How to treat VAP due to MDR pathogens in ICU patients.

BACKGROUND: The increasing occurrence of multidrug resistant (MDR) bacteria arises at a time when there is a lack of antibiotics active against these pathogens and few new antimicrobials are in the pipelines of the pharmaceutical industry. Treatment of ventilator-associated pneumonia (VAP) caused especially by MDR Gram-negative bacilli (GNB) represents a real challenge due to the dearth of treatment options. METHODS: We searched the medical literature relevant about management of ventilator-associated pneumonia caused by multi-drug resistant pathogens including GNB and methicillin-resistant S. aureus. RESULTS: Empirical therapy should be prescribed based on the local pattern of susceptibilities. Colistin and tigecycline are in many cases the unique options for the treatment of many episodes of VAP caused by MDR-GNB. Tigecyline (not licensed for treatment of pneumonia) should be used with an initial bolus of 200 mg followed by 100 mg every 12 h. The need for a loading dose and the administration of high doses of colistin (9 million IU/day in two or three doses) is currently accepted. Vancomycin has been considered the treatment of choice for pneumonia due to MRSA although linezolid may provide higher rate of clinical cure for MRSA VAP with a good safety profile. The initial antibiotic treatment must be reassessed and simplify in accordance of culture results. CONCLUSIONS: Empirical treatment of VAP due to MDR pathogens should be based on knowledge of local ecology. A strategy combining early high doses of effective agents with subsequent simplification in the light of microbiologic information is recommended.

Clinical efficacy and safety of the combination of colistin plus vancomycin for the treatment of severe infections caused by carbapenem-resistant Acinetobacter baumannii.

A potent synergy of a glycopeptide-colistin combination against Acinetobacter baumannii has recently been described. We set out to assess the efficacy and safety of this combination in a retrospective study including episodes of ventilator-associated pneumonia or bacteremia caused by carbapenem-resistant A. baumannii. We compared 29 patients (group I) treated with colistin plus vancomycin with 28 patients treated with colistin alone (group II). Group I received vancomycin (for empirical or targeted therapy) at the onset of colistin administration and both antimicrobials coincided for at least 5 days. Baseline characteristics, clinical cure, microbiological eradication, and mortality were similar in both groups but the rate of acute kidney injury was higher in group I (55.2 vs. 28%; p = 0.04). In critically ill patients with carbapenem-resistant A. baumannii infections, clinical outcomes do not differ in patients treated with colistin plus vancomycin from those receiving colistin without vancomycin. This combination significantly increases the risk of renal failure.

Right Ventricular Assist Devices After Heart Transplantation.

BACKGROUND: Severe right ventricular failure (RVF) has a significant incidence among cardiac transplant patients. It is a serious complication and an independent risk factor for postoperative mortality. In this setting, ventricular assist devices (VADs) must be considered if conservative medical management fails. This study sought to examine our series of patients with early RVF after heart transplantation requiring VAD support. METHOD: We analyzed consecutive, adult heart transplant recipients at a third level intensive care unit who underwent transplantation from January 2011 to March 2019 requiring post-transplant mechanical circulatory support for RVF. Demographic characteristics, clinical data, complications, and survival rates were collected. RESULTS: Ten patients were included. Median age was 50 years (range, 31.7-57). Eight patients (80%) were male. The most frequent indication for heart transplantation was ischemic heart disease (4 patients) followed by dilated cardiomyopathy and congenital heart disease (2 patients). Preoperative pulmonary hypertension was present in 6 patients. Three patients required a VAD before transplant. Whole survival rate was 60%. After heart transplantation, 7 patients required renal replacement therapy, 2 patients suffered a hemorrhagic stroke, and 5 patients needed a tracheostomy for long-term ventilation. CONCLUSION: Patients who develop RVF after transplantation have an increased incidence of complications and high mortality after surgery. VADs could be implanted immediately after heart transplantation in high-risk patients.

Transplantation in Congenital Heart Disease: A Challenge.

BACKGROUND: Heart failure is the leading cause of death in grown-up congenital heart disease patients (GUCH). Although heart transplantation (OHT) remains the gold standard in end-stage heart failure, the ratio of GUCH patients undergoing this procedure remains low. OBJECTIVE: Describe the cohort of GUCH patients undergoing heart transplantation at a third-level hospital. METHODS: A retrospective review of GUCH patients undergoing OHT between 1997 and 2019 was conducted at a single tertiary university hospital. We included different preoperative (demographic and clinical data, cardiac catheterization data from the last routine hemodynamic monitoring) and postoperative variables (complications, survival). RESULTS: Fourteen patients were enrolled. The median age was 25.5 years (range, 20.7-32.2). Eight patients (57.1%) were male. The median preoperative left ventricular ejection fraction was 37% (range, 22.5%-55%). As for preoperative hemodynamic evaluation, the median for the mean arterial pulmonary pressure was 19 mm Hg (range, 12-22.5), for the capillary wedge pressure was 16 mm Hg (range, 13.5-19.5), and for pulmonary vascular resistance was 1.83 Wood units (range, 1-4). After OHT, 6 patients (42.9%) suffered an infection, the most common of which was respiratory (3 out of 6). Four patients (28.6%) needed renal replacement therapy, and 4 patients (28.6%) presented liver failure. Four patients (28.6%) developed graft failure, thus requiring mechanical support with extracorporeal membrane oxygenation during a median of 6 days (range, 1-17.5). Survival rate of patients under extracorporeal membrane oxygenation was 50%, and overall survival rate was 78.6%. CONCLUSION: OHT represents a good option for GUCH patients, with good overall survival rates.

Antibioterapia empírica tras una parada cardiaca reanimada / Empiric antibiotic therapy after cardiac arrest

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Takotsubo, algo más que corazón / Takotsubo, thinking outside the heart

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