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1.
J Crit Care ; 53: 46-52, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31195155

RESUMO

PURPOSE: To evaluate the incidence and mortality of adult patients with community-acquired septic shock (CASS) and the influence of source control (SC) and other risk factors on the outcome. MATERIAL AND METHODS: The study included patients with CASS admitted to the ICU at a university hospital (2003-2016). Multivariate analyses were performed to identify risk factors of ICU mortality. RESULTS: A total of 625 patients were included. The incidence showed an average annual increase of 4.9% and the mortality an average annual decrease of 1.4%. The patients who required SC showed a lower mortality (20.4%) than patients who did not require SC (31.3%) (p = 0.002). However, the evolution in mortality was different: Mortality decreased in patients who did not require SC (from 56.3% to 20%; p = 0.02), but did not differ in those who required SC (from 21.4% to 27.6%; p = 0.43). In the multivariate analysis, severity at admission, age, alcoholism, cirrhosis, ARDS, neutropenia and thrombocytopenia were associated with worse outcome, whereas appropriate antibiotic treatment and adequate SC were independently associated with better survival. CONCLUSIONS: The incidence of CASS increased and the ICU mortality decreased during the study period. The mortality was mainly due to a decrease in mortality in infections not requiring SC.

2.
J Clin Med ; 8(5)2019 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-31137863

RESUMO

BACKGROUND: Community-acquired pneumonia (CAP) is a frequent cause of death worldwide. As recently described, CAP shows different biological endotypes. Improving characterization of these endotypes is needed to optimize individualized treatment of this disease. The potential value of the leukogram to assist prognosis in severe CAP has not been previously addressed. METHODS: A cohort of 710 patients with CAP admitted to the intensive care units (ICUs) at Hospital of Mataró and Parc Taulí Hospital of Sabadell was retrospectively analyzed. Patients were split in those with septic shock (n = 304) and those with no septic shock (n = 406). A single blood sample was drawn from all the patients at the time of admission to the emergency room. ICU mortality was the main outcome. RESULTS: Multivariate analysis demonstrated that lymphopenia <675 cells/mm3 or <501 cells/mm3 translated into 2.32- and 3.76-fold risk of mortality in patients with or without septic shock, respectively. In turn, neutrophil counts were associated with prognosis just in the group of patients with septic shock, where neutrophils <8850 cells/mm3 translated into 3.6-fold risk of mortality. CONCLUSION: lymphopenia is a preserved risk factor for mortality across the different clinical presentations of severe CAP (sCAP), while failing to expand circulating neutrophils counts beyond the upper limit of normality represents an incremental immunological failure observed just in those patients with the most severe form of CAP, septic shock.

3.
Ann Transl Med ; 6(21): 415, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30581823

RESUMO

Background: Ventilator-associated pneumonia (VAP) is one of the most commonly encountered intensive care unit (ICU) acquired infections worldwide. The objective of the study was to identify the immune alteration occurring in patients suffering from VAP at the transcriptomic level and explore its potential use for clinical diagnoses of this disease. Methods: We performed a prospective observational study in five medical ICUs. Immunological gene expression profiles in the blood of VAP patients were compared with those of controls by using whole transcriptome microarrays and droplet digital polymerase chain reaction (ddPCR) in the first 24 hours following diagnosis. Results: VAP patients showed significantly lower expression levels of HLA-DOA, HLA-DMA, HLA-DMB, ICOS, ICOSLG, IL2RA, CD1, CD3, CD28 and CD40LG. The molecules coded by these genes participate of the immunological synapse. CD1C, CD40LG and ICOS showed the highest values of area under the receiver operating characteristic curve (AUROC) with a good balance between sensibility and specificity. Conclusions: Patients with VAP show a transcriptomic depression of genes participating of the immunological synapse. It takes a commonplace event, namely VAP, and highlights a quite significant underlying immune suppressive state. In effect this small study will change how we regard VAP, and proposes that we regard it as an infection in an immune compromised host, and that immunity has a central role for ICU acquired infections. This may in time change clinical practice, as it has profound implications for the role of protocolised care, or bundles, in the prevention of VAP. Quantifying the expression in blood of this genes using ddPCR could be a useful approach for the diagnosis of VAP.

4.
Respir Res ; 19(1): 191, 2018 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-30285741

RESUMO

BACKGROUND: Cough pressure, an expression of expiratory muscle strength, is usually measured with esophageal or gastric balloons, but these invasive catheters can be uncomfortable for the patient or their placement impractical. Because pressure in the thorax and abdomen are expected to be similar during a cough, we hypothesized that measurement at other thoracic or abdominal locations might also be similar as well as useful in clinical scenarios. This study aimed to compare cough pressures measured at thoracic and abdominal sites that could serve as alternatives to esophageal pressures (Pes). METHODS: Nine patients scheduled for laparotomy were asked to cough as forcefully as possible from total lung capacity in supine position. Three cough maneuvers were performed while Pes (the gold standard) as well as gastric, central venous, bladder and rectal pressures (Pga, Pcv, Pbl, and Prec, respectively) were measured simultaneously. The intraclass correlation coefficient (ICC) was used to evaluate the repeatability of the measurements in each patient at each site and evaluate agreement between alternative sites (Pga, Pcv, Pbl, and Prec) and Pes. Bland-Altman plots were used to compare Pes and the measurements at the other sites. RESULTS: Median (first quartile, third quartile) maximum pressures were as follows: Pes 112 (89,148), Pga 105 (92,156), Pcv 102 (91,149), Pbl 118 (93,157), and Prec 103 (88,150) cmH2O. The ICCs showed excellent within-site repeatability of the measurements (p < 0.001) and excellent agreement between alternative sites and Pes (p < 0.004). The Bland-Altman plots showed minimal differences between Pes, Pga, Pcv, and Prec. However, Pbl was higher than the other pressures in most patients, and the difference between Pes and Pbl was slightly larger. CONCLUSIONS: Cough pressure can be measured in the esophagus, stomach, superior vena cava or rectum, since their values are similar. It can also be measured in the bladder, although the value will be slightly higher. These results potentially facilitate the assessment of dynamic expiratory muscle strength with fewer invasive catheter placements in most hospitalized patients, thus providing an option that will be particularly useful in those undergoing thoracic or abdominal surgery. TRIAL REGISTRATION: NCT02957045 registered at November 7, 2016. Retrospectively registered.


Assuntos
Pressão Venosa Central/fisiologia , Tosse/fisiopatologia , Esôfago/fisiologia , Reto/fisiologia , Estômago/fisiologia , Bexiga Urinária/fisiologia , Idoso , Tosse/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Estudos Prospectivos
5.
Enferm Infecc Microbiol Clin ; 36(2): 112-119, 2018 02.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29412895

RESUMO

Catheter-related bloodstream infections (CRBSI) constitute an important cause of hospital-acquired infection associated with morbidity, mortality, and cost. The aim of these guidelines is to provide updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Experts in the field were designated by the two participating Societies (Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias). Short-term peripheral venous catheters, non-tunneled and long-term central venous catheters, tunneled catheters and hemodialysis catheters are covered by these guidelines. The panel identified 39 key topics that were formulated in accordance with the PICO format. The strength of the recommendations and quality of the evidence were graded in accordance with ESCMID guidelines. Recommendations are made for the diagnosis of CRBSI with and without catheter removal and of tunnel infection. The document establishes the clinical situations in which a conservative diagnosis of CRBSI (diagnosis without catheter removal) is feasible. Recommendations are also made regarding empirical therapy, pathogen-specific treatment (coagulase-negative staphylococci, Sthaphylococcus aureus, Enterococcus spp, Gram-negative bacilli, and Candida spp), antibiotic lock therapy, diagnosis and management of suppurative thrombophlebitis and local complications.


Assuntos
Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/tratamento farmacológico , Adulto , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Bacteriemia/etiologia , Técnicas Bacteriológicas , Hemocultura , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Cateteres/efeitos adversos , Cateteres/microbiologia , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/etiologia , Remoção de Dispositivo , Contaminação de Equipamentos , Fungemia/diagnóstico , Fungemia/tratamento farmacológico , Fungemia/etiologia , Humanos , Micologia/métodos , Diálise Renal , Dispositivos de Acesso Vascular/efeitos adversos , Dispositivos de Acesso Vascular/microbiologia
6.
Enferm. infecc. microbiol. clín. (Ed. impr.) ; 36(2): 112-119, feb. 2018. tab
Artigo em Inglês | IBECS | ID: ibc-170700

RESUMO

Catheter-related bloodstream infections (CRBSI) constitute an important cause of hospital-acquired infection associated with morbidity, mortality, and cost. The aim of these guidelines is to provide updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Experts in the field were designated by the two participating Societies (Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias). Short-term peripheral venous catheters, non-tunneled and long-term central venous catheters, tunneled catheters and hemodialysis catheters are covered by these guidelines. The panel identified 39 key topics that were formulated in accordance with the PICO format. The strength of the recommendations and quality of the evidence were graded in accordance with ESCMID guidelines. Recommendations are made for the diagnosis of CRBSI with and without catheter removal and of tunnel infection. The document establishes the clinical situations in which a conservative diagnosis of CRBSI (diagnosis without catheter removal) is feasible. Recommendations are also made regarding empirical therapy, pathogen-specific treatment (coagulase-negative staphylococci, Sthaphylococcus aureus, Enterococcus spp, Gram-negative bacilli, and Candida spp), antibiotic lock therapy, diagnosis and management of suppurative thrombophlebitis and local complications (AU)


La bacteriemia relacionada con catéteres (BRC) constituye una causa importante de infección hospitalaria y se asocia con elevada morbilidad, mortalidad y costo. El objetivo de esta guía de práctica clínica es proporcionar recomendaciones actualizadas para el diagnóstico y el tratamiento de la BRC en pacientes adultos. De este documento se excluye la prevención de la BRC. Expertos en la materia fueron designados por las 2 sociedades participantes (Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica y Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias). Los catéteres venosos periféricos a corto plazo, los catéteres venosos centrales no tunelizados y de largo plazo, los catéteres tunelizados y los catéteres de hemodiálisis están incluidos por estas guías. El panel identificó 39 temas claves que fueron formulados de acuerdo con el formato PICO. La fuerza de las recomendaciones y la calidad de la evidencia se clasificaron de acuerdo con las directrices de la ESCMID. Se hacen recomendaciones para el diagnóstico de BRC con y sin extracción de catéter y de la infección en túnel. El documento establece las situaciones clínicas en las que es factible un diagnóstico conservador de CRBSI (diagnóstico sin retirada de catéter). También se hacen recomendaciones con respecto a la terapia empírica, el tratamiento específico según el patógeno identificado (estafilococos coagulasa negativos, Staphylococcus aureus, Enterococcus spp, bacilos gramnegativos y Candida spp), la terapia con sellado del catéter, el diagnóstico, así como el tratamiento de la tromboflebitis supurativa y las complicaciones locales (AU)


Assuntos
Humanos , Conferências de Consenso como Assunto , Sociedades Médicas/normas , Bacteriemia/diagnóstico , Bacteriemia/microbiologia , Infecções Relacionadas a Cateter/microbiologia , Tromboflebite/terapia , Sociedades Médicas/organização & administração , Infecções Relacionadas a Cateter/diagnóstico , Cateteres/microbiologia , Unidades de Terapia Intensiva/normas , Unidades de Cuidados Coronarianos/normas , Tromboflebite/complicações , Antibacterianos/uso terapêutico
7.
ERJ Open Res ; 3(4)2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29164144

RESUMO

The clinical course of intensive care unit (ICU) patients may be complicated by a large spectrum of lower respiratory tract infections (LRTI), defined by specific epidemiological, clinical and microbiological aspects. A European network for ICU-related respiratory infections (ENIRRIs), supported by the European Respiratory Society, has been recently established, with the aim at studying all respiratory tract infective episodes except community-acquired ones. A multicentre, observational study is in progress, enrolling more than 1000 patients fulfilling the clinical, biochemical and radiological findings consistent with a LRTI. This article describes the methodology of this study. A specific interest is the clinical impact of non-ICU-acquired nosocomial pneumonia requiring ICU admission, non-ventilator-associated LRTIs occurring in the ICU, and ventilator-associated tracheobronchitis. The clinical meaning of microbiologically negative infectious episodes and specific details on antibiotic administration modalities, dosages and duration are also highlighted. Recently released guidelines address many unresolved questions which might be answered by such large-scale observational investigations. In light of the paucity of data regarding such topics, new interesting information is expected to be obtained from our network research activities, contributing to optimisation of care for critically ill patients in the ICU.

8.
Ann Intensive Care ; 7(1): 109, 2017 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-29098448

RESUMO

BACKGROUND: Continuous aspiration of subglottic secretions is effective in preventing ventilator-associated pneumonia, but it involves a risk of mucosal damage. The main objective of our study was to determine the incidence of airway complications related to continuous aspiration of subglottic secretions. METHODS: In consecutive adult patients with continuous aspiration of subglottic secretions, we prospectively recorded clinical airway complications during the period after extubation. A multidetector computed tomography of the neck was performed during the period of 5 days following extubation to classify subglottic and tracheal lesions as mucosal thickening, cartilage thickening or deep ulceration. RESULTS: In the 86 patients included in the study, 6 (6.9%) had transient dyspnea, 7 (8.1%) had upper airway obstruction and 18 (20.9%) had dysphonia at extubation. Univariate analysis identified more attempts required for intubation (2.3 ± 1.1 vs. 1.2 ± 0.5; p = 0.001), difficult intubation (71.4 vs. 10.1%, p = 0.001) and Cormack score III-IV (71.4 vs. 8.8%; p < 0.001) as risk factors for having an upper airway obstruction at extubation. The incidence of failed extubation among patients after planned extubation was 18.9% and 11 patients (12.7%) required tracheostomy. A multidetector computed tomography was performed in 37 patients following extubation, and injuries were observed in 9 patients (24.3%) and classified as tracheal injuries in 2 patients (1 cartilage thickening and 1 mild stenosis with cartilage thickening) and as subglottic mucosal thickenings in 7 patients. CONCLUSIONS: The incidence of upper airway obstruction after extubation in patients with continuous aspiration of subglottic secretions was 8.1%, and the injuries observed by computed tomography were not severe and located mostly in subglottic space.

9.
Ann Intensive Care ; 7(1): 67, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28620893

RESUMO

BACKGROUND: Early-onset ventilator-associated pneumonia (EO-VAP) is the leading cause of morbidity and mortality in comatose patients. However, VAP prevention bundles focus mainly on late-onset VAP and may be less effective in preventing EO-VAP in comatose patients. Systemic antibiotic administration at the time of intubation may have a role in preventing EO-VAP. Therefore, we evaluated the effectiveness of systemic antibiotic administration in VAP prevention in comatose patients through a systematic review and meta-analysis. METHODS: We searched for studies published through December 2015 that evaluated systemic antibiotic prophylaxis in comatose patients. Two authors independently selected and evaluated full-length reports of randomized clinical trials or prospective cohorts in patients aged >16 years that evaluated the impact of systemic antibiotics at the time of intubation on EO-VAP compared to placebo or no prophylaxis. The outcome variables were the incidence of EO-VAP, the duration of mechanical ventilation, ICU length of stay, and ICU mortality. RESULTS: We identified 10,988 citations, yielding 26 articles for further analysis; three studies with 267 patients were finally analyzed. Most patients (n = 135) were comatose due to head trauma. Systemic antibiotic administration was associated with decreased incidence of EO-VAP (RR 0.32; 95% CI 0.19-0.54) and shorter ICU LOS (standardized mean difference -0.32; 95% CI -0.56 to -0.08), but had no effect on mortality (RR 1.03; 95% CI 0.7-1.53) or duration of mechanical ventilation (standardized mean difference -0.16; 95% CI -0.41 to 0.08). CONCLUSIONS: Antibiotic prophylaxis in comatose patients reduced the incidence of EO-VAP and decreased the ICU stay slightly. Future trials are needed to confirm these results.

10.
Enferm. infecc. microbiol. clín. (Ed. impr.) ; 33(9): 625.e1-625.e23, nov. 2015. tab, graf
Artigo em Inglês | IBECS | ID: ibc-144640

RESUMO

Both bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. The prognosis may darken not infrequently, especially in the presence of intracardiac devices or methicillin-resistance. Indeed, the optimization of the antimicrobial therapy is a key step in the outcome of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and - resistant isolates has led to the research of novel therapeutic schemes. Specifically, the interest raised in recent years on the new antimicrobials with activity against methicillin-resistant staphylococci has been also extended to infections caused by susceptible strains, which still carry the most important burden of infection. Recent clinical and experimental research has focused in the activity of new combinations of antimicrobials, their indication and role still being debatable. Also, the impact of an appropriate empirical antimicrobial treatment has acquired relevance in recent years. Finally, it is noteworthy the impact of the implementation of a systematic bundle of measures for improving the outcome. The aim of this clinical guideline is to provide an ensemble of recommendations in order to improve the treatment and prognosis of bacteremia and infective endocarditis caused by S. aureus, in accordance to the latest evidence published (AU)


Tanto la bacteriemia como la endocarditis infecciosa causada por Staphylococcus aureus son infecciones graves y frecuentes. El pronóstico puede verse ensombrecido por la presencia de dispositivos cardíacos o por la resistencia a meticilina. La optimización del tratamiento antimicrobiano es clave en los resultados. Las considerables tasas de fracaso terapéutico y la influencia de la susceptibilidad a vancomicina en el pronóstico, tanto de los episodios causados por cepas resistentes como sensibles a meticilina, ha conducido a la investigación de nuevos esquemas terapéuticos. Específicamente, el interés que en los últimos años han generado los nuevos antibióticos con actividad frente a cepas resistentes a meticilina se ha extendido a las cepas sensibles, que son aún responsables de la mayoría de los casos. Recientes estudios en el ámbito clínico y experimental se han centrado en la actividad de nuevas combinaciones, cuyo papel e indicación clínicas son aún objeto de debate. Por otro lado, la importancia de un tratamiento antibiótico empírico precoz y adecuado ha cobrado interés en los últimos años. Finalmente, cabe destacar el impacto que la instauración de un conjunto sistemático de medidas en el manejo de la bacteriemia estafilocócica tiene en el pronóstico global de la infección. Esta guía clínica reúne un conjunto de recomendaciones a la luz de la última evidencia científica, con el objeto de mejorar el tratamiento y pronóstico de la bacteriemia y endocarditis infecciosa causada por S. Aureus (AU)


Assuntos
Humanos , Bacteriemia/tratamento farmacológico , Endocardite Bacteriana/tratamento farmacológico , Infecções Estafilocócicas/tratamento farmacológico , Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Endocardite Bacteriana/diagnóstico , Staphylococcus aureus/patogenicidade , Staphylococcus aureus Resistente à Meticilina/patogenicidade
11.
Enferm. infecc. microbiol. clín. (Ed. impr.) ; 33(9): 626-632, nov. 2015. tab
Artigo em Inglês | IBECS | ID: ibc-144641

RESUMO

Bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. Optimization of treatment is fundamental in the prognosis of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates have led to research on novel therapeutic schemes. The interest in the new antimicrobials with activity against methicillin-resistant staphylococci has been extended to susceptible strains, which still carry the most important burden of infection. New combinations of antimicrobials have been investigated in experimental and clinical studies, but their role is still being debated. Also, the appropriateness of the initial empirical therapy has acquired relevance in recent years. The aim of this guideline is to update the 2009 guidelines and to provide an ensemble of recommendations in order to improve the treatment of staphylococcal bacteremia and infective endocarditis, in accordance with the latest published evidence (AU)


La bacteriemia y la endocarditis infecciosa causadas por Staphylococcus aureus son enfermedades frecuentes y graves. El tratamiento antibiótico es clave en el éxito terapéutico. El reciente descubrimiento de la relación entre la susceptibilidad a vancomicina y el pronóstico de estas infecciones, tanto cuando en cepas resistentes como sensibles a meticilina, ha llevado a la investigación de nuevos tratamientos. El interés por los nuevos antibióticos con actividad frente a cepas resistentes a meticilina se ha extendido a las cepas sensibles, aún responsables de la mayor parte de infecciones. Estudios clínicos y experimentales han evaluado la eficacia de nuevas combinaciones de antimicrobianos, si bien su indicación no ha sido aún establecida. También la necesidad de un tratamiento inicial empírico correcto ha cobrado relevancia. El objetivo de este documento es actualizar el documento de consenso del 2009 y obtener un conjunto de recomendaciones para mejorar el tratamiento de la bacteriemia y endocarditis estafilocócicas, de acuerdo a la última evidencia científica publicada (AU)


Assuntos
Humanos , Bacteriemia/tratamento farmacológico , Endocardite Bacteriana/tratamento farmacológico , Infecções Estafilocócicas/tratamento farmacológico , Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Endocardite Bacteriana/diagnóstico , Staphylococcus aureus/patogenicidade , Staphylococcus aureus Resistente à Meticilina/patogenicidade
12.
Lancet Respir Med ; 3(11): 859-68, 2015 11.
Artigo em Inglês | MEDLINE | ID: mdl-26472037

RESUMO

BACKGROUND: Ventilator-associated tracheobronchitis has been suggested as an intermediate process between tracheobronchial colonisation and ventilator-associated pneumonia in patients receiving mechanical ventilation. We aimed to establish the incidence and effect of ventilator-associated tracheobronchitis in a large, international patient cohort. METHODS: We did a multicentre, prospective, observational study in 114 intensive care units (ICU) in Spain, France, Portugal, Brazil, Argentina, Ecuador, Bolivia, and Colombia over a preplanned time of 10 months. All patients older than 18 years admitted to an ICU who received invasive mechanical ventilation for more than 48 h were eligible. We prospectively obtained data for incidence of ventilator-associated lower respiratory tract infections, defined as ventilator-associated tracheobronchitis or ventilator-associated pneumonia. We grouped patients according to the presence or absence of such infections, and obtained data for the effect of appropriate antibiotics on progression of tracheobronchitis to pneumonia. Patients were followed up until death or discharge from hospital. To account for centre effects with a binary outcome, we fitted a generalised estimating equation model with a logit link, exchangeable correlation structure, and non-robust standard errors. This trial is registered with ClinicalTrials.gov, number NCT01791530. FINDINGS: Between Sept 1, 2013, and July 31, 2014, we obtained data for 2960 eligible patients, of whom 689 (23%) developed ventilator-associated lower respiratory tract infections. The incidence of ventilator-associated tracheobronchitis and that of ventilator-associated pneumonia at baseline were similar (320 [11%; 10·2 of 1000 mechanically ventilated days] vs 369 [12%; 8·8 of 1000 mechanically ventilated days], p=0·48). Of the 320 patients with tracheobronchitis, 250 received appropriate antibiotic treatment and 70 received inappropriate antibiotics. 39 patients with tracheobronchitis progressed to pneumonia; however, the use of appropriate antibiotic therapy for tracheobronchitis was associated with significantly lower progression to pneumonia than was inappropriate treatment (19 [8%] of 250 vs 20 [29%] of 70, p<0·0001; crude odds ratio 0·21 [95% CI 0·11-0·41]). Significantly more patients with ventilator-associated pneumonia died (146 [40%] of 369) than those with tracheobronchitis (93 [29%] of 320) or absence of ventilator-associated lower respiratory tract infections (673 [30%] of 2271, p<0·0001). Median time to discharge from the ICU for survivors was significantly longer in the tracheobronchitis (21 days [IQR 15-34]) and pneumonia (22 [13-36]) groups than in the group with no ventilator-associated lower respiratory tract infections (12 [8-20]; hazard ratio 1·65 [95% CI 1·38-1·97], p<0·0001). INTERPRETATION: This large database study emphasises that ventilator-associated tracheobronchitis is a major health problem worldwide, associated with high resources consumption in all countries. Our findings also show improved outcomes with use of appropriate antibiotic treatment for both ventilator-associated tracheobronchitis and ventilator-associated pneumonia, underlining the importance of treating both infections, since inappropriate treatment of tracheobronchitis was associated with a higher risk of progression to pneumonia. FUNDING: None.


Assuntos
Bronquite/epidemiologia , Infecção Hospitalar/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Respiração Artificial/efeitos adversos , Traqueíte/epidemiologia , Adulto , Antibacterianos/uso terapêutico , Bronquite/tratamento farmacológico , Bronquite/etiologia , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/etiologia , Europa (Continente)/epidemiologia , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/tratamento farmacológico , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , América do Sul/epidemiologia , Traqueíte/tratamento farmacológico , Traqueíte/etiologia , Adulto Jovem
13.
Crit Care ; 19: 335, 2015 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-26369551

RESUMO

INTRODUCTION: We aimed to compare intensive care unit mortality due to non-pneumococcal severe community-acquired pneumonia between the periods 2000-2002 and 2008-2014, and the impact of the improvement in antibiotic strategies on outcomes. METHODS: This was a matched case-control study enrolling 144 patients with non-pneumococcal severe pneumonia: 72 patients from the 2000-2002 database (CAPUCI I group) were paired with 72 from the 2008-2014 period (CAPUCI II group), matched by the following variables: microorganism, shock at admission, invasive mechanical ventilation, immunocompromise, chronic obstructive pulmonary disease, and age over 65 years. RESULTS: The most frequent microorganism was methicillin-susceptible Staphylococcus aureus (22.1%) followed by Legionella pneumophila and Haemophilus influenzae (each 20.7%); prevalence of shock was 59.7%, while 73.6% of patients needed invasive mechanical ventilation. Intensive care unit mortality was significantly lower in the CAPUCI II group (34.7% versus 16.7%; odds ratio (OR) 0.78, 95% confidence interval (CI) 0.64-0.95; p = 0.02). Appropriate therapy according to microorganism was 91.5% in CAPUCI I and 92.7% in CAPUCI II, while combined therapy and early antibiotic treatment were significantly higher in CAPUCI II (76.4 versus 90.3% and 37.5 versus 63.9%; p < 0.05). In the multivariate analysis, combined antibiotic therapy (OR 0.23, 95% CI 0.07-0.74) and early antibiotic treatment (OR 0.07, 95% CI 0.02-0.22) were independently associated with decreased intensive care unit mortality. CONCLUSIONS: In non-pneumococcal severe community-acquired pneumonia , early antibiotic administration and use of combined antibiotic therapy were both associated with increased intensive care unit survival during the study period.


Assuntos
Antibacterianos/uso terapêutico , Unidades de Terapia Intensiva/estatística & dados numéricos , Pneumonia Bacteriana/tratamento farmacológico , Melhoria de Qualidade , Idoso , Antibacterianos/administração & dosagem , Estudos de Casos e Controles , Infecções Comunitárias Adquiridas , Quimioterapia Combinada , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/normas , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Pneumonia Bacteriana/mortalidade
14.
Ann Intensive Care ; 5(1): 54, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26059205

RESUMO

BACKGROUND: Cuff pressure (P cuff) control is mandatory to avoid leakage of oral secretions passing the tracheal tube and tracheal ischemia. The aim of the present trial was to determine the efficacy of a mechanical device (PressureEasy®) in the continuous control of P cuff in patients intubated with polyvinyl chloride (PVC)-cuffed tracheal tubes, compared with routine care using a manometer. METHODS: This is a prospective, randomized, controlled, cross-over study. All patients requiring intubation with a predicted duration of mechanical ventilation ≥48 h were eligible. Eighteen patients randomly received continuous control of P cuff with PressureEasy® device for 24 h, followed by discontinuous control (every 4 h) with a manual manometer for 24 h, or vice versa. P cuff and airway pressure were continuously recorded. P cuff target was 25 cmH2O during the two periods. RESULTS: The percentage of time spent with P cuff 20-30 cmH2O (median (IQR) 34 % (17-57) versus 50 % (35-64), p = 0.184) and the percentage of time spent with P cuff <20 cmH2O (23 % (5-63) versus 43 % (16-60), p = 0.5) were similar during continuous control of P cuff and routine care, respectively. However, the percentage of time spent with P cuff >30 cmH2O was significantly higher during continuous control compared with routine care of tracheal cuff (26 % (14-39) versus 7 % (1-18), p = 0.002). No significant difference was found in P cuff (25 (18-28) versus 21 (18-26), p = 0.17), mean airway pressure (14 (10-17) versus 14 (11-16), p = 0.679), or coefficient of variation of P cuff (19 % (11-26) versus 20 % (11-25), p = 0.679) during continuous control compared with routine care of tracheal cuff, respectively. CONCLUSIONS: PressureEasy® did not demonstrate a better control of P cuff between 20 and 30 cmH2O, compared with routine care using a manometer. Moreover, the device use resulted in significantly higher time spent with overinflation of tracheal cuff, which might increase the risk for tracheal ischemic lesions. TRIAL REGISTRATION: Clinicaltrial.gov: NCT02109003.

15.
Enferm Infecc Microbiol Clin ; 33(9): 626-32, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25937456

RESUMO

Bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. Optimization of treatment is fundamental in the prognosis of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates have led to research on novel therapeutic schemes. The interest in the new antimicrobials with activity against methicillin-resistant staphylococci has been extended to susceptible strains, which still carry the most important burden of infection. New combinations of antimicrobials have been investigated in experimental and clinical studies, but their role is still being debated. Also, the appropriateness of the initial empirical therapy has acquired relevance in recent years. The aim of this guideline is to update the 2009 guidelines and to provide an ensemble of recommendations in order to improve the treatment of staphylococcal bacteremia and infective endocarditis, in accordance with the latest published evidence.


Assuntos
Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/tratamento farmacológico , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/tratamento farmacológico , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Bacteriemia/microbiologia , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/microbiologia , Gerenciamento Clínico , Farmacorresistência Bacteriana Múltipla , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/cirurgia , Humanos , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Testes de Sensibilidade Microbiana , Reação em Cadeia da Polimerase , Vigilância da População , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Padrão de Cuidado , Infecções Estafilocócicas/diagnóstico por imagem
16.
Enferm Infecc Microbiol Clin ; 33(9): 625.e1-625.e23, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25937457

RESUMO

Both bacteremia and infective endocarditis caused by Staphylococcus aureus are common and severe diseases. The prognosis may darken not infrequently, especially in the presence of intracardiac devices or methicillin-resistance. Indeed, the optimization of the antimicrobial therapy is a key step in the outcome of these infections. The high rates of treatment failure and the increasing interest in the influence of vancomycin susceptibility in the outcome of infections caused by both methicillin-susceptible and -resistant isolates has led to the research of novel therapeutic schemes. Specifically, the interest raised in recent years on the new antimicrobials with activity against methicillin-resistant staphylococci has been also extended to infections caused by susceptible strains, which still carry the most important burden of infection. Recent clinical and experimental research has focused in the activity of new combinations of antimicrobials, their indication and role still being debatable. Also, the impact of an appropriate empirical antimicrobial treatment has acquired relevance in recent years. Finally, it is noteworthy the impact of the implementation of a systematic bundle of measures for improving the outcome. The aim of this clinical guideline is to provide an ensemble of recommendations in order to improve the treatment and prognosis of bacteremia and infective endocarditis caused by S. aureus, in accordance to the latest evidence published.


Assuntos
Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/tratamento farmacológico , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/tratamento farmacológico , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Bacteriemia/microbiologia , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/microbiologia , Gerenciamento Clínico , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/cirurgia , Humanos , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Testes de Sensibilidade Microbiana , Reação em Cadeia da Polimerase , Vigilância da População , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , Padrão de Cuidado , Infecções Estafilocócicas/diagnóstico por imagem
17.
Med. intensiva (Madr., Ed. impr.) ; 39(3): 135-141, abr. 2015. ilus, tab
Artigo em Inglês | IBECS | ID: ibc-135020

RESUMO

Objective To evaluate the clinical usefulness and safety of the differential-time-to-positivity (DTP) method for managing the suspicion of catheter-related bloodstream infection (CR-BSI) in comparison with a standard method that includes catheter removal in critically ill patients. Methods-Design A prospective randomized study was carried out. Setting: A 16-bed clinical-surgical ICU (July 2007-February 2009). Interventions: Patients were randomly assigned to one of two groups at the time CR-BSI was suspected. In the standard group, a standard strategy requiring catheter withdrawal was used to confirm or rule out CR-BSI. In the DTP group, DTP without catheter withdrawal was used to confirm or rule out CR-BSI. Measurements: clinical and microbiological data, CR-BSI rates, unnecessary catheter removals, and complications due to new puncture or to delays in catheter removal. Results Twenty-six patients were analyzed in each group. In the standard group, 6 of 37 suspected episodes of CR-BSI were confirmed and 5 colonizations were diagnosed. In the DTP group, 5 of 26 suspected episodes of CR-BSI were confirmed and four colonizations were diagnosed. In the standard group, all catheters (58/58, 100%) were removed at the time CR-BSA was suspected, whereas in the DTP group, only 13 catheters (13/41, 32%) were removed at diagnosis, and 10 due to persistent septic signs (10/41, 24%). In cases of confirmed CR-BSI, there were no differences between the two groups in the evolution of inflammatory parameters during the 48hours following the suspicion of CR-BSI. Conclusions In critically ill patients with suspected CR-BSI, the DTP method makes it possible to keep the central venous catheter in place safely (AU)


Objetivo Evaluar la utilidad clínica y la seguridad de la diferencia del tiempo de positivización (DTP) de hemocultivos en el manejo de la sospecha de bacteriemia asociada a catéter (BAC) comparándola con un método estándar que incluye la retirada de catéter en los pacientes de cuidados intensivos. Métodos-diseño Estudio prospectivo aleatorizado. Ámbito: UCI médico-quirúrgica de 16 camas (julio de 2007-febrero de 2009). Intervención: aleatorización en 2 ramas de los pacientes en el momento de la sospecha de BAC. Grupo estándar: estrategia clásica que requiere la retirada de catéter para descartar o confirmar la BAC; grupo DTP: método DTP sin retirada de catéter que confirma o descarta la BAC. Variables: datos clínicos y microbiológicos, tasas de BAC, recambios innecesarios de catéteres, complicaciones debidas al recambio de catéter o al retraso en el recambio de catéter. Resultados Veintiséis pacientes fueron estudiados en cada grupo. En el grupo estándar 6 de los 37 episodios de sospecha de BAC fueron confirmados y 5 colonizaciones de catéter fueron diagnosticadas. En el grupo DTP 5 de los 26 episodios de BAC fueron confirmados y 4 colonizaciones diagnosticadas. En el grupo estándar todos los catéteres (58/58, 100%) se retiraron en el momento de la sospecha de BAC, mientras que en el grupo DTP solo 13 catéteres (13/41, 32%) se retiraron en el momento del diagnóstico y 10 por persistencia de signos inflamatorios (10/41, 24%). En los casos de BAC confirmada no se encontraron diferencias en la evolución de los parámetros inflamatorios en las 48h que siguieron la sospecha de BAC. Conclusiones En los pacientes críticos con sospecha de BAC el método DTP permite mantener los catéteres venosos centrales de forma segura (AU)


Assuntos
Humanos , Infecções Relacionadas a Cateter/epidemiologia , Cateterismo Venoso Central/efeitos adversos , Bacteriemia/epidemiologia , Análise Bacteriológica/métodos , Cuidados Críticos , Cuidados Críticos , Testes de Sensibilidade Microbiana , Técnicas Microbiológicas
18.
Med Intensiva ; 39(3): 135-41, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24661917

RESUMO

OBJECTIVE: To evaluate the clinical usefulness and safety of the differential-time-to-positivity (DTP) method for managing the suspicion of catheter-related bloodstream infection (CR-BSI) in comparison with a standard method that includes catheter removal in critically ill patients. METHODS-DESIGN: A prospective randomized study was carried out. SETTING: A 16-bed clinical-surgical ICU (July 2007-February 2009). INTERVENTIONS: Patients were randomly assigned to one of two groups at the time CR-BSI was suspected. In the standard group, a standard strategy requiring catheter withdrawal was used to confirm or rule out CR-BSI. In the DTP group, DTP without catheter withdrawal was used to confirm or rule out CR-BSI. MEASUREMENTS: clinical and microbiological data, CR-BSI rates, unnecessary catheter removals, and complications due to new puncture or to delays in catheter removal. RESULTS: Twenty-six patients were analyzed in each group. In the standard group, 6 of 37 suspected episodes of CR-BSI were confirmed and 5 colonizations were diagnosed. In the DTP group, 5 of 26 suspected episodes of CR-BSI were confirmed and four colonizations were diagnosed. In the standard group, all catheters (58/58, 100%) were removed at the time CR-BSA was suspected, whereas in the DTP group, only 13 catheters (13/41, 32%) were removed at diagnosis, and 10 due to persistent septic signs (10/41, 24%). In cases of confirmed CR-BSI, there were no differences between the two groups in the evolution of inflammatory parameters during the 48hours following the suspicion of CR-BSI. CONCLUSIONS: In critically ill patients with suspected CR-BSI, the DTP method makes it possible to keep the central venous catheter in place safely.


Assuntos
Técnicas Bacteriológicas , Sangue/microbiologia , Infecções Relacionadas a Cateter/diagnóstico , Cateterismo Venoso Central/efeitos adversos , Cateteres de Demora/microbiologia , Adulto , Idoso , Infecções Relacionadas a Cateter/sangue , Infecções Relacionadas a Cateter/microbiologia , Remoção de Dispositivo , Enterobacter cloacae/isolamento & purificação , Infecções por Enterobacteriaceae/diagnóstico , Infecções por Enterobacteriaceae/etiologia , Infecções por Enterobacteriaceae/microbiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Masculino , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Pessoa de Meia-Idade , Estudos Prospectivos , Infecções por Pseudomonas/diagnóstico , Infecções por Pseudomonas/etiologia , Infecções por Pseudomonas/microbiologia , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/etiologia , Infecções Estafilocócicas/microbiologia , Fatores de Tempo , Resultado do Tratamento , Procedimentos Desnecessários
19.
Curr Opin Crit Care ; 20(5): 516-24, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25188366

RESUMO

PURPOSE OF REVIEW: The impact of multidrug-resistant organisms (MDROs) is rising and often underestimated. The epidemiology of MDROs is extremely complex and multifactorial. There is increasing antibiotic resistance, mainly related to antibiotic pressure and patients' characteristics. RECENT FINDINGS: Emphasis on MDRO epidemiology is needed to better understand current strategies of prevention and management. Among them, antibiotic stewardship has been one of the most successful strategies. It is important to note that there is a controversial issue when considering community and healthcare-related infections. In addition, different strategies have been determined to find the impact and optimal use of recently launched antibiotics for MDRO treatment. SUMMARY: Infections with MDROs can prolong hospital stay, promote antibiotic use and prolong duration of mechanical ventilation. Some points should be further explored in clinical research such as the heterogeneity of healthcare-associated pneumonia and the need of new drug development. Resistance to non fermentative Gram-negative bacilli, rising minimum inhibitory concentration in methicillin-resistant Staphylococcus aureus and spread of MDROs in patients without known risk factors suggest a review of guideline validation, taking into account ecology and severity of patient illness to provide timely and appropriate empiric therapy.


Assuntos
Infecções por Acinetobacter/prevenção & controle , Acinetobacter baumannii/patogenicidade , Unidades de Terapia Intensiva , Staphylococcus aureus Resistente à Meticilina/patogenicidade , Infecções por Pseudomonas/prevenção & controle , Pseudomonas aeruginosa/patogenicidade , Infecções Estafilocócicas/prevenção & controle , Infecções por Acinetobacter/tratamento farmacológico , Acinetobacter baumannii/crescimento & desenvolvimento , Antibacterianos , Estado Terminal , Desenho de Drogas , Humanos , Tempo de Internação/estatística & dados numéricos , Staphylococcus aureus Resistente à Meticilina/crescimento & desenvolvimento , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Infecções por Pseudomonas/tratamento farmacológico , Pseudomonas aeruginosa/crescimento & desenvolvimento , Fatores de Risco , Infecções Estafilocócicas/tratamento farmacológico
20.
Crit Care ; 18(3): R129, 2014 Jun 23.
Artigo em Inglês | MEDLINE | ID: mdl-24958136

RESUMO

INTRODUCTION: Two small randomized controlled trials have suggested beneficial effects of antibiotic treatment in patients with ventilator-associated tracheobronchitis (VAT). The primary aim of this study is to determine the impact of appropriate antibiotic treatment on transition from VAT to ventilator-associated pneumonia (VAP) in critically ill patients. The secondary objective was to determine the incidence of VAP in patients with VAT. METHODS: This was a prospective observational multicenter study. All patients with a first episode of VAT were eligible. Patients with tracheostomy at intensive care unit (ICU) admission, and those with VAP prior to VAT were excluded. VAT was defined using all the following criteria: fever > 38 °C with no other cause, purulent tracheal secretions, positive tracheal aspirate (≥ 10(5) cfu/mL), and absence of new infiltrate on chest X ray. Only VAP episodes diagnosed during the 96 h following VAT, and caused by the same bacteria, were taken into account. Antibiotic treatment was at the discretion of attending physicians. Risk factors for transition from VAT to VAP were determined using univariate and multivariate analysis. All variables from univariate analysis with P values <0.1 were incorporated in the multivariate logistic regression analysis. RESULTS: One thousand seven hundred and ten patients were screened for this study. Eighty-six, and 123 patients were excluded for tracheostomy at ICU admission, and VAP prior to VAT; respectively. One hundred and twenty two (7.1%) patients were included. 17 (13.9%) patients developed a subsequent VAP. The most common microorganisms in VAT patients were Pseudomonas aeruginosa (30%), Staphylococcus aureus (18%), and Acinetobacter baumannii (10%). Seventy-four (60%) patients received antimicrobial treatment, including 58 (47.5%) patients who received appropriate antimicrobial treatment. Appropriate antibiotic treatment was the only factor independently associated with reduced risk for transition from VAT to VAP (OR [95% CI] 0.12[0.02-0.59], P = 0.009). The number of patients with VAT needed to treat to prevent one episode of VAP, or one episode of VAP related to P. aeruginosa was 5, and 34; respectively. CONCLUSIONS: Appropriate antibiotic treatment is independently associated with reduced risk for transition from VAT to VAP.


Assuntos
Antibacterianos/uso terapêutico , Bronquite/tratamento farmacológico , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Respiração Artificial/efeitos adversos , Traqueíte/tratamento farmacológico , Idoso , Bronquite/etiologia , Feminino , Humanos , Incidência , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Números Necessários para Tratar , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Traqueíte/etiologia
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