[Infections related to invasive devices in COVID-19 patients admitted to critical care units]. / Infecciones relacionadas con dispositivos invasivos en pacientes COVID-19 ingresados en unidades de críticos.

Introduction: COVID-19 patients admitted to critical care units present an intense inflammatory response and the need to replace organs or systems for long periods of time, which facilitates the presence of infectious complications. Objectives: To present the national rates of infections related to invasive devices (IRDI) in COVID-19 patients, as well as the rates of multi-resistant bacteria (MBR) acquired during their stay in critical care units. Method: Retrospective analysis of COVID-19 patients included during the first, second and fourth waves of the pandemic in a national observational and multicenter database (ENVIN-HELICS). Pneumonias related to mechanical ventilation (N-MV), urinary tract infections related to urethral catheter (UTI-SU) and primary bacteremia related to central venous catheters (BP-CVC) were recorded, whose rates are presented as incidence density (ID). The BMRs acquired during the stay in the critical care units were recorded and presented as cumulative incidence (CI). Results: Seven thousand seven hundred seventy-eight patients were included, 1,525 (19.6%) in the first wave of the pandemic, 3,484 (44.8%) in the second, and 2,769 (35.6%) in the fourth. ICU stay of 21 days in the first and second waves and 19.7 days in the fourth. Intra-ICU mortality in the first wave, decreasing from 31% to 26.3% in the second and 18.9% in the fourth. N-MV rates of 14.31, 13.56, and 19.99 episodes per 1,000 days of MV in each wave. UTI-SU rates of 6.54, 5.63 and 7.97 episodes per 1000 days of SU. BP-CVC rates of 12.42, 7.95, and 8.13 per 1,000 CVC days. The BMR rate was 22.9, 15.3, and 15.3 BMR per 100 admitted patients. Conclusions: High rates of the different IRDI in COVID patients that are maintained in the three waves analyzed. High rates of BMR acquired during the stay in critical care units with a tendency to decrease in the fourth wave.

Dosage Individualization of Linezolid: Precision Dosing of Linezolid To Optimize Efficacy and Minimize Toxicity.

The high interindividual variability in the pharmacokinetics (PK) of linezolid has been described, which results in an unacceptably high proportion of patients with either suboptimal or potentially toxic concentrations following the administration of a fixed regimen. The aim of this study was to develop a population pharmacokinetic model of linezolid and use this to build and validate alogorithms for individualized dosing. A retrospective pharmacokinetic analysis was performed using data from 338 hospitalized patients (65.4% male, 65.5 [±14.6] years) who underwent routine therapeutic drug monitoring for linezolid. Linezolid concentrations were analyzed by using high-performance liquid chromatography. Population pharmacokinetic modeling was performed using a nonparametric methodology with Pmetrics, and Monte Carlo simulations were employed to calculate the 100% time >MIC after the administration of a fixed regimen of 600 mg administered every 12 h (q12h) intravenously (i.v.). The dose of linezolid needed to achieve a PTA ≥ 90% for all susceptible isolates classified according to EUCAST was estimated to be as high as 2,400 mg q12h, which is 4 times higher than the maximum licensed linezolid dose. The final PK model was then used to construct software for dosage individualization, and the performance of the software was assessed using 10 new patients not used to construct the original population PK model. A three-compartment model with an absorptive compartment with zero-order i.v. input and first-order clearance from the central compartment best described the data. The dose optimization software tracked patients with a high degree of accuracy. The software may be a clinically useful tool to adjust linezolid dosages in real time to achieve prespecified drug exposure targets. A further prospective study is needed to examine the potential clinical utility of individualized therapy.

[Management of infectious complications associated with coronavirus infection in severe patients admitted to ICU]. / Manejo de las complicaciones infecciosas asociadas con la infección por coronavirus en pacientes graves ingresados en UCI.

Infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia admitted in ICU. Poor immune status, frequent development of organic failure requiring invasive supportive treatments, and prolonged ICU length of stay in saturated structural areas of patients are risk factors for infection development. The Working Group on Infectious Diseases and Sepsis GTEIS of the Spanish Society of Intensive Medicine and Coronary Units SEMICYUC emphasizes the importance of infection prevention measures related to health care, the detection and early treatment of major infections in the patient with SARS-CoV-2 infections. Bacterial co-infection, respiratory infections related to mechanical ventilation, catheter-related bacteremia, device-associated urinary tract infection and opportunistic infections are review in the document.

Population Pharmacokinetics of Anidulafungin in Critically Ill Patients.

A two-compartment pharmacokinetic (PK) population model of anidulafungin was fitted to PK data from 23 critically ill patients (age, 65 years [range, 28 to 81 years]; total body weight [TBW], 75 kg [range, 54 to 168 kg]). TBW was associated with clearance and incorporated into a final population PK model. Simulations suggested that patients with higher TBWs had less-extensive MIC coverage. Dosage escalation may be warranted in patients with high TBWs to ensure optimal drug exposures for treatment of Candida albicans and Candida glabrata infections.

Characteristics and outcomes of patients admitted to Spanish ICU: A prospective observational study from the ENVIN-HELICS registry (2006-2011).

OBJECTIVE: To describe the case-mix of patients admitted to intensive care units (ICUs) in Spain during the period 2006-2011 and to assess changes in ICU mortality according to severity level. DESIGN: Secondary analysis of data obtained from the ENVN-HELICS registry. Observational prospective study. SETTING: Spanish ICU. PATIENTS: Patients admitted for over 24h. INTERVENTIONS: None. VARIABLES: Data for each of the participating hospitals and ICUs were recorded, as well as data that allowed to knowing the case-mix and the individual outcome of each patient. The study period was divided into two intervals, from 2006 to 2008 (period 1) and from 2009 to 2011 (period 2). Multilevel and multivariate models were used for the analysis of mortality and were performed in each stratum of severity level. RESULTS: The study population included 142,859 patients admitted to 188 adult ICUs. There was an increase in the mean age of the patients and in the percentage of patients >79 years (11.2% vs. 12.7%, P<0.001). Also, the mean APACHE II score increased from 14.35±8.29 to 14.72±8.43 (P<0.001). The crude overall intra-UCI mortality remained unchanged (11.4%) but adjusted mortality rate in patients with APACHE II score between 11 and 25 decreased modestly in recent years (12.3% vs. 11.6%, odds ratio=0.931, 95% CI 0.883-0.982; P=0.008). CONCLUSION: This study provides observational longitudinal data on case-mix of patients admitted to Spanish ICUs. A slight reduction in ICU mortality rate was observed among patients with intermediate severity level.

[Patients treated with micafungin during their stay in intensive care unit]. / Micafungina en pacientes críticos ingresados en unidad de cuidados intensivos.

OBJECTIVES: To determine the reasons of prescription, the characteristics of patients and factors that affected the outcome of critically ill patients treated with micafungin (MCF) during their stay in Spanish ICUs. MATERIAL AND METHODS: Observational, retrospective and multicenter study. Patients admitted to the ICU between March 2011 and October 2012 (20-month period) treated with MCF for any reason were included in the study. Severity of patients at the beginning of treatment was measured with the APACHE II, SOFA, Child-Pugh and MELD scores. Reasons for the use of MCF were classified as prophylaxis, preemptive treatment, empirical treatment and directed treatment. Continuous variables are expressed as mean and standard deviation or median, and categorical variables as percentages. A multivariate analysis was performed to identify variables related to intra-ICU mortality. RESULTS: The study population included 139 patients admitted to 19 Spanish ICUs, with a mean age of 57.3 (17.1) years, 89 (64%) men, with surgical (53.2%) and/or medical (44.6%) conditions, APACHE II score of 20.6 (7.7) and SOFA score of 8.4 (4.3), with 84.2% of patients requiring mechanical ventilation, 59% parenteral nutrition, 37.4% extrarenal depuration procedures and 37.4% treatment with steroids. MCF was indicated as empirical treatment of a proven infection in 51 (36.7%) cases, pre-emptive treatment in 50 (36%) especially as a result of the application of the Candida score (32 cases), directed treatment of fungal infection in 23 (16.5%) and as prophylactic treatment in 15 (10.8%) cases. In 108 (77%) cases, a daily dose of 100mg was administered, with a loading dose in only 9 cases (6.5%). The mean duration of treatment was 13.1 (13) days. A total of 59 (42.4%) patients died during their stay in the ICU and 16 after ICU discharge (hospital mortality 53.9%). Independent risk factors for intra-ICU mortality were the Child-Pugh score (OR 1.45, 95% CI 1.162-1.813; P=.001) and the MELD score (OR 1.05, 95% CI 1.011-1.099; P=.014). CONCLUSIONS: MCF is usually administered at a dose of 100mg/day, without loading dose and in 72.7% of cases as pre-emptive or empirical treatment. Factors that better predicted mortality were indicators of liver insufficiency at the time of starting treatment.

[Comparative analysis of patients admitted to Spanish Intensive Care Units due to medical and surgical disease]. / Análisis comparativo de pacientes ingresados en Unidades de Cuidados Intensivos españolas por causa médica y quirúrgica.

OBJECTIVE: To describe the characteristics of the patients case-mix admitted to ICUs due to medical and surgical disease, and to compare both groups. DESIGN: Analysis of data covering the period 2006-2011 in the ENVIN-HELICS registry. An observational, prospective, multicenter and voluntary participation study. SETTING: A total of 188 Spanish ICUs. PATIENTS: All patients admitted for more than 24 hours. MAIN VARIABLES: Demographic data, cause of admission, severity scores, length of stay, mortality. RESULTS: A total of 138,999 patients were analyzed. Of these, 65,467 (47.1%) were admitted due to a non-coronary medical cause, 27,785 (20,0%) due to coronary-related illness, 28,044 (20,2%) after elective surgery and 17,613 (12.7%) after urgent surgery. Use of devices, nosocomial infections and isolation of multirresistant organisms were more prevalent in urgent surgery patients. Longer length of stay (median 5 days; interquartile range 2-11) as well as higher severity scale values (APACHE II and SAPS II) corresponded to this same group of patients. Mortality was higher in non-coronay medical patients. On categorizing the patients according to the APACHE II score, mortality was seen to be higher in urgent surgery cases than in elective surgery patients in all groups. The largest difference was observed in the APACHE II score 6-10 group (3% vs. 0.9%) (OR: 2.14, 95% CI 1.825-2.513; p<0.001). CONCLUSIONS: The mortality rate is higher in non-coronary medical patients, though resource use per patient is greater in the urgent surgery cases. The APACHE II scale underestimates mortality in emergency surgery patients.

[Pneumocystis jiroveci pneumonia: Clinical characteristics and mortality risk factors in an Intensive Care Unit]. / Neumonía por Pneumocystis jiroveci: características clínicas y factores de riesgo asociados a mortalidad en una Unidad de Cuidados Intensivos.

OBJECTIVE: To describe the epidemiological characteristics of the population with Pneumocystis jiroveci (P. jiroveci) pneumonia, analyzing risk factors associated with the disease, predisposing factors for admission to an intensive care unit (ICU), and prognostic factors of mortality. DESIGN AND PATIENTS: A retrospective observational study was carried out, involving a cohort of patients consecutively admitted to a hospital in Spain from 1 January 2007 to 31 December 2011, with a final diagnosis of P. jiroveci pneumonia. SETTING: The ICU and hospitalization service of Hospital del Mar, Barcelona (Spain). RESULTS: We included 36 patients with pneumonia due to P. jiroveci. Of these subjects, 16 required ICU admission (44.4%). The average age of the patients was 41.3 ± 12 years, and 23 were men (63.9%). A total of 86.1% had a history of human immunodeficiency virus (HIV) infection, and the remaining 13.9% presented immune-based disease subjected to immunosuppressive therapy. Risk factors associated to hospital mortality were age (51.8 vs. 37.3 years, P=.002), a higher APACHE score upon admission (17 vs. 13 points, P=.009), the need for invasive mechanical ventilation (27.8% vs. 11.1%, P=.000), requirement of vasoactive drugs (25.0% vs. 11.1%, P=.000), fungal coinfection (22.2% vs. 11.1%, P=.001), pneumothorax (16.7% vs. 83.3%, P=.000) and admission to the ICU (27.8% vs. 72.2% P=.000). CONCLUSIONS: The high requirement of mechanical ventilation and vasoactive drugs associated with fungal coinfection and pneumothorax in patients admitted to the ICU remain as risk factors associated with mortality in patients with P. jiroveci pneumonia.

Optimization of pre-emptive isolations in a polyvalent ICU through implementation of an intervention strategy.

BACKGROUND: Pre-emptive isolation refers to the application of contact precaution measures in patients with strongly suspected colonization by multiresistant bacteria. OBJECTIVE: To assess the impact of an intervention program involving the implementation of a consensus-based protocol of pre-emptive isolation (CPPI) on admission to a polyvalent ICU of a general hospital. METHODS: A comparative analysis of 2 patient cohorts was made: a historical cohort including patients in which pre-emptive isolation was established according to physician criterion prior to starting CPPI (from January 2010 to February 2011), and a prospective cohort including patients in which CPPI was implemented (from March to November 2011). CPPI included the identification and diffusion of pre-emptive isolation criteria, the definition of sampling methodology, the evaluation of results, and the development of criteria for discontinuation of pre-emptive isolation. Pre-emptive isolation was indicated by the medical staff, and follow-up was conducted by the nursing staff. Pre-emptive isolation was defined as "adequate" when at least one multiresistant bacteria was identified in any of the samples. Comparison of data between the 2 periods was made with the chi-square test for categorical variables and the Student t-test for quantitative variables. Statistical significance was set at P<.05. RESULTS: Among the 1,740 patients admitted to the ICU (1,055 during the first period and 685 during the second period), pre-emptive isolation was indicated in 199 (11.4%); 111 (10.5%) of these subjects corresponded to the historical cohort (control group) and 88 (12.8%) to the posterior phase after the implementation of CPPI (intervention group). No differences were found in age, APACHE II score or patient characteristics between the 2 periods. The implementation of CPPI was related to decreases in non-indicated pre-emptive isolations (29.7 vs. 6.8%, P<.001), time of requesting surveillance cultures (1.56 vs. 0.37 days, P<.001), and days of duration of treatment (4.77 vs. 3.58 days, P<.001). In 44 patients (22.1%) in which pre-emptive isolation was indicated, more than one multiresistant bacteria was identified, with an "adequate pre-emptive isolation rate" of 19.8% in the first period and 25.0% in the second period (P<.382). CONCLUSIONS: The implementation of CPPI resulted in a significant decrease in pre-emptive isolations which were not indicated correctly, a decrease in the time elapsed between isolation and collection of samples, and a decrease in the duration of isolation measures in cases in which isolation was unnecessary, without increasing the rate of "adequate pre-emptive isolation".

[Respiratory infections caused by Aspergillus spp. in critically ill patients admitted to the intensive care units]. / Infecciones respiratorias por Aspergillus spp. en pacientes críticos ingresados en unidades de cuidados intensivos.

UNLABELLED: The presence of respiratory fungal infection in the critically ill patient is associated with high morbidity and mortality. OBJECTIVES: To assess the incidence of respiratory infection caused by Aspergillus spp. independently of the origin of infection in patients admitted to Spanish ICUs, as well as to describe the rates, characteristics, outcomes and prognostic factors in patients with this type of infection. MATERIAL AND METHODS: An observational, retrospective, open-label and multicenter study was carried out in a cohort of patients with respiratory infection caused by Aspergillus spp. admitted to Spanish ICUs between 2006 and 2012 (months of April, May and June), and included in the ENVIN-HELICS registry (108,244 patients and 825,797 days of ICU stay). Variables independently related to in-hospital mortality were identified by multiple logistic regression analysis. RESULTS: A total of 267 patients from 79 of the 198 participating ICUs were included (2.46 cases per 1000 ICU patients and 3.23 episodes per 10,000 days of ICU stay). From a clinical point of view, infections were classified as ventilator-associated pneumonia in 93 cases (34.8%), pneumonia unrelated to mechanical ventilation in 120 cases (44.9%), and tracheobronchitis in 54 cases (20.2%). The study population included older patients (mean 64.8±17.1 years), with a high severity level (APACHE II score 22.03±7.7), clinical diseases (64.8%) and prolonged hospital stay before the identification of Aspergillus spp. (median 11 days), transferred to the ICU mainly from hospital wards (58.1%) and with high ICU (57.3%) and hospital (59.6%) mortality rates, exhibiting important differences depending on the type of infection involved. Independent mortality risk factors were previous admission to a hospital ward (OR=7.08, 95%CI: 3.18-15.76), a history of immunosuppression (OR=2.52, 95%CI: 1.24-5.13) and severe sepsis or septic shock (OR=8.91, 95%CI: 4.24-18.76). CONCLUSIONS: Respiratory infections caused by Aspergillus spp. in critically ill patients admitted to the ICU in Spain are infrequent, and affect a very selected group of patients, characterized by high mortality and conditioned by non-modifiable risk factors.

Quality indicators on the use of antimicrobials in critically ill patients.

Quality indicators have been applied to many areas of health care in recent years, including intensive care. However, they have not been specifically developed and validated for antimicrobial use in critically ill patients. Antimicrobials play a key role in intensive care units not only in the prognosis of each individual patient, but also in the development of resistance and changes in the flora in this setting. Evaluating the use of these agents is complex in the intensive care unit, however, because the indications vary greatly and antimicrobial treatment is often changed during admission. We designed and developed specific quality indicators regarding the use of antimicrobials in critically ill patients admitted to the intensive care unit. These indicators are proposed as a tool for application in intensive care units to detect problems in the use of antimicrobials. Future trials are needed, however, to validate these indicators in a large population over time.

Epidemiological study of Clostridium difficile infection in critical patients admitted to the Intensive Care Unit.

UNLABELLED: Data on the epidemiology of infections caused by Clostridium difficile (CDI) in critically ill patients are scarce and center on studies with a limited time framework and/or epidemic outbreaks. OBJECTIVE: To describe the characteristics and risk factors of critically ill patients admitted to the ICU with CDI, as well as the treatments used for the control of such infections. MATERIAL AND METHODS: A retrospective study was made of patients included in the ENVIN-ICU registry with CDI in 2012. Patients were followed up to 72 h after discharge from the ICU. A case report form was used to record the following data: demographic variables, risk factors related to CDI, treatment and outcome. Infections were classified as community-acquired, nosocomial out-ICU and nosocomial in-ICU, according to the day on which Clostridium difficile isolates were obtained. Infection rates as episodes per 10,000 days of ICU stay are presented. The global in-ICU and hospital mortality rates were calculated. RESULTS: Sixty-eight episodes of CDI in 33 out of a total of 173 ICUs participating in the registry were recorded (19.1%) (2.1 episodes per 10,000 days of ICU stay). Forty-five patients were men (66.2%), with a mean (SD) age of 63.4 (16.4) years, a mean APACHE II score on ICU admission of 19.9 (7.4), and an underlying medical condition in 44 (64.7%). Sixty-two patients (91.2%) presented more than 3 liquid depositions/day, 40 (58.8%) in association with severe sepsis or septic shock. Community-acquired infection occurred in 13 patients (19.1%), nosocomial out-ICU infection in 13 (19.1%), and in-ICU infection in 42 (61.8%). Risk factors included age>64 years in 39 cases (57.4%), previous hospital admission (3 months) in 32 (45.6%), use of antimicrobials (previous 7 days) in 57 (83.8%), enteral nutrition in 23 (33.8%), and the use of H2 inhibitors in 39 (57.4%). Initial combined treatment was administered to 18 patients (26.5%). Metronidazole was used in 60 (88.2%) and vancomycin in 31 (45.6%). The in-ICU mortality rate was 25.0% (n=17), with a hospital mortality 27.9% (n=19). CONCLUSIONS: The rate of ICD in ICU patients is low, the infection affects severely ill patients, and is associated with high mortality. The presence of CDI is a marker of poor prognosis.

Guidelines for the prevention of ventilator-associated pneumonia and their implementation. The Spanish "Zero-VAP" bundle.

BACKGROUND: "Zero-VAP" is a proposal for the implementation of a simultaneous multimodal intervention in Spanish intensive care units (ICU) consisting of a bundle of ventilator-associated pneumonia (VAP) prevention measures. METHODS/DESIGN: An initiative of the Spanish Societies of Intensive Care Medicine and of Intensive Care Nurses, the project is supported by the Spanish Ministry of Health, and participation is voluntary. In addition to guidelines for VAP prevention, the "Zero-VAP" Project incorporates an integral patient safety program and continuous online validation of the application of the bundle. For the latter, VAP episodes and participation indices are entered into the web-based Spanish ICU Infection Surveillance Program "ENVIN-HELICS" database, which provides continuous information about local, regional and national VAP incidence rates. Implementation of the guidelines aims at the reduction of VAP to less than 9 episodes per 1000 days of mechanical ventilation. A total of 35 preventive measures were initially selected. A task force of experts used the Grading of Recommendations, Assessment, Development and Evaluation Working Group methodology to generate a list of 7 basic "mandatory" recommendations (education and training in airway management, strict hand hygiene for airway management, cuff pressure control, oral hygiene with chlorhexidine, semi-recumbent positioning, promoting measures that safely avoid or reduce time on ventilator, and discouraging scheduled changes of ventilator circuits, humidifiers and endotracheal tubes) and 3 additional "highly recommended" measures (selective decontamination of the digestive tract, aspiration of subglottic secretions, and a short course of iv antibiotic). DISCUSSION: We present the Spanish VAP prevention guidelines and describe the methodology used for the selection and implementation of the recommendations and the organizational structure of the project. Compared to conventional guideline documents, the associated safety assurance program, the online data recording and compliance control systems, as well as the existence of a pre-defined objective are the distinct features of "Zero VAP".

Urethral catheter-related urinary infection in critical patients admitted to the ICU. Descriptive data of the ENVIN-UCI study.

OBJECTIVE: To describe trends in national catheter-related urinary tract infection (CRUTI) rates, as well as etiologies and multiresistance markers. DESIGN: An observational, prospective, multicenter voluntary participation study was conducted from 1 April to 30 June in the period between 2005 and 2010. SETTING: Intensive Care Units (ICUs) that participated in the ENVIN-ICU registry during the study period. PATIENTS: We included all patients admitted to the participating ICUs and patients with urinary catheter placement for more than 24 hours (78,863 patients). INTERVENTION: Patient monitoring was continued until discharge from the ICU or up to 60 days. VARIABLES OF INTEREST: CRUTIs were defined according to the CDC system, and frequency is expressed as incidence density (ID) in relation to the number of urinary catheter-patients days. RESULTS: A total of 2329 patients (2.95%) developed one or more CRUTI. The ID decreased from 6.69 to 4.18 episodes per 1000 days of urinary catheter between 2005 and 2010 (p<0.001). In relation to the underlying etiology, gramnegative bacilli predominated (55.6 to 61.6%), followed by fungi (18.7 to 25.2%) and grampositive cocci (17.1 to 25.9%). In 2010, ciprofloxacin-resistant E. coli strains (37.1%) increased, as well as imipenem-resistant (36.4%) and ciprofloxacin-resistant (37.1%) strains of P. aeruginosa. CONCLUSIONS: A decrease was observed in CRUTI rates, maintaining the same etiological distribution and showing increased resistances in gramnegative pathogens, especially E. coli and P. aeruginosa.

Invasive device-related infections after heart surgery.

OBJECTIVE: To analyze postoperative infections in critically ill patients undergoing heart surgery. SETTING: Intensive care units (ICUs). DESIGN: An observational, prospective, multicenter study was carried out. PATIENTS: Patients in the postoperative period of heart surgery admitted to the ICU and included in the ENVIN-HELICS registry between 2005 and 2011. MAIN OUTCOME VARIABLES: Mechanical ventilation associated pneumonia (MVP), urinary catheter-related infection (UCI), primary bacteremia (PB), PB related to vascular catheters (PB-VC) and secondary bacteremia. RESULTS: Of a total of 97,692 patients included in the study, 9089 (9.3%) had undergone heart surgery. In 440 patients (4.8%), one or more infections were recorded. Infection rates were 9.94 episodes of MVP per 1000 days of mechanical ventilation, 3.4 episodes of UCI per 1000 days of urinary catheterization, 3.10 episodes of BP-VC per 1000 days of central venous catheter, and 1.84 episodes of secondary bacteremia per 1000 days of ICU stay. Statistically significant risk factors for infection were ICU stay (odds ratio [OR] 1.18, 95%CI 1.16-1.20), APACHE II upon admission to the ICU (OR 1.05, 95%CI 1.03-1.07), emergency surgery (OR 1.67, 95%CI 1.13-2.47), previous antibiotic treatment (OR 1.38, 95%CI 1.04-1.83), and previous colonization by Pseudomonas aeruginosa (OR 18.25, 95%CI 3.74-89.06) or extended spectrum beta-lactamase producing enterobacteria (OR 16.97, 95%CI 5.4-53.2). The overall ICU mortality rate was 4.1% (32.2% in patients who developed one or more infections and 2.9% in uninfected patients) (P < .001). CONCLUSIONS: Of the patients included in the ENVIN-HELICS registry, 9.3% were postoperative heart surgery patients. The overall mortality was low but increased significantly in patients who developed one or more infection episodes.

Determinants of mortality in cancer patients with unscheduled admission to the Intensive Care Unit: A prospective multicenter study.

OBJECTIVES: To analyze clinical features associated to mortality in oncological patients with unplanned admission to the Intensive Care Unit (ICU), and to determine whether such risk factors differ between patients with solid tumors and those with hematological malignancies. DESIGN: An observational study was carried out. SETTING: A total of 123 Intensive Care Units across Spain. PATIENTS: All cancer patients with unscheduled admission due to acute illness related to the background oncological disease. INTERVENTIONS: None. MAIN VARIABLES: Demographic parameters, severity scores and clinical condition were assessed, and mortality was analyzed. Multivariate binary logistic regression analysis was performed. RESULTS: A total of 482 patients were included: solid cancer (n=311) and hematological malignancy (n=171). Multivariate regression analysis showed the factors independently associated to ICU mortality to be the APACHE II score (OR 1.102; 95% CI 1.064-1.143), medical admission (OR 3.587; 95% CI 1.327-9.701), lung cancer (OR 2.98; 95% CI 1.48-5.99) and mechanical ventilation after the first 24h of ICU stay (OR 2.27; 95% CI 1.09-4.73), whereas no need for mechanical ventilation was identified as a protective factor (OR 0.15; 95% CI 0.09-0.28). In solid cancer patients, the APACHE II score, medical admission, antibiotics in the previous 48h and lung cancer were identified as independent mortality indicators, while no need for mechanical ventilation was identified as a protective factor. In the multivariate analysis, the APACHE II score and mechanical ventilation after 24h of ICU stay were independently associated to mortality in hematological cancer patients, while no need for mechanical ventilation was identified as a protective factor. Neutropenia was not identified as an independent mortality predictor in either the total cohort or in the two subgroups. CONCLUSIONS: The risk factors associated to mortality did not differ significantly between patients with solid cancers and those with hematological malignancies. Delayed intubation in patients requiring mechanical ventilation might be associated to ICU mortality.

Impact of administration of vancomycin or linezolid to critically ill patients with impaired renal function.

The aim of this study was to assess the impact of vancomycin (VAN) versus linezolid (LZD) on renal function in patients with renal failure (RF) admitted to intensive care units. This was a multicenter, retrospective, comparative cohort study. Renal failure patients were treated with VAN or LZD for proven or suspected infections by multiresistant Gram-positive cocci. Changes in plasma creatinine levels and creatinine clearance at the start and end of treatment were used as endpoints. A total of 147 patients were treated with VAN (group A, n = 68) or LZD (group B, n = 79). Group B included more patients with diabetes mellitus [9 (13.2%) vs. 25 (31.6%); p = 0.007], septic shock [39 (57.4%) vs. 60 (75.9%); p = 0.013] and greater RF (mean ClCr 42.24 ml/min vs. 37.57 ml/min; p = 0.04). Renal function improved in patients from both groups who did not require renal replacement therapy. A greater improvement was seen in group B [percent decrease in Cr (27.94 vs. 9.48; p = 0.02) and percent increase in ClCr (95.96 vs. 55.06; p = 0.05)]. In group A, nine patients (13.2%) experienced an antibiotic-related increase in RF, and antibiotic was discontinued in five patients due to adverse effects. It is reasonable to avoid use of VAN in critically ill patients with acute renal failure.

[Should the diagnosis of ventilator associated pneumonia be improved?]. / ¿Debemos mejorar el diagnóstico de la neumonía asociada a ventilación mecánica?

Ventilator associated pneumonia (VAP) is the leading nosocomial infection in intensive care. It is associated with increased ICU and hospital stay, an increased use of antibiotics, and greater hospital costs. The recently launched Pneumonia Zero project (NZ) undoubtedly constitutes a challenge for professionals in the ICU, and has been designed to reduce the high incidence rates described. It is necessary to establish the true incidence, and whether the latter is influenced by the diagnostic method employed. The lack of a reference standard for the microbiological diagnosis of VAP has generated controversy over the diagnostic algorithms to be used, with the distinction of two strategies: a noninvasive or clinical strategy based on upper respiratory tract cultures, and an invasive method based on the use of quantitative cultures of samples from the lower respiratory tract obtained by bronchoscopic techniques. Despite the recommendations of scientific societies, which do not justify the use of qualitative tracheal aspirates in the microbiological diagnosis of VAP, this method is still routinely used. This study underscores the need to stop using qualitative tracheal aspirates as a routine diagnostic method for VAP, recommending the use of bronchoscopic techniques or quantitative tracheal aspirates.