[Recommendations for the treatment of severe in-hospital pneumonia. Spanish Society of Critical, Coronary, and Intensive Medicine. Spanish Society for Respiratory Tract Pathology. Spanish Society of Infectious Diseases and Clinical Microbiology]. / Recomendaciones para el tratamiento de la neumonía intrahospitalaria grave. Sociedad Española de Medicina Intensiva, Critica y Coronarias. Sociedad Española de Patología del Aparato Respiratorio. Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica.

INTRODUCTION: Given the sanitary repercussion of serious intrahospital pneumonia (SIP), representatives of three scientific societies (SEMICYUC; SEPAR and SEIMC) have developed during 2002 and 2003 a practical guide for its treatment. METHOD: A task force was constituted to value five clinical situations related with the treatment of SIP: 1) critical revision of the existent guidelines and groups of risk definition; 2) entry criteria in ICU for SIP; 3) SIP treatment in function of the groups of risk; 4) special situations in SIP treatment, and 5) control treatment. After the bibliographical revision drafts were developed and discussed until the elaboration of the final document. RESULTS: It is necessary the stratification of the patients according to the presence or not of risk factors in order to make an appropriate use of treatments. SIP without risk factors can be treated with monotherapy with several antibiotics. SIP with risk factors specifies therapy combined with betalactamic plus aminoglycoside. Its substitution for a quinolon is a topic debate. Infections for multiresistance microorganisms require an individualized approach that can end up including the use of topical antibiotics. In SIP without microorganism isolation the use of a score system can be of utility in the taking of decisions. Revision of the therapeutic rule after 72 hours, carrying out the necessary adjustments according to the clinical evolution and microbiological results is necessary in all cases. CONCLUSIONS: Scientific evidence in the treatment of SIP allows the development of different strategies to achieve a higher efficiency both in antibiotic handling and in the control of its evolution.

Recomendaciones para el tratamiento de la neumonía intrahospitalaria grave / Recommendations for the treatment of severe nosocomial pneumonia

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Meningitis bacteriana aguda con hipertensión endocraneal / Acute bacterial meningitis with intracranial hypertension

A pesar del uso de la dexametasona, la mortalidad de la meningitis bacteriana aguda (MBA) continúa siendo elevada en los casos que precisan ingreso en UCI. Este hecho podría relacionarse, entre otros factores, con la presencia de hipertensión endocraneal (HTEC), que en la mayoría de ocasiones no es tratada de modo intensivo. El estudio de Doppler transcraneal con codificación de color (DTCC), una técnica no invasora que nos permite monitorizar la hemodinámica cerebral, seleccionaría a un grupo de pacientes con alta sospecha de HTEC, permitiendo un tratamiento más agresivo de estos pacientes, que incluiría el tratamiento neurocrítico como en el traumatismo craneoencefálico. Presentamos un caso clínico de una meningitis bacteriana aguda tratada según los resultados obtenidos en el DTCC. La paciente recibió tratamiento con manitol y coma barbitúrico, con un resultado favorable. (AU)

Efficacy and tolerability of piperacillin/tazobactam versus ceftazidime in association with amikacin for treating nosocomial pneumonia in intensive care patients: a prospective randomized multicenter trial.

OBJECTIVE: To compare clinical and bacteriological efficacy as well as tolerability of two regimens of broad-spectrum antibiotics (ceftazidime versus piperacillin/tazobactam) combined with amikacin in the treatment of nosocomial pneumonia in intensive care patients. DESIGN: Open label, prospective, multicenter, and randomized phase III clinical trial. SETTING: Medical or surgical intensive care units (ICUs) of nine acute-care teaching hospitals in Spain. PATIENTS AND PARTICIPANTS: One hundred and twenty-four ICU patients with nosocomial pneumonia and requiring mechanical ventilation were included. They were randomized to receive amikacin (15 mg/day divided into two doses) combined with either piperacillin (4 g every 6 h) and tazobactam (0.5 g every 6 h) (n = 88) or ceftazidime (2 g every 8 h) (n = 36). MEASUREMENTS AND RESULTS: The causative pathogen was determined in 60.2% of patients in the group of amikacin plus piperacillin/tazobactam and in 76.9% in the group of amikacin plus ceftazidime. A total of 94 bacterial organisms were isolated among which gram-negative bacilli predominated, Pseudomonas aeruginosa being the most frequent. Clinical response at the end of antibiotic therapy was considered satisfactory (cure and/or improvement) in 63.9% of patients in the amikacin plus piperacillin/tazobactam group and in 61.5% in the amikacin plus ceftazidime (odds ratio 1.1; 95% confidence interval 0.44-2.75). Eradication or presumptive eradication rates for each pathogen and for either gram-negative or gram-positive bacteria were similar in both antibiotic combinations (odds ratio 1.2; 95% confidence interval 0.39-3.66). A total of 21 adverse effects (23.9%) occurred in the amikacin plus piperacillin and tazobactam group and six (16.7%) in the amikacin plus ceftazidime group, thrombocytosis, renal dysfunction, and hepatic cytolysis being the most common. The efficacy and tolerability of the two therapeutic regimens were similar not only in the whole study population, but also in the subset of P. aeruginosa-related pneumonia (odds ratio 1; 95% confidence interval 0.08-13.37). CONCLUSIONS: Amikacin associated with either ceftazidime or piperacillin and tazobactam has shown comparable efficacy and tolerability in the treatment of ICU patients with nosocomial pneumonia.

[Study of 51 cases of disseminated intravascular coagulation with reference to the association with acute renal failure. Results in severely ill patients (author's transl)]. / Estudio de 51 casos de coagulación intravascular diseminada con referencia a la asociación con insuficiencia renal aguda. Resultados en pacientes gravemente enfermos.

During the years 1977 to 1979 51 patients admitted to a general Intensive Care Unit were diagnosed of disseminated intravascular coagulation (DIC); their clinical histories were reviewed and they form the basis of this report. The diagnosis was made independently of the eventual clinical manifestations and it was based on the platelet count, serum fibrinogen levels, alteration of the prothrombin time and the cephalin-kaolin time, elevation of fibrin degradation products, and positivity of the ethanol test. An attempt was made to elucidate the precipitating cause of the coagulopathy, and to see if there was one or more of them. Particular emphasis is made on the association with Gram negative sepsis. Survival was evaluated in relation to heparin therapy, massive doses of corticosteroids, and association to acute renal failure. In conclusion, severe DIC with or without bleeding appears to be a manifestation of multiorgan failure seen in severely ill patients; the prognosis and mortality of this form of DIC is worse than the usual DIC and treatment with heparin or corticosteroids do not increase survival, while its association to acute renal failure implies a higher mortality (p less than 0.02).