratory tract samples, antifungal treatment is not recommended since pneumonia by this fungal species is exceptional in non-neutropenic patients. In the case of Aspergillus spp., approximately 50% isolates from the ICU represent colonization, and the remaining 50% cases are linked to invasive pulmonary aspergillosis (IPA), an infection of high mortality. Main risk factors for invasive disease in the ICU are previous treatment with steroids and chronic obstructive pulmonary disease (COPD). Collection of BAL sample is recommended for culture and galactomannan determination. Voriconazole and liposomal amphotericin B have the indication as primary therapy while caspofungin has the indication as salvage therapy. Although there is no solid data supporting scientific evidence, the group of experts recommends combination therapy in the critically ill patient with sepsis or severe respiratory failure. Zygomycetes cause respiratory infection mainly in neutropenic patients, and liposomal amphotericin B is the elective therapy. CONCLUSIONS: Presence of fungi in respiratory samples from critically ill patients drives to different diagnostic and clinical management approaches. IPA is the most frequent infection and with high mortality.

Morbidity and mortality associated with primary and catheter-related bloodstream infections in critically ill patients.

PURPOSE: To analyze the impact of primary and catheterrelated bloodstream infections (PBSI/CRBSI) on morbidity and mortality. METHODS: A matched case-control study (1:4) was carried out on a Spanish epidemiological database of critically ill patients (ENVIN-HELICS). To determine the risk of death in patients with PBSI/CRBSI a matched Cox proportional hazard regression analysis was performed. RESULTS: Out of the 74,585 registered patients, those with at least one episode of monomicrobial PBSI/CRBSI were selected and paired with patients without PBSI/CRBSI for demographic and diagnostic criteria and seriousness of their condition on admission to the Intensive Care Unit (ICU). for mortality analysis, 1,879 patients with PBSI/CRBSI were paired with 7,516 controls. The crude death rate in the ICU was 28.1% among the cases and 18.7% among the controls. Attributable mortality 9.4% (HR:1.20; 95% confidence interval: 1.07-1.34; p<0.001). Risk of death varied according to the source of infection, aetiology, moment of onset of bloodstream infection and severity on admission to the ICU. The median stay in the ICU of patients who survived PBSI/CRBSI was 13 days longer than the controls, also varying according to aetiology, moment of onset of bloodstream infection and severity on admission. CONCLUSIONS: Acquisition of PBSI/CRBSI in critically ill patients significantly increases mortality and length of ICU stay, which justifies prevention efforts.

Morbidity and mortality associated with primary and catheter-related bloodstream infections in critically ill patients

Objetivos. El propósito de este estudio es analizar el impacto de la bacteriemia primaria y relacionada con catéter (BP/ BRC) en la morbilidad y mortalidad. Métodos. Con datos pertenecientes a la base de datos epidemiológica de pacientes críticos en España ENVIN-HELICS, se realiza un estudio casos controles (1:4). Para analizar el riesgo de muerte en pacientes con BP/BRC se realiza un estudio emparejado de riesgos proporcionales de Cox. Resultados. De 74.585 pacientes registrados, se buscó pacientes con al menos un episodio de BP/BRC monomicrobiana y fueron emparejados con pacientes sin BP/BRC por criterios demográficos, diagnósticos y de gravedad al ingreso en la Unidad de Cuidados Intensivos (UCI). Para el análisis de mortalidad 1.879 pacientes con BP/BRC fueron emparejados con 7.516 controles. La mortalidad cruda en UCI fue del 28,1 % en los casos y 18,7 % en los controles. Mortalidad atribuida 9,4 %. (HR:1,20; intervalo confianza 95 %: 1,07 - 1,34; p<0,001). El riesgo de muerte varía de acuerdo a la fuente de la infección, la etiología, el momento de aparición de la bacteriemia y la gravedad al ingreso en UCI. Los pacientes que sobreviven y sufren una BP/BRC tienen una estancia en UCI 13 días de mediana más prolongada que los controles, variando también según la etiología, el momento de aparición de la bacteriemia y la gravedad al ingreso en UCI. Conclusiones. En pacientes críticos, la adquisición de una BP/BRC produce un significativo incremento de la mortalidad y la estancia, lo que justifica los esfuerzos de prevención(AU)

Purpose. To analyze the impact of primary and catheterrelated bloodstream infections (PBSI/CRBSI) on morbidity and mortality. Methods. A matched case-control study (1:4) was carried out on a Spanish epidemiological database of critically ill patients (ENVIN-HELICS). To determine the risk of death in patients with PBSI/CRBSI a matched Cox proportional hazard regression analysis was performed. Results. Out of the 74,585 registered patients, those with at least one episode of monomicrobial PBSI/CRBSI were selected and paired with patients without PBSI/CRBSI for demographic and diagnostic criteria and seriousness of their condition on admission to the Intensive Care Unit (ICU). For mortality analysis, 1,879 patients with PBSI/CRBSI were paired with 7,516 controls. The crude death rate in the ICU was 28.1% among the cases and 18.7% among the controls. Attributable mortality 9.4% (HR:1.20; 95% confidence interval: 1.07-1.34; p<0.001). Risk of death varied according to the source of infection, aetiology, moment of onset of bloodstream infection and severity on admission to the ICU. The median stay in the ICU of patients who survived PBSI/CRBSI was 13 days longer than the controls, also varying according to aetiology, moment of onset of bloodstream infection and severity on admission. Conclusions. Acquisition of PBSI/CRBSI in critically ill patients significantly increases mortality and length of ICU stay, which justifies prevention efforts(AU)

Guía multidisciplinar para la valoración pronóstica, diagnóstico y tratamiento de la neumonía adquirida en la comunidad / Multidisciplinary guidelines for the management of community-acquired pneumonia

La neumonía adquirida en la comunidad (NAC) es una enfermedad infecciosa respiratoria aguda que tiene una incidencia que oscila entre 3 y 8 casos por 1.000 habitantes por año. Esta incidencia aumenta con la edad y las comorbilidades. El 40% de los pacientes con NAC requieren ingreso hospitalario y alrededor del 10% necesitan ser admitidos en una Unidad de Cuidados Intensivos (UCI). La mortalidad global de la NAC está alrededor del 10%. Diversos estudios han sugerido que la implementación de guías clínicas mejora la evolución del paciente tanto en mortalidad como en estancia hospitalaria. Las guías clínicas más recientes y más utilizadas son la de la Infectious Diseases Society of America/American Thoracic Society, publicada en 2007, la de la British Thoracic Society, publicada en 2009, y la de la European Respiratory Society en colaboracio´n con la European Society of Clinical Microbiology and Infectious Diseases, publicada en 2011. En España, la más reciente es la normativa de la Sociedad Española de Neumología y Cirugía Torácica, publicada en el año 2010. La presente guía clínica GNAC es multidisciplinar y ha contado con la ayuda del Centro Cochrane Iberoamericano (CCIB) para la síntesis de las guías previas y la selección de la bibliografía. Esta guía clínica está diseñada para ser utilizada por todos los profesionales que pueden participar en el proceso asistencial de la NAC en sus vertientes diagnóstica, de caracterización de la gravedad, de tratamiento y de prevención. Para cada uno de los siguientes apartados se han desarrollado tablas con recomendaciones donde se clasifica su evidencia, la fortaleza de la misma y su aplicabilidad práctica según la clasificación Grading of Recommendations of Assessment Development and Evaluations (GRADE): 1. Epidemiología, etiología microbiana y resistencias microbianas. 2. Diagnóstico clínico y microbiológico. 3. Escalas pronósticas y decisión de ingreso hospitalario. 4. Criterios de ingreso en la UCI. 5. Tratamiento antibiótico empírico y tratamiento antibiótico definitivo. 6. Falta de respuesta al tratamiento antibiótico. 7. Vacunaciones en la prevención de la NAC (AU)

Community-acquired pneumonia (CAP) is an infectious respiratory disease with an incidence that ranges from 3 to 8 cases per 1,000 inhabitants per year. This incidence increases with age and comorbidities. Forty per cent of CAP patients require hospitalization and around 10% of these patients are admitted in an Intensive Care Unit (ICU). Several studies have suggested that the implementation of clinical guidelines has a positive impact in the outcome of patients including mortality and length of stay. The more recent and used guidelines are those from Infectious Diseases Society of America/American Thoracic Society, published in 2007, the 2009 from the British Thoracic Society, and that from the European Respiratory Society/European Society of Clinical Microbiology and Infectious Diseases, published in 2010. In Spain, the most recently released guideline is the Sociedad Española de Neumología y Cirugía Torácica-2011 guideline. The present guidelines GNAC are designed to be used by the majority of health-care professionals that can participate in the care of CAP patients including diagnosis, decision of hospital and ICU admission, treatment and prevention. The Centro Cochrane Iberoamericano (CCIB) has participated in summarizing the previous guidelines and in the bibliography search. For each one of the following sections the panel of experts has developed a table with recommendations classified according to its evidence, strength and practical applicability using the Grading of Recommendations of Assessment Development and Evaluations (GRADE) system: 1. Epidemiology, microbiological etiology and antibiotic resistances. 2. Clinical and microbiological diagnosis. 3. Prognostic scales and decision of hospital admission. 4. ICU admission criteria. 5. Empirical and definitive antibiotic treatment. 6. Treatment failure. 7. Prevention (AU)

[Multidisciplinary guidelines for the management of community-acquired pneumonia]. / Guía multidisciplinar para la valoración pronóstica, diagnóstico y tratamiento de la neumonía adquirida en la comunidad.

Community-acquired pneumonia (CAP) is an infectious respiratory disease with an incidence that ranges from 3 to 8 cases per 1,000 inhabitants per year. This incidence increases with age and comorbidities. Forty per cent of CAP patients require hospitalization and around 10% of these patients are admitted in an Intensive Care Unit (ICU). Several studies have suggested that the implementation of clinical guidelines has a positive impact in the outcome of patients including mortality and length of stay. The more recent and used guidelines are those from Infectious Diseases Society of America/American Thoracic Society, published in 2007, the 2009 from the British Thoracic Society, and that from the European Respiratory Society/European Society of Clinical Microbiology and Infectious Diseases, published in 2010. In Spain, the most recently released guideline is the Sociedad Española de Neumología y Cirugía Torácica-2011 guideline. The present guidelines GNAC are designed to be used by the majority of health-care professionals that can participate in the care of CAP patients including diagnosis, decision of hospital and ICU admission, treatment and prevention. The Centro Cochrane Iberoamericano (CCIB) has participated in summarizing the previous guidelines and in the bibliography search. For each one of the following sections the panel of experts has developed a table with recommendations classified according to its evidence, strength and practical applicability using the Grading of Recommendations of Assessment Development and Evaluations (GRADE) system: 1. Epidemiology, microbiological etiology and antibiotic resistances.2. Clinical and microbiological diagnosis.3. Prognostic scales and decision of hospital admission.4. ICU admission criteria. 5. Empirical and definitive antibiotic treatment.6. Treatment failure. 7. Prevention.

[Bacterial infections in critically ill patients: review of studies published between 2006 and 2008]. / Infecciones bacterianas en el paciente crítico: revisión de los estudios publicados entre 2006 y 2008.

A systematic revision of medical publications between 2006 and 2008 regarding bacterial infections that affect the critical patients was performed. Four subjects were selected: Community-acquired pneumonia, ventilator-associated pneumonia, catheter-related bloodstream infection and new antimicrobial treatments. When dealing with community-acquired pneumonia and due to the absence of completely reliable standards, it is necessary to follow the locally adapted guidelines of clinical practice, to identify patients related to the health-care system and admit patients to the ICU in accordance with the criteria. Regarding the etiological diagnosis of ventilator-associated pneumonia, any microbiological information available must be used. Due to the risk of multidrug bacteria, combined empiric therapy should be initiated immediately and then mono-therapy adjusted to the antibiogram should be established. Already established measures for mechanical ventilation associated pneumonia and catheter-related bacteriemias, which have been effective, should be implemented. The empirical treatment of catheter-related bacteremia must be directed towards the most probable pathogens according to the puncture site. The most recently sold antibiotics are basically directed towards multidrug gram positive resistant bacteria. However, for the treatment of gram negative resistant bacilli, the use of the new antimicrobials must be combined with a new evaluation of the antibiotics that have been used for years and the possibility of choosing different administration forms.

Evaluación del estado de gravedad de pacientes con infecciones graves. Criterios de ingreso en unidades de cuidados intensivos / Evaluation of the status of patients with severe infection, criteria for intensive care unit admittance

En los últimos años se ha constatado que la atención precoz de pacientes con infecciones graves se asocia a una mejoría en el pronóstico. La asistencia en la unidad de cuidados intensivos (UCI) puede proporcionar gran parte de esta atención, por lo que el ingreso en la UCI debe realizarse de la manera más precoz posible, antes de que el deterioro clínico sea irreversible.El objetivo de este artículo es recoger las recomendaciones de evaluación del estado de gravedad de los pacientes con infecciones y los criterios para el ingreso en la UCI y actualizar los criterios publicados hace 10 años.Se ha realizado una revisión de la literatura médica y se recogen las opiniones de expertos pertenecientes a la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica y a la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias y dentro de éstas a los grupos de trabajo de infecciones en el paciente crítico. Se describen las recomendaciones específicas de ingreso en la UCI referidas a las infecciones más frecuentes que afectan a pacientes que pueden beneficiarse de cuidados críticos. Se incide en la valoración del estado de gravedad que permita una asistencia intensiva más precoz (AU)

Recent studies have shown that early attention in patients with serious infections is associated with a better outcome. Assistance in intensive care units (ICU) can effectively provide this attention; hence patients should be admitted to the ICU as soon as possible, before clinical deterioration becomes irreversible. The objective of this article is to compile the recommendations for evaluating disease severity in patients with infections and describe the criteria for ICU admission, updating the criteria published 10 years ago.A literature review was carried out, compiling the opinions of experts from the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC, Spanish Society for Infectious Diseases and Clinical Microbiology) and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC, Spanish Society for Intensive Medicine, Critical Care and Coronary Units) as well as the working groups for infections in critically ill patients (GEIPC-SEIMC and GTEI-SEMICYUC).We describe the specific recommendations for ICU admission related to the most common infections affecting patients, who will potentially benefit from critical care. Assessment of the severity of the patient's condition to enable early intensive care is stressed (AU)

[Evaluation of the status of patients with severe infection, criteria for intensive care unit admittance. Spanish Society for Infectious Diseases and Clinical Microbiology. Spanish Society of Intensive and Critical Medicine and Coronary Units]. / Evaluación del estado de gravedad de pacientes con infecciones graves. Criterios de ingreso en unidades de cuidados intensivos. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica y a la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias.

Recent studies have shown that early attention in patients with serious infections is associated with a better outcome. Assistance in intensive care units (ICU) can effectively provide this attention; hence patients should be admitted to the ICU as soon as possible, before clinical deterioration becomes irreversible. The objective of this article is to compile the recommendations for evaluating disease severity in patients with infections and describe the criteria for ICU admission, updating the criteria published 10 years ago. A literature review was carried out, compiling the opinions of experts from the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC, Spanish Society for Infectious Diseases and Clinical Microbiology) and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC, Spanish Society for Intensive Medicine, Critical Care and Coronary Units) as well as the working groups for infections in critically ill patients (GEIPC-SEIMC and GTEI-SEMICYUC). We describe the specific recommendations for ICU admission related to the most common infections affecting patients, who will potentially benefit from critical care. Assessment of the severity of the patient's condition to enable early intensive care is stressed.

Infecciones bacterianas en el paciente crítico: revisión de los estudios publicados entre 2006 y 2008 / Bacterial infections in critically ill patients: review of studies published between 2006 and 2008

Se ha realizado una revisión de las publicaciones médicas entre los años 2006 y 2008 sobre infecciones bacterianas que afectan a los pacientes críticos. Se han seleccionado cuatro temas: neumonía adquirida en la comunidad, neumonía asociada a ventilación mecánica, bacteriemia asociada a catéter y nuevos tratamientos antimicrobianos. En neumonía comunitaria se debe seguir las guías de práctica clínica adaptadas localmente, identificar a los pacientes con relacionados con los sistemas sociosanitarios e ingresar a los pacientes en UCI según criterios clínicos, por la ausencia de normativas completamente fiables. Es necesario aprovechar cualquier información microbiológicapara el diagnóstico de neumonía asociada a ventilación mecánica. Ante el riesgo de patógenos multirresistentes, hay que iniciar tratamiento combinado y luego pasar a monoterapia ajustada al antibiograma. Se debe implantar medidas de prevención de neumonía asociada a ventilación mecánica y bacteriemias relacionadas con catéter ya establecidas y que hayan resultado eficaces. El tratamiento empírico de la bacteriemia relacionada con catéter debe ir dirigido contra los patógenos más probables según el lugar de punción. Los nuevos antibióticos recientemente comercializados están dirigidos básicamente hacia bacterias grampositivas resistentes, mientras que para el tratamiento de los bacilos gramnegativos resistentes es necesario combinar el uso de los nuevos antimicrobianos con una nueva valoración de los antibióticos utilizados desde hace años y la posibilidad de elegir distintas formas de administración (AU)

A systematic revision of medical publications between 2006 and 2008 regarding bacterial infections that affect the critical patients was performed. Four subjects were selected: Community-acquired pneumonia, ventilator-associated pneumonia, catheter-related bloodstream infection and new antimicrobial treatments. When dealing with community-acquired pneumonia and due to the absence of completely reliable standards, it is necessary to follow the locally adapted guidelines of clinical practice, to identify patients related to the health-care system and admit patients to the ICU in accordance with the criteria. Regarding the etiological diagnosis of ventilator-associated pneumonia, any microbiological information available must be used. Due to the risk of multidrug bacteria, combined empiric therapy should be initiated immediately and then monotherapy adjusted to the antibiogram should be established. Already established measures for mechanical ventilation associated pneumonia and catheter-related bacteriemias, which have been effective, should be implemented. The empirical treatment of catheter-related bacteremia must be directed towards the most probable pathogens according to the puncture site. The most recently sold antibiotics are basically directed towards multidrug gram positive resistant bacteria. However, for the treatment of gram negative resistant bacilli, the use of the new antimicrobials must be combined with a new evaluation of the antibiotics that have been used for years and the possibility of choosing different administration forms (AU)

[Recommendations for antibiotic monitoring in ICU patients]. / Recomendaciones para la monitorización de antibióticos en pacientes críticos ingresados en UCI.

Monitoring plasma concentrations of antimicrobial agents used to treat infection in critically ill patients is one of the recommended strategies for improving clinical outcome. Drug monitoring has a double aim: to limit adverse events and to increase the effectiveness of the drugs. In clinical practice, however, this approach is mainly limited to monitoring plasma concentrations of vancomycin and aminoglycosides, although future extension to other antimicrobial agents would be desirable. Application of this technique varies considerably between hospitals, and this makes interpretation and comparison of the results obtained difficult. For this reason, representatives of various scientific societies related to the pharmacokinetic area have developed a series of recommendations for monitoring plasma concentrations of antimicrobials using vancomycin and several aminoglycosides as the reference. The recommendations are based on 14 questions encompassing all steps of the process: indication for the test, blood sampling (timing of blood collection, blood volume, tubes), transport to the laboratory, techniques applied, normal values, dose adjustment, and reporting the results. The purpose of these guidelines is to develop a process of monitoring plasma antimicrobial concentrations that is as homogeneous as possible to facilitate the design of multicenter studies, as well as the interpretation and comparison of results.

[Recommendations for antibiotic monitoring in ICU patients]. / Recomendaciones para la monitorización de antibióticos en pacientes críticos ingresados en UCI.

UNLABELLED: Monitoring plasma concentrations of antimicrobial agents used to treat infection in critically ill patients is one of the recommended strategies for improving clinical outcome. Drug monitoring has a double AIM: to limit adverse events and to increase the effectiveness of the drugs. In clinical practice, however, this approach is mainly limited to monitoring plasma concentrations of vancomycin and aminoglycosides, although future extension to other antimicrobial agents would be desirable. Application of this technique varies considerably between hospitals, and this makes interpretation and comparison of the results obtained difficult. For this reason, representatives of various scientific societies related to the pharmacokinetic area have developed a series of recommendations for monitoring plasma concentrations of antimicrobials using vancomycin and several aminoglycosides as the reference. The recommendations are based on 14 questions encompassing all steps of the process: indication for the test, blood sampling (timing of blood collection, blood volume, tubes), transport to the laboratory, techniques applied, normal values, dose adjustment, and reporting the RESULTS: The purpose of these guidelines is to develop a process of monitoring plasma antimicrobial concentrations that is as homogeneous as possible to facilitate the design of multicenter studies, as well as the interpretation and comparison of results.

Actualización sobre infecciones en pacientes de la UCI / Update on infections in ICU patients

Studies carried out in 2006 on severe community-acquiredpneumonia or nosocomial pneumonia requiring admissionto the ICU are numerous and of a high quality. Amongstudies of community-acquired pneumonia, the mostrelevant are those focused on the development andevaluation of systems for the identification of patientswith severe pneumonia, analysis of the impact of theinitial inflammatory response on the course of the disease,and level of adherence to therapeutic guidelines proposedby different scientific societies. Among studiesof nosocomial pneumonia, those involving ventilatorassociatedpneumonia and health care-associatedpneumonia should be emphasized. The reliabilityof different respiratory sampling methods for theetiological diagnosis of pneumonia, the impact of differentetiological agents, and the efficacy of prophylacticmeasures have been the object of different investigations.Important aspects of these studies include the assessmentof different strategies in the use of antimicrobial agentsto decrease the selection of multiresistant pathogens.Moreover, early identification of patients at risk of invasivefungal infections, as well as preemptive treatmentof these infections in selected patients have beentopics of increasing interest(AU)

Los estudios realizados en 2006 sobre la neumoníaextrahospitalaria grave o la neumonía nosocomialque requieren el ingreso en la UCI son numerosos y degran calidad. Entre los trabajos sobre la neumoníaextrahospitalaria, los más relevantes son los que se basanen el desarrollo y la valoración de los sistemas paraidentificar a los pacientes con neumonía grave, en elanálisis del impacto de la respuesta inflamatoria inicialsobre el curso de la enfermedad, y en el nivel deseguimiento de las normas terapéuticas propuestas pordiferentes sociedades científicas. Entre los estudios sobrela neumonía nosocomial, cabe destacar los relacionadoscon la neumonía asociada al respirador o a la asistenciasanitaria. La fiabilidad de los distintos métodos paraobtener muestras respiratorias con el fin de establecerel diagnóstico etiológico, el impacto de los diferentesagentes etiológicos, y la eficacia de las medidasprofilácticas, han sido objeto de diversas investigaciones.Entre los aspectos importantes de estos estudios se hallala valoración de las diferentes estrategias para el usode los agentes antimicrobianos con el fin de reducir laselección de los gérmenes plurirresistentes. Además,la identificación precoz de los pacientes con riesgo deinfecciones micóticas invasivas, así como el tratamientoprecoz de estas infecciones en determinados pacientes,han sido otros tantos temas de interés general(AU)

Recomendaciones para la monitorización de antibióticos en pacientes críticos ingresados en UCI / Recommendations for antibiotic monitoring in ICU patients

La monitorización de concentraciones plasmáticas de los antimicrobianos utilizados para el tratamiento de infecciones en pacientes críticos es una de las estrategias planteadas para mejorar los resultados clínicos. El objetivo de la monitorización es doble: limitar los efectos adversos y aumentar la efectividad de los antimicrobianos. Su desarrollo clínico se limita prácticamente a la monitorización de vancomicina y aminoglucósidos, aunque es deseable su extensión, en el futuro, al resto de antimicrobianos. La aplicación de esta técnica está sometida a múltiples variaciones entre hospitales, lo que dificulta la interpretación y comparación de resultados. Por este motivo, representantes de diversas sociedades científicas relacionadas con el área de la farmacocinética han elaborado un conjunto de recomendaciones para la monitorización plasmática de antimicrobianos utilizando como referencia la vancomicina y los distintos aminoglucósidos. La recomendaciones se realizan en torno a 14 preguntas que abarcan todas las etapas de proceso: indicación de la prueba, extracción de la muestra (tiempo de extracción, cantidad de sangre, tubos), traslado al laboratorio, técnicas aplicables, valores de normalidad, ajuste de dosis y comunicación de resultados. El objetivo de las recomendaciones es homogeneizar en la medida de lo posible el proceso de la monitorización de estos antimicrobianos y facilitar con ello la realización de estudios multicéntricos y la comparación e interpretación de los resultados (AU)

Monitoring plasma concentrations of antimicrobial agents used to treat infection in critically ill patients is one of the recommended strategies for improving clinical outcome. Drug monitoring has a double aim: to limit adverse events and to increase the effectiveness of the drugs. In clinical practice, however, this approach is mainly limited to monitoring plasma concentrations of vancomycin and aminoglycosides, although future extension to other antimicrobial agents would be desirable. Application of this technique varies considerably between hospitals, and this makes interpretation and comparison of the results obtained difficult. For this reason, representatives of various scientific societies related to the pharmacokinetic area have developed a series of recommendations for monitoring plasma concentrations of antimicrobials using vancomycin and several aminoglycosides as the reference. The recommendations are based on 14 questions encompassing all steps of the process: indication for the test, blood sampling (timing of blood collection, blood volume, tubes), transport to the laboratory, techniques applied, normal values, dose adjustment, and reporting the results. The purpose of these guidelines is to develop a process of monitoring plasma antimicrobial concentrations that is as homogeneous as possible to facilitate the design of multicenter studies, as well as the interpretation and comparison of results (AU)

Update on infections in ICU patients

Los estudios realizados en 2006 sobre la neumoníaextrahospitalaria grave o la neumonía nosocomialque requieren el ingreso en la UCI son numerosos y degran calidad. Entre los trabajos sobre la neumoníaextrahospitalaria, los más relevantes son los que se basan en el desarrollo y la valoración de los sistemas para identificar a los pacientes con neumonía grave, en el análisis del impacto de la respuesta inflamatoria inicial sobre el curso de la enfermedad, y en el nivel deseguimiento de las normas terapéuticas propuestas pordiferentes sociedades científicas. Entre los estudios sobre la neumonía nosocomial, cabe destacar los relacionados con la neumonía asociada al respirador o a la asistencia sanitaria. La fiabilidad de los distintos métodos para obtener muestras respiratorias con el fin de establecer el diagnóstico etiológico, el impacto de los diferentes agentes etiológicos, y la eficacia de las medidas profilácticas, han sido objeto de diversas investigaciones. Entre los aspectos importantes de estos estudios se halla la valoración de las diferentes estrategias para el uso de los agentes antimicrobianos con el fin de reducir la selección de los gérmenes plurirresistentes. Además, la identificación precoz de los pacientes con riesgo de infecciones micóticas invasivas, así como el tratamiento precoz de estas infecciones en determinados pacientes,han sido otros tantos temas de interés general

Studies carried out in 2006 on severe community-acquiredpneumonia or nosocomial pneumonia requiring admissionto the ICU are numerous and of a high quality. Amongstudies of community-acquired pneumonia, the mostrelevant are those focused on the development andevaluation of systems for the identification of patientswith severe pneumonia, analysis of the impact of theinitial inflammatory response on the course of the disease, and level of adherence to therapeutic guidelines proposed by different scientific societies. Among studies of nosocomial pneumonia, those involving ventilatorassociated pneumonia and health care-associatedpneumonia should be emphasized. The reliabilityof different respiratory sampling methods for theetiological diagnosis of pneumonia, the impact of different etiological agents, and the efficacy of prophylactic measures have been the object of different investigations. Important aspects of these studies include the assessment of different strategies in the use of antimicrobial agents to decrease the selection of multiresistant pathogens. Moreover, early identification of patients at risk of invasive fungal infections, as well as preemptive treatment of these infections in selected patients have been topics of increasing interest (AU)

Update: sepsis and septic shock / Actualización: sepsis y shock séptico

Severe sepsis and septic shock are common causes of death in intensive care units (ICU). The incidence of sepsis has been increasing over the past two decades, and is expected to continue rising during the next few years. Despite the fact that we know much about the complex pathophysiologic alterations that occur in severe sepsis and septic shock, patients with sepsis remain at a high risk of death. However, in the last few years, new treatment strategies have significantly improved patient outcome. This article reviews nine major studies published during 2004 and 2005: two deal with incidence rates, distribution of pathogens and trends in antibiotic resistance among ICU patients with sepsis; two discuss selected aspects of antibiotic therapy, the usefulness of combination therapy for sepsis in immunocompetent patients and the impact of empirical treatment in Pseudomonas aeruginosa bloodstream infections; two consider the usefulness of risk assessment in the management of sepsis and the importance of dynamic clinical evolution of critically ill patients with infection. The remaining three studies analyze adjunctive therapy in severe sepsis: the effect of an intensive glucose-management protocol on the outcome of critically ill patients; the evaluation of relative adrenal insufficiency and the variability of cortisol plasma concentrations over a 24-hour period; and the use of Drotrecogin alfa (Activated) for adults with severe sepsis and a low risk of death

La sepsis grave y el shock séptico son causas frecuentes de fallecimiento en las unidades de cuidados intensivos (UCI). La incidencia de sepsis se ha incrementado durante los 2 últimos decenios y se considera que lo va a seguir haciendo durante los próximos años. A pesar de que actualmente poseemos mucha más información acerca de las complejas alteraciones fisiopatológicas que tienen lugar en la sepsis grave y en el shock séptico, los pacientes con sepsis siguen presentando un elevado riesgo de muerte. Sin embargo, durante los últimos años la introducción de nuevas estrategias terapéuticas ha mejorado significativamente el pronóstico de estos pacientes. En este artículo se revisan nueve estudios de gran envergadura publicados en 2004 y 2005: en dos de ellos se abordan las tasas de incidencia, la distribución de los patógenos y las tendencias en la resistencia frente a los antibióticos en los pacientes con sepsis atendidos en la UCI; en otros dos artículos se exponen diversos aspectos seleccionados del tratamiento antibiótico, la utilidad del tratamiento de combinación en los cuadros de sepsis que presentan los pacientes inmunocompetentes y el impacto del tratamiento empírico en los cuadros de sepsis causados por Pseudomonas aeruginosa; en otras dos publicaciones se consideran la utilidad de la evaluación del riesgo en el tratamiento de la sepsis y la importancia de una evaluación clínica dinámica en los pacientes con infección y en situación clínica crítica. En los tres estudios restantes se analiza el tratamiento complementario en la sepsis grave: el efecto de un protocolo de control intensivo de la glucemia sobre la evolución de los pacientes en situación clínica crítica; la evaluación de la insuficiencia suprarrenal relativa y de la variabilidad de las concentraciones plasmáticas de cortisol durante un período de 24 horas, y el uso de drotrecogina alfa (activada) en los adultos con sepsis grave y riesgo bajo de muerte

[Staphylococcus aureus nosocomial infections in critically ill patients admitted in intensive care units]. / Infecciones nosocomiales por Staphylococcus aureus en pacientes críticos en unidades de cuidados intensivos.

BACKGROUND AND OBJECTIVE: To investigate the frequency of nosocomial infections caused by Staphylococcus aureus in critically ill patients admitted to Spanish intensive care units (ICUs) and to describe the characteristics and outcome of patients in whom this pathogen was isolated. PATIENTS AND METHOD: Prospective, observational, and multicenter study. All patients admitted during one or 2 months to the participating ICUs in the National Nosocomial Infection Surveillance Study (ENVIN) between 1997 and 2003 were included. Patients were classified as infected by S. aureus, infected by other microorganisms, and without nosocomial infection. RESULTS: A total of 34,914 patients were controlled of whom 3,450 (9.9%) had acquired a nosocomial infection during his/her ICU stay (16.0 infections per 100 patients). In 682 (19.8%) patients, a total of 775 infectious episodes in which one of the microorganisms isolated was S. aureus were documented (cumulative incidence 2.2 episodes of S. aureus infection per 100 patients). There was a predominance of S. aureus infection in patients with pneumonia associated with mechanical ventilation (21.4%) and in patients with catheter-related bacteremia (13%). Independent variables associated with S. aureus infection were male sex (odds ratio [OR] = 1.25; 95% confidence interval [CI], 1.03-1.52) and underlying trauma pathology (OR = 1.72, 95%; 95%CI, 1.26-2.35), whereas an older age has been a protective factor (OR = 0.90; 95%CI, 0.84-0.96). Mortality in patients with S. aureus infection was significantly higher than in infections caused by other microorganisms, and in both cases higher than in patients without infection (34.5%, 30.3%, and 10.7%, respectively). In 208 (30.5%) patients, infections due to methicillin-resistant S. aureus were diagnosed, which in turn had increased significantly over the years (p = 0.001). Mortality in patients with methicillin-resistant S. aureus infection was 35.1% compared with 34.2% in patients with methicillin sensitive S. aureus infections (p = NS). CONCLUSIONS: S. aureus was isolated in 19.8% of patients with ICU-acquired infection, particularly in relation to pneumonia in mechanically ventilated patients. Mortality in patients with S. aureus infection was higher than that in patients with infections due to other microorganisms and patients without infection. In contrast, differences in the outcome of patients with infections caused by methicillin-sensitive or methicillin-resistant S. aureus were not found.

Infecciones nosocomiales por Staphylococcus aureus en pacientes críticos en unidades de cuidados intensivos / Staphylococcus aureus nosocomial infections in critically ill patients admitted in intensive care units

Fundamento y objetivo: Investigar la frecuencia de infecciones nosocomiales por Staphylococcus aureus en pacientes críticos ingresados en unidades de cuidados intensivos (UCI) de España y describir las características y la evolución de aquellos en quienes se han aislado. Pacientes y método: Se ha realizado un estudio prospectivo, observacional y multicéntrico, en el que se ha incluido a los pacientes ingresados en las UCI de los hospitales participantes en el Estudio Nacional de Vigilancia de Infección Nosocomial (ENVIN) durante 1 o 2 meses desde el año 1997 hasta 2003. Los pacientes se clasificaron como infectados por S. aureus, infectados por otros microorganismos y sin infecciones nosocomiales. Resultados: De 34.914 pacientes controlados 3.450 (9,9%) adquirieron 5.599 infecciones nosocomiales durante su estancia en la UCI (16,0 infecciones por cada 100 pacientes). En 682 (19,8%) de los pacientes con infecciones se identificaron 775 infecciones en las que uno de los microorganismos responsables era S. aureus (incidencia acumulada: 2,2 episodios de infección por S. aureus por 100 pacientes). Se observó un predominio de S. aureus en las neumonías relacionadas con ventilación mecánica (21,4%) y en las bacteriemias relacionadas con catéteres (13,0%). Las variables que se asociaron de forma individual con la aparición de infección por S. aureus fueron el sexo masculino (odds ratio [OR] = 1,25; intervalo de confianza [IC] del 95%, 1,03-1,52) y los procesos de base traumática (OR = 1,72; IC del 95%, 1,26-2,35), mientras que la mayor edad fue un factor protector (OR = 0,90; IC del 95%, 0,84-0,96). La mortalidad de los pacientes con infección por S. aureus fue significativamente superior a la de los pacientes con infecciones por otros microorganismos y, a su vez, la de ambas fue superior a la de los pacientes sin infecciones (el 34,5, el 30,3 y el 10,7%, respectivamente). En 208 (30,5%) pacientes las infecciones fueron debidas a S. aureus resistentes a meticilina, las cuales aumentaron de forma significativa a lo largo de los años analizados (p = 0,001). La mortalidad de los pacientes con infecciones producidas por S. aureus resistente a meticilina fue del 35,1%, y la de las producidas por S. aureus sensibles a meticilina del 34,2% (p = NS). Conclusiones: S. aureus está presente en el 19,8% de los pacientes con infecciones adquiridas en las UCI, principalmente en neumonías relacionadas con ventilación mecánica. La mortalidad de los pacientes con infecciones por S. aureus ha sido superior a la de los pacientes con infecciones por otros microorganismos y a la de pacientes sin infecciones. Por el contrario, no se han identificado diferencias en la evolución de los pacientes con infecciones por S. aureus sensibles o resistentes a meticilina

Background and objective: To investigate the frequency of nosocomial infections caused by Staphylococcus aureus in critically ill patients admitted to Spanish intensive care units (ICUs) and to describe the characteristics and outcome of patients in whom this pathogen was isolated. Patients and method: Prospective, observational, and multicenter study. All patients admitted during one or 2 months to the participating ICUs in the National Nosocomial Infection Surveillance Study (ENVIN) between 1997 and 2003 were included. Patients were classified as infected by S. aureus, infected by other microorganisms, and without nosocomial infection. Results: A total of 34,914 patients were controlled of whom 3,450 (9.9%) had acquired a nosocomial infection during his/her ICU stay (16.0 infections per 100 patients). In 682 (19.8%) patients, a total of 775 infectious episodes in which one of the microorganisms isolated was S. aureus were documented (cumulative incidence 2.2 episodes of S. aureus infection per 100 patients). There was a predominance of S. aureus infection in patients with pneumonia associated with mechanical ventilation (21.4%) and in patients with catheter-related bacteremia (13%). Independent variables associated with S. aureus infection were male sex (odds ratio [OR] = 1.25; 95% confidence interval [CI], 1.03-1.52) and underlying trauma pathology (OR = 1.72, 95%; 95%CI, 1.26-2.35), whereas an older age has been a protective factor (OR = 0.90; 95%CI, 0.84-0.96). Mortality in patients with S. aureus infection was significantly higher than in infections caused by other microorganisms, and in both cases higher than in patients without infection (34.5%, 30.3%, and 10.7%, respectively). In 208 (30.5%) patients, infections due to methicillin-resistant S. aureus were diagnosed, which in turn had increased significantly over the years (p = 0.001). Mortality in patients with methicillin-resistant S. aureus infection was 35.1% compared with 34.2% in patients with methicillin sensitive S. aureus infections (p = NS). Conclusions: S. aureus was isolated in 19.8% of patients with ICU-acquired infection, particularly in relation to pneumonia in mechanically ventilated patients. Mortality in patients with S. aureus infection was higher than that in patients with infections due to other microorganisms and patients without infection. In contrast, differences in the outcome of patients with infections caused by methicillin-sensitive or methicillin-resistant S. aureus were not found