Severe sepsis and its impact on outcome in elderly and very elderly patients admitted in intensive care unit.

BACKGROUND: Elderly patients comprise an increasing proportion of intensive care unit (ICU) admissions. Advanced age and multiple comorbidities compromise their immunity and hence they may be more prone to succumbing to severe infection and have poorer outcome. We undertook this study to review impact of severe sepsis on mortality in the elderly patients. METHODS: All patients admitted to a medical ICU of a tertiary care institute with severe sepsis or septic shock were prospectively included. Patients were divided into young (age below 60 years), old (age between 60 and 80 years), and very old (age above 80 years) groups. Data regarding baseline patient characteristics, admission APACHE II score, and ICU course including need for organ support and ICU length of stay were noted. Categorical data were analyzed using χ(2) or Fisher Exact test as appropriate and continuous data were analyzed using Student t test. Primary outcome measure was the ICU mortality. RESULTS: Of 387 patients with sepsis, 132 patients who fulfilled the criteria for severe sepsis/septic shock were included in the analysis. The most common suspected site of infection was lungs (45.5%), followed by urinary tract (21.2%) and abdomen (16.7%). Intensive care unit mortality in younger patients was 45.6% as compared to 60.7% in old and 78.9% in very old patients (P = .035). The relative risk (RR) for dying in the old age was 1.125 and RR for dying in the very old age group was 1.487 as compared to the young patients. There was an increased need for organ support in the elderly and very elderly population as compared to the younger population. On multivariate analysis, only age of the patient was found to be independently predicting ICU mortality (P = .002, OR: 1.038, 95% CI: 1.014-1.062). CONCLUSIONS: The risk of dying from severe sepsis is considerably higher in the elderly and very elderly subgroup of patients with age as an independent risk factor for mortality. Hence, early aggressive care to recognize and manage severe sepsis is required to improve outcome.

An observational study on bloodstream extended-spectrum beta-lactamase infection in critical care unit: incidence, risk factors and its impact on outcome.

BACKGROUND: The incidence of nosocomial infections caused by extended-spectrum beta-lactamase (ESBL) producing microbes is increasing rapidly in the last few years. However, the clinical significance of infections caused by ESBL-producing bacteria in ICU patients remains unclear. We did a prospective study to look for incidence, risk factors and outcome of these infections in ICU patients. METHODS: Consecutive isolates of Escherichia coli and Klebsiella pneumoniae in blood cultures were included for the analysis. Patients were divided into two groups based on the production of ESBL. Primary outcome measure was ICU mortality. Logistic regression analysis was done to identify risk factors for ESBL production. RESULTS: Among the 95 isolates tested, 73 (76.8%) produced ESBL. Transfer from other hospitals or wards (OR 3.65; 95% CI: 1.3-10.1 and RR 1.35; 95% CI: 1.05-1.73) and previous history of antibiotics usage (OR 3.54; 95% CI: 1.04-11.97 and RR 1.5; 95% CI: 0.89-2.5) were risk factors for ESBL production. There was no significant difference in ICU mortality (p=0.588), need for organ support between two groups. CONCLUSION: There is a high incidence of ESBL producing organisms causing blood stream infections in critically ill patients. Transfer from other hospitals and previous antibiotic usage are important risk factors for ESBL production. However ESBL production may not be associated with a poorer outcome if appropriate early antibiotic therapy is instituted.

Admission hyperlactatemia: causes, incidence, and impact on outcome of patients admitted in a general medical intensive care unit.

PURPOSE: The aim of this study was to evaluate the causes, incidence, and impact on outcome of admission hyperlactatemia in patients admitted to a general medical intensive care unit (ICU). METHODS: A retrospective cohort study was done in an 8-bed general ICU of tertiary care hospital over 15 months. Data regarding patient demographics, probable cause of hyperlactatemia, presence of shock, need for organ support, and ICU outcome were recorded. Patients were divided into 2 groups based on admission lactate levels as follows: high lactate (>2 mmol/L) and normal lactate (<2 mmol/L). Patients were compared in terms of need for organ support and ICU mortality. RESULTS: Admission hyperlactatemia was present in 199 of 653 (30.47%) patients. Shock was the commonest cause, 53.3% patients, followed by respiratory and renal failure in 26 (13.1%) and 16 (8%) patients, respectively. Mean ± SD lactate levels in survivors and nonsurvivors were 1.64 ± 1.56 and 4.77 ± 4.72 mmol/L, respectively (P = .000). Receiver operating characteristic curve for lactate was 0.803 (95% confidence interval [CI], 0.753-0.853). Sensitivity and specificity of lactate (>2 mmol/L) to predict ICU mortality was 74.8% and 77.8%, respectively. Odds ratio for dying in patients with hyperlactatemia was 10.39 (95% CI, 6.378-16.925) with a relative risk of 1.538 (95% CI, 1.374-1.721). On subgroup analysis, in patients without hypotension too, ICU mortality was significantly increased in patients with hyperlactatemia (1.3% vs 6.45%, P = .009). CONCLUSIONS: Admission hyperlactatemia is common in a general ICU and is associated with increased mortality, irrespective of presence of hypotension. Shock was the commonest cause for hyperlactatemia, followed by respiratory and renal failures.

Prevention and management of ventilator-associated pneumonia: A survey on current practices by intensivists practicing in the Indian subcontinent.

Implementation of evidence-based guidelines to prevent and manage ventilator-associated pneumonia (VAP) in the clinical setting may not be adequate. We aimed to assess the implementation of selected VAP prevention strategies, and to learn how VAP is managed by the intensivists practicing in the Indian Subcontinent. Three hundred 10-point questionnaires were distributed during an International Critical Care Conferenceheld at New Delhi in 2009. A total of 126 (42%) questionnaires distributed among delegates from India, Nepal and Sri Lanka were analyzed. Majority (96.8%) reported using VAP bundles with a high proportion including head elevation (98.4%), chlorhexidine mouthcare (83.3%), stress ulcer prophylaxis (96.8%), heat and moisture exchangers (HME, 92.9%), early weaning (94.4%), and hand washing (97.6%) as part of their VAP bundle. Use of subglottic secretion drainage (SSD, 45.2%) and closed suction systems (CSS, 74.6%) was also reported by many intensivists, whereas use of selective gut decontamination was reported by only 22.2%. Commonest method for sampling was endotracheal suction by 68.3%. Gram negative organisms were reported to be the most commonly isolated. Majority (39.7%) reported using proton pump inhibitors for stress ulcer prophylaxis and 84.1% believed that VAP contributed to increased mortality. De-escalating therapy was considered in patients responding to treatment by 57.9% and 65.9% considered adding empirical methicillin resistant Staphylococcus aureus (MRSA)coverage, while 63.5% considered adding nebulized antibiotics in certain high-risk patients. There was good concordance regarding VAP prophylaxis among the intensivists with a majority adhering to evidence-based guidelines. We could identify certain issues like the choice of agent for stress ulcer prophylaxis, use of HME filters, SSD and CSS, where there still exists some practice variability and opportunities for improvement.

Clinical profile, intensive care unit course, and outcome of patients admitted in intensive care unit with dengue.

PURPOSE: The purpose of the study was to assess the clinical profile and course of dengue patients admitted to the intensive care unit (ICU) and to identify factors related to poor outcome. METHODS: All patients with dengue admitted to ICU over 2.5 years were included prospectively. Severity of illness was assessed by the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and organ failure was determined by the Sequential Organ Failure Assessment score. Primary outcome measure was 28-day mortality. Logistic regression analysis was performed to identify factors predicting mortality. RESULTS: Data from 198 patients were analyzed. Mean age was 39.56 ± 17.1 years, and 61.1% were male. The commonest complaints were fever (96%) and rash (37.9%). Mean admission APACHE II and Sequential Organ Failure Assessment scores were 7.52 ± 7.8 and 4.52 ± 3.4, respectively. The commonest organ failure was coagulation (43.4%) followed by respiratory failure (13.1%). Vasopressors were required by 11.6%; and dialysis and mechanical ventilation were required by 7.6% and 9.1%, respectively. Mortality was 12 (6.1%); and on multivariate analysis, APACHE II score (odds ratio, 1.781; 95% confidence interval, 0.967-3.281; P = .048) could independently predict mortality. CONCLUSIONS: Patients with dengue fever may require ICU admission for organ failure. Outcome is good if appropriate aggressive care and organ support are instituted. Admission APACHE II score may predict patients at higher risk of death.

Candida sake candidaemia in non-neutropenic critically ill patients: a case series.

Candida sake infections are rare, but have been shown to cause severe infections including fungal endocarditis, peritonitis and bloodstream infection. As the reported incidence of C. sake candidaemia is very low, there is a dearth of data regarding the associated risk factors, antifungal agent-susceptibility patterns, optimal treatment policies, clinical course and outcomes of patients with such infections. We report a series of seven non-neutropenic intensive care unit patients with C. sake candidaemia. Most of the patients were men (6/7), were over 65 years of age (5/7) and had a history of recent hospitalisation (4/7) and comorbidities (4/7). However, all seven patients had a previous history of antibiotic uptake for more than 5 days and had a central venous catheter in situ at the time of taking specimens for culture. In four patients, infection was azole-resistant. Four patients required vasopressor support, three required mechanical ventilation and two required renal replacement therapy. Three of the seven patients died. This case series emphasises the importance of performing species identification and antifungal susceptibility testing in ICU patients with candidaemia, especially those with advanced age, underlying chronic diseases, indwelling vascular catheters, or a history of previous antibiotics or recent hospitalisations, as these patients may be at an increased risk of developing rare Candida infections like C. sake. Moreover, these rare Candida species may be more frequently resistant to azole antifungal agents, and may be associated with significant mortality.

Profile and outcome of patients with acute toxicity admitted in intensive care unit: Experiences from a major corporate hospital in urban India.

BACKGROUND AND AIM: There is scarcity of data from the Indian subcontinent regarding the profile and outcome of patients presenting with acute poisoning admitted to intensive care units (ICU). We undertook this retrospective analysis to assess the course and outcome of such patients admitted in an ICU of a tertiary care private hospital. METHODS: We analyzed data from 138 patients admitted to ICU with acute poisoning between July 2006 and March 2009. Data regarding type of poisoning, time of presentation, reason for ICU admission, ICU course and outcome were obtained. RESULTS: Seventy (50.7%) patients were males and majority (47.8%) of admissions were from age group 21 to 30 years. The most common agents were benzodiazepines, 41/138 (29.7%), followed by alcohol, 34/138 (24.63%) and opioids, 10/138 (7.2%). Thirty-two (23%) consumed two or more agents. Commonest mode of toxicity was suicidal (78.3%) and the route of exposure was mainly oral (97.8%). The highest incidence of toxicity was due to drugs (46.3%) followed by household agents (13%). Organ failure was present in 67 patients (48.5%). During their ICU course, dialysis was required in four, inotropic support in 14 and ventilator support in 13 patients. ICU mortality was 3/138 (2.8%). All deaths were due to aluminium phosphide poisoning. CONCLUSIONS: The present data give an insight into epidemiology of poisoning and represents a trend in urban India. The spectrum differs as we cater to urban middle and upper class. There is an increasing variety and complexity of toxins, with substance abuse attributing to significant number of cases.

Incidence of bacteremia at the time of ICU admission and its impact on outcome.

CONTEXT: Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome. METHODS: Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score. STATISTICAL ANALYSIS: Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality. RESULTS: Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6-100). CONCLUSIONS: Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.