Epidemiology and outcomes of source control procedures in critically ill patients with intra-abdominal infection

This research by de Groep and colleagues was published online in the Journal of Critical Care during May 2019.
Purpose:  To describe the characteristics and procedural outcomes of source control interventions among Intensive Care Unit (ICU) patients with severe intra-abdominal-infection (IAI).
Material and methods:  We identified consecutive patients with suspected IAI in whom a source control intervention had been performed in two tertiary ICUs in the Netherlands, and performed retrospective in-depth case reviews to evaluate procedure type, diagnostic yield, and adequacy of source control after 14 days.
Results:  A total of 785 procedures were observed among 353 patients, with initial interventions involving 266 (75%) surgical versus 87 (25%) percutaneous approaches. Surgical index procedures typically involved IAI of (presumed) gastrointestinal origin (72%), whereas percutaneous index procedures were mostly performed for infections of the biliary tract/pancreas (50%) or peritoneal cavity (33%). Overall, 178 (50%) patients required multiple interventions (median 3 (IQR 2–4)). In a subgroup of 236 patients having their first procedure upon ICU admission, effective source control was ultimately achieved for 159 (67%) subjects. Persistence of organ failure was associated with inadequacy of source control at day 14, whereas trends in inflammatory markers were non-predictive.
Conclusions:  Approximately half of ICU patients with IAI require more than one intervention, yet successful source control is eventually achieved in a majority of cases.
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Inhaled amikacin for severe Gram-negative pulmonary infections in the intensive care unit: current status and future prospects

This article by Torres et al was published in Critical Care December 2018 issue.
Recently, the use of nebulized antibiotics in the intensive care unit, in particular amikacin, has been the subject of much discussion, owing to unconvincing results from the latest randomized clinical trials. Here, we examine and reappraise the evidence in favor and against this therapeutic strategy; we then discuss the potential factors that might have played a role in the negative findings of recent clinical trials. Also, we call attention to several factors that are seldom considered by study developers and regulatory agencies, to promote translational research in this field and improve the design of future randomized clinical trials.
The full text of the article is freely available via this link.

Ten-year trends in intensive care admissions for respiratory infections in the elderly

This article by Laporte and colleagues was published in Annals of Intensive Care August issue.
Background:  The consequences of the ageing population concerning ICU hospitalisation need to be adequately described. We believe that this discussion should be disease specific. A focus on respiratory infections is of particular interest, because it is strongly associated with old age. Our objective was to assess trends in demographics over a decade among elderly patients admitted to the ICU for acute respiratory infections.
Methods:  A cross-sectional study was performed between 2006 and 2015 based on hospital discharge databases in one French region (2.5 million inhabitants). Patients with acute respiratory infection were selected according to the specific ICD-10 diagnosis codes recorded, including acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP). We also identified comorbid conditions based on any significant ICD-10 secondary diagnoses adapted from the Charlson and Elixhauser indexes.
Results:  A total of 98,381 hospital stays for acute respiratory infection were identified among the 3,856,785 stays over the 10-year period. The number of patients 75 y/o and younger increased 1.6-fold from 2006 to 2015, whereas the numbers of patients aged 85-89 and ≥ 90 y/o increased by 2.5- and 2.1-fold, respectively. Both CAP and AECOPD hospitalisations significantly increased for all age groups over the decade. ICU hospitalisations for respiratory infection increased 2.7-fold from 2006 to 2015 (p = 0.0002). The greatest increases in the use of ICU resources were for the 85-89 and ≥ 90 y/o groups, which corresponded to increases of 3.3- and 5.8-fold. Indeed, the proportion of patients hospitalized for respiratory infection in ICU that were elderly clearly grew during the decade: 11.3% were ≥ 85 y/o in 2006 versus 16.4% in 2015 (p < 0.0001). This increase in ICU hospitalisation rate of ageing patients was not associated with significant changes in the level of care or ICU mortality except for patients ≥ 90 y/o (for whom ICU mortality dropped from 40.9 to 22.3%, p = 0.03).
Conclusion:  We observed a substantial increase in acute respiratory infection diagnoses associated with hospitalisation between 2006 and 2015, with a growing demand for critical care services. Both the absolute number and the percentage of elderly patient ICU admissions increased over the last decade, with the greatest increases being observed for patients 85 years and older.
The full text of this article is freely available via this link.

Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials

The secondary research was published in the journal Critical Care in August 2018 by Wirz and others.
Background:  The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection.
Methods:  For this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the “procalcitonin-guided” group) or the current standard of care (the “controls”). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay.
Results:  Mortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient -1.19 days, 95% CI -1.73 to -0.66; p < 0.001).
Conclusion:  Procalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration.
The full text of this article is freely available via this link.

Latest issue of Critical Care Reviews Newsletter 280 23rd April 2017

The 280th Critical Care Reviews Newsletter provides the best critical care research and open access articles from across the medical literature over the past seven days.  The highlights of this week’s edition are a randomised controlled trial examining immunoglobulin G for patients with necrotising soft tissue infection and a feasibility trial investigating corticosteroids in paediatric septic shock; review articles on arginine in the critically ill, nutrition and metabolism in burn patients and pre-hospital ultrasound; as well as three excellent study critiques on FLORALI, HELMET-NIV and targeted temperature management in deceased organ donors.

The full newsletter can be accessed via this link.

Oral care in ventilated intensive care unit patients

Diaz, T.L. et al. American Journal of Infection Control. Published online: 23 January 2017

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Highlights:

  • A quality improvement project was developed to evaluate the pre/post effects of standardized placement and supply of oral care equipment in patient rooms.
  • Daily audits were performed to assess nursing behavior related to the performance of oral care on intubated patients with components from a 24 hour kit.
  • Increasing supply and creating uniform placement of oral care tools in patient rooms contributes to increased performance of oral hygiene interventions by nurses.

Read the full abstract here

Prevention of Catheter-Associated Bloodstream Infections in a Pediatric ICU

Düzkaya, D.S. et al. (2016) Critical Care Nurse. 36(6) pp. e1-e7

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Background: Bloodstream infections related to use of catheters are associated with increased morbidity and mortality rates, prolonged hospital lengths of stay, and increased medical costs.

Conclusions: Use of chlorhexidine-impregnated dressings reduced rates of catheter-related bloodstream infections, contamination, colonization, and local catheter infection in a pediatric intensive care unit but was not significantly better than use of standard dressings.

Read the full abstract here