Clinical features and disease progression of elderly patients at the ICU setting.

OBJECTIVE: To describe and characterize a cohort of octogenarian patients admitted to the ICU of the University Central Hospital of Asturias (HUCA). DESIGN: Retrospective, observational and descriptive study of 14 months' duration. SETTING: Cardiac and Medical intensive care units (ICU) of the HUCA (Oviedo). PARTICIPANTS: Patients over 80 years old who were admitted to the ICU for more than 24 h. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Age, sex, comorbidity, functional dependence, treatment, complications, evolution, mortality. RESULTS: The most frequent reasons for admission were cardiac surgery and pneumonia. The average admission stay was significantly longer in patients under 85 years of age (p = 0,037). 84,3% of the latter benefited from invasive mechanical ventilation compared to 46,2% of older patients (p = <0,001). Patients over 85 years of age presented greater fragility. Admission for cardiac surgery was associated with a lower risk of mortality (HR = 0,18; 95% CI (0,062-0,527; p = 0,002). CONCLUSIONS: The results have shown an association between the reason for admission to the ICU and the risk of mortality in octogenarian patients. Cardiac surgery was associated with a better prognosis compared to medical pathology, where pneumonia was associated with a higher risk of mortality. Furthermore, a significant positive association was observed between age and frailty.

Evaluation and Clinical Impact of Biofire FilmArray Pneumonia Panel Plus in ICU-Hospitalized COVID-19 Patients.

Microbiological diagnosis by using commercial multiplex quantitative PCR systems provides great advantages over the conventional culture. In this work, the Biofire FilmArray Pneumonia Panel Plus (FAPP+) was used to test 144 low respiratory tract samples from 105 COVID-19 patients admitted to an Intensive Care Unit (ICU), detecting 78 pathogens in 59 (41%) samples. The molecular panel was evaluated by using the conventional culture (CC) as comparator, which isolated 42 pathogens in 40 (27.7%) samples. The overall percentage of agreement was 82.6%. Values of sensitivity (93%), specificity (62%), positive predictive value (50%), and negative predictive value (96%) were obtained. The mean time elapsed from sample extraction to modification of antibiotic treatment was 7.6 h. A change in antimicrobial treatment after the FAPP+ results was performed in 27% of patients. The FAPP+ is a highly sensitive diagnostic method that can be used to significantly reduce diagnostic time and that allows an early optimization of antimicrobial treatment.

Nosocomial Pneumonia Caused in an Immunocompetent Patient by the Emergent Monophasic ST34 Variant of Salmonella enterica Serovar Typhimurium: Treatment-Associated Selection of Fluoroquinolone and Piperacillin/Tazobactam Resistance.

The present report describes an uncommon case of nosocomial pneumonia caused by Salmonellaenterica in an immunocompetent patient. The patient was admitted to ICU of a tertiary hospital due to low level of consciousness, aphasia and seizure episodes. Four days after hospitalization, he developed nosocomial pneumonia, which evolved into septic shock. Gram-negative bacilli were recovered from blood, tracheal aspirate and fecal samples of the patient. The isolates, which were identified as Salmonella enterica, proved to be resistant to ciprofloxacin, amoxicillin/clavulanic acid and piperacillin/tazobactam. Four months before, the same bacterial species was recovered from feces and blood cultures of the patient, admitted to the nephrology ward of the same hospital with diagnosis of gastroenteritis and acute renal failure. However, at that time, the isolates were susceptible to the above-mentioned antibiotics. Genome sequencing revealed that all isolates were closely related and belonged to the emergent ST34 monophasic variant of S. enterica serovar Typhimurium. Since the patient has received therapy with fluoroquinolones and amoxicillin/clavulanic acid, these results support treatment-associated selection of the acquired resistances. In conclusion, this case represents a paradigm of selective pressure leading to in vivo development of resistance to highly relevant antibiotics, including the piperacillin/tazobactam combination used for empirical management of severe infections at ICU.

In Vivo Evolution of GES ß-Lactamases Driven by Ceftazidime/Avibactam Treatment of Pseudomonas aeruginosa Infections.

The mechanisms underlying an in vivo switch in the resistance phenotype of P. aeruginosa after ceftazidime-avibactam treatment was investigated. The initial isolate (a blood culture) was resistant to meropenem but remained susceptible to antipseudomonal cephalosporins and combinations with ß-lactamase inhibitors. One week after ceftazidime-avibactam therapy, a subsequent isolate (a rectal swab) recovered from the same patient showed the opposite phenotype. Whole-genome sequence analysis revealed a single SNP difference between both (ST235) isolates, leading to a P162S change in blaGES-5, creating blaGES-15. Thus, blaGES-1, blaGES-5, and blaGES-15 were cloned and expressed in the wild-type strain PAO1. Susceptibility profiles confirmed the P162S substitution reverted the carbapenemase phenotype determined by the G170S change of GES-5 back into the ESBL phenotype of GES-1.

Spread of OXA-48-producing Klebsiella pneumoniae among COVID-19-infected patients: The storm after the storm.

The impact of secondary infections by multidrug-resistant bacteria in COVID-19- infected patients has yet to be evaluated. Here, we report the clinical and molecular features of an outbreak of seven patients carrying CTX-M-15- and OXA-48-producing Klebsiella pneumoniae belonging to ST326 during COVID-19 pandemic in an ICU in northern Spain. Those patients were admitted to beds close to each other, two of them developed ventilator-associated pneumonia (VAP), one exhibited primary bacteremia and the remaining four were considered to be colonized. None of them was colonized prior to admission to the ICU an all, except one of those who developed VAP, were discharged. Hydroxychloroquine and lopinavir/ritonavir were administered to all of them as COVID-19 therapy and additionally, three of them received tocilizumab and corticosteroids, respectively. Reusing of personal protective equipment due to its initial shortage, relaxation in infection control measures and negative-pressure air in ICU rooms recommended for the protection of health care workers (HCWs), could have contributed to this outbreak. Maximization of infection control measures is essential to avoid secondary infections by MDR bacteria in COVID-infected patients.

SARS-CoV-2 analysis on environmental surfaces collected in an intensive care unit: keeping Ernest Shackleton's spirit.

BACKGROUND: Intensive care unit workers are at high risk of acquiring COVID-19 infection, especially when performing invasive techniques and certain procedures that generate aerosols (< 5 µm). Therefore, one of the objectives of the health systems should implement safety practices to minimize the risk of contagion among these health professionals. Monitoring environmental contamination of SARS-CoV-2 may help to determine the potential of the environment as a transmission medium in an area highly exposed to SARS-CoV-2, such as an intensive care unit. The objective of the study was to analyze the environmental contamination by SARS-CoV-2 on surfaces collected in an intensive care unit, which is dedicated exclusively to the care of patients with COVID-19 and equipped with negative pressure of - 10 Pa and an air change rate of 20 cycles per hour. Furthermore, all ICU workers were tested for COVID-19 by quantitative RT-PCR and ELISA methods. RESULTS: A total of 102 samples (72 collected with pre-moistened swabs used for collection of nasopharyngeal exudates and 30 with moistened wipes used in the environmental microbiological control of the food industry) were obtained from ventilators, monitors, perfusion pumps, bed rails, lab benches, containers of personal protective equipment, computer keyboards and mice, telephones, workers' shoes, floor, and other areas of close contact with COVID-19 patients and healthcare professionals who cared for them. The analysis by quantitative RT-PCR showed no detection of SARS-CoV-2 genome in environmental samples collected by any of the two methods described. Furthermore, none of the 237 ICU workers was infected by the virus. CONCLUSIONS: Presence of SARS-CoV-2 on the ICU surfaces could not be determined supporting that a strict cleaning protocol with sodium hypochlorite, a high air change rate, and a negative pressure in the ICU are effective in preventing environmental contamination. These facts together with the protection measures used could also explain the absence of contagion among staff inside ICUs.

Utilidad de la PCR-múltiple (FilmArray Blood Culture Identification) en otros líquidos biológicos. Detección de Streptococcus pyogenes en absceso cerebral y líquido sinovial / Utility of multiplex PCR (FilmArray Blood Culture Identification) in other biological liquids. Detection of Streptococcus pyogenes in brain abscess and synovial fluid

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Complicaciones infecciosas relacionadas con el drenaje ventricular externo. Incidencia y factores de riesgo / Infectious complications related to external ventricular shunt. Incidence and risk factors

Introducción. Las complicaciones infecciosas relacionadas con el drenaje ventricular externo (CIRDVE) son un problema importante en las Unidades de Cuidados Intensivos (UCI) neuroquirúrgicos. El objetivo del estudio es conocer la incidencia de CIRDVE y analizar los factores implicados. Material y métodos. Estudio retrospectivo en una UCI polivalente de adultos de un hospital universitario de tercer nivel. Se incluyeron todos los pacientes con drenaje ventricular externo (DVE) excepto aquellos diagnosticados de una infección del sistema nervioso central previa al implante. Resultados. Se incluyeron 87 pacientes, 106 DVE. Diagnóstico previo más frecuente: hemorragia subaracnoidea (49,4%). Presentaron CIRDVE 31 pacientes con 32 DVE. La tasa de CIRDVE fue de 19,5 por mil días de catéter y de ventriculitis 14 por mil días de catéter. Presentaron CIRDVE el 31,6% de los pacientes y ventriculitis el 25,3%. Los pacientes con CIRDVE tuvieron más manipulaciones del DVE (2,0 ± 0,6 vs. 3,3 ± 1,0 p=0,02), reposicionamiento (0,1 ± 0,1 vs. 0,2 ± 0,1) y mayor estancia media en UCI y hospitalaria (29,8 ± 4,9 vs. 49,8 ± 5,2, p<0,01 y 67,4 ± 18,8 vs, 108,9 ± 30,2, p=0,02 respectivamente). Los DVE con CIRDVE tuvieron mayor permanencia, tanto al diagnóstico como a la retirada (12,6 ± 2,1 vs. 18,3 ± 3,6 y 12,6 ± 2,1 vs. 30,4 ± 7,3, p<0,01). No hubo diferencias en mortalidad. Conclusiones. Uno de cada 3 pacientes presentó CIRDVE. Los factores relacionados fueron el número de manipulaciones, el reposicionamiento del DVE y el tiempo de permanencia. Los pacientes con CIRDVE tuvieron estancia media en UCI y hospitalaria más larga pero sin incremento en la mortalidad (AU)

Introduction. Infectious complications related to external ventricular shunt (ICREVS) are a main problem in neurocritical intensive care units (ICU). The aim of the review is to assess the incidence of ICREVS and to analyse factors involved. Material and methods: Retrospective analysis, adult polyvalent ICU in a third level reference hospital. Patients carrying external ventricular shunt (DVE) were included. Those patients with central nervous system infection diagnosed prior DVE placement were excluded. Results: 87 patients were included with 106 DVE. Most common admittance diagnosis was subarachnoid haemorrhage (49.4%). 31 patients with 32 DVE developed an ICREVS. Infection rate is 19.5 per 1000 days of shunt for ICREVS and 14 per 1000 days for ventriculitis. 31.6% of the patients developed ICREVS and 25.3% ventriculitis. Patients who developed ICREVS presented higher shunt manipulations (2.0 ± 0.6 vs. 3.26 ± 1.02, p=0.02), shunt repositioning (0.1 ± 0.1 vs. 0.2 ± 0.1) and ICU and hospital stay (29.8 ± 4.9 vs 49.8 ± 5.2, p<0.01 y 67.4 ± 18.8 vs. 108.9 ± 30.2, p=0.02. Those DVE with ICREVS were placed for longer not only at infection diagnosis but also at removal (12.6 ± 2.1 vs. 18.3 ± 3.6 and 12.6 ± 2.1 vs. 30.4 ± 7.3 days, p<0.01). No difference in mortality was found. Conclusions. One out of three patients with a DVE develops an infection. The risk factors are the number of manipulations, repositioning and the permanency days. Patients with ICREVS had a longer ICU and hospital average stay without an increase in mortality (AU)

Vigilancia epidemiológica para microorganismos multirresistentes en una UCI polivalente / Epidemiological surveillance for multidrug-resistant microorganisms in a general ICU

Introducción. Los microorganismos multirresistentes (MMR) suponen una amenaza para los pacientes ingresados en las Unidades de Cuidados Intensivos (UCIs). El objetivo de este estudio es analizar los resultados de los cultivos de vigilancia epidemiológica de dichos microorganismos en una de estas unidades. Material y métodos. UCI polivalente. Análisis retrospectivo, estadística descriptiva. Análisis de cultivos de vigilancia epidemiológica para MMR. Microorganismos estudiados: Staphylococcus aureus resistente a meticilina (SARM), Klebsiella pneumoniae productora de BLEE y/o carbapenemasa (KPBLEE-C) y Acinetobacter baumannii multirresistente (ABMR). Resultados. 1.259 pacientes ingresados. Se analizaron 2.234 muestras (exudado rectal 690, faríngeo 634, nasal 624, cutáneo 286) procedentes de 384 pacientes. La mayor rentabilidad alcanzada con las diferentes muestras para los distintos microorganismos fue: SARM, exudado nasal 79%, nasal + faríngeo 90%. ABMR: faríngeo 80%, faríngeo + rectal 95%. KPBLEE-C: rectal 95%, faríngeo + rectal 98%. De los 384 pacientes 94 (24,4%) estaban colonizados/infectados al ingreso con alguno de estos microorganismos. Durante su estancia, 134 pacientes (10,6% del total de pacientes ingresados) se colonizaron/infectaron por un total de 169 microorganismos. La colonización/infección más precoz fue para SARM (9,2 ± 6,4 días) y la más tardía para enterobacterias productoras de BLEE (18,7±16,4 días). Conclusiones. El 24,4% de los pacientes estaban colonizados/infectados por MMR al ingreso. Las muestras más rentables fueron exudado nasal para SARM, faríngeo para ABMR y rectal para KPBLEE-C. La asociación de dos muestras mejora la detección, excepto en KPBLEE-C. Los exudados cutáneos son poco rentables. El MMR más frecuente al ingreso son las enterobacterias productoras de BLEE y el adquirido intra UCI el ABMR (AU)

Introduction. Multidrug resistant (MDR) microorganisms represent a threat for patients admitted in Intensive Care Units (ICUs). The objective of the present study is to analyse the results of epidemiological surveillance cultures for these microorganisms in one of these units. Material and methods. General ICU. Retrospective analysis, descriptive statistics. Analysis of epidemiological surveillance cultures for MDR microorganisms in 2015. Studied microorganisms: Methicillin-resistant Staphylococcus aureus (MRSA), ESBL-and/or carbapenemase-producing Klebsiella pneumoniae (CESBL-KP) and MDR Acinetobacter baumannii (MDRAB). Results. One thousand, two hundred and fifty nine patients admitted. A total of 2,234 specimens from 384 patients were analysed (690, 634, 62 and 286 were rectal, throat, nasal and skin swabs respectively). Global APACHE II was 18.3 ± 8 versus 21.7 ± 7.8 in patients colonized/infected on admission. Global mortality was 19.7% versus 22.3% in patients colonized/infected on admission. The higher sensitivities achieved with the different samples for the different microorganism detection were as follows. MRSA: 79% and 90% for nasal and nasal + throat swabs, respectively. MDRAB: 80% and 95% for throat and throat + rectal swabs, respectively. CESBL-KP: 95% and 98% for rectal and rectal + throat swabs, respectively. 94 out of the 384 patients (24.4%) were colonized/infected with MDR at admission. 134 patients (10.6% of the total patients admitted) were colonized/infected with a total of 169 MMR during the hospital stay. MRSA has the earliest colonization/ infection (9.2 ± 6.4days) and ESBL-producing Enterobacteriaceae, the latest (18.7± 16.4 days). Conclusions. 24.4% of patients were colonized/infected by MDR at admission. Nasal, throat and rectal swabs were the most effective specimens for recovering MRSA, MDRAB and CESBL-KP, respectively. The combination of two specimens improves MDR detection except for CESBL-KP. Skin swabs are worthless. The most prevalent MDR at admission were ESBL-producing Enterobacteriaceae while the most frequent hospital acquired MDR was MDRAB (AU)