Efficacy of cefiderocol- vs colistin-containing regimen for treatment of bacteraemic ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii in patients with COVID-19.

INTRODUCTION: Ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB) in patients hospitalized in intensive care units (ICUs) is an important and challenging complication, including in patients with coronavirus disease 2019 (COVID-19). Considering the poor lung penetration of most antibiotics, including intravenous colistin due to the poor pharmacokinetics/pharmacodynamics at the infection site, the choice of the best antibiotic regimen is still being debated. METHODS: This single-centre, observational study was conducted from March 2020 to August 2022, and included all patients hospitalized consecutively with VAP and concomitant bloodstream infection due to CRAB in the COVID-ICU. The main goal of the study was to evaluate risk factors associated with survival or death at 30 days from VAP onset. A propensity score for receiving therapy was added to the model. RESULTS: During the study period, 73 patients who developed VAP and concomitant positive blood cultures caused by CRAB were enrolled in the COVID-ICU. Of these patients, 67 (91.7%) developed septic shock, 42 (57.5%) had died at 14 days and 59 (80.8%) had died at 30 days. Overall, 54 (74%) patients were treated with a colistin-containing regimen and 19 (26%) were treated with a cefiderocol-containing regimen. Cox regression analysis showed that chronic obstructive pulmonary disease and age were independently associated with 30-day mortality. Conversely, cefiderocol-containing regimens and cefiderocol + fosfomycin in combination were independently associated with 30-day survival, as confirmed by propensity score analysis. CONCLUSIONS: This real-life study in patients with bacteraemic VAP caused by CRAB provides useful suggestions for clinicians, showing a possible benefit of cefiderocol and its association with fosfomycin.

CRRT impact on outcomes of patients treated with ECMO and fluid overload: a case report

Background: ECMO is an extracorporeal circulation used as a short-term life-saving support in patients with refractory cardiac and respiratory failure. Fluid overload (FO) in patient with this support, sometimes due to the onset of AKI, is associated with an increased morbidity and mortality rate and with prolonged duration of mechanical ventilation and ECMO. It also alters the volume of distribution of most drugs and can even mask the presence of AKI. Mantaining a negative fluid balance is an essential goal to improve gas exchanges in patients with respiratory failure who have undergone ECMO support. So, fluid overload removal has a significant prognostic value. Diuretic therapy, at the maximal dosage, can be insufficient to reach a negative water balance and it can also lead to metabolic disorders. Initiating RRT may help to obtain this goal. Method(s): A 32-years-old man, without any comorbidity, was admitted to the intensive care unite (ICU) with severe acute respiratory distress syndrome (ARDS) due to SARS Cov-2 infection and refractory hypoxemia. After intubation and mechanical ventilation, he was treated with VV-ECMO. In order to maintain a negative fluid balance, diuretic therapy at maximum dosage was started. Despite this therapy, the patient continued to show fluid overload clinical and its radiological signs, with a little improvement in gas exchanges. For that reason and in order to avoid metabolic alterations due to the diuretic therapy, it was decided to start CVVHF treatment. Thus, the patient was submitted to 3 sessions of CVVHF with a total ultrafiltration of 12 liters. He never lost spontaneous diuresis (his hourly dieresis was about of 150 ml). Diuretic therapy was restarted at the end of the CRRT sessions. Result(s): There was an improvement in patient's gas exchanges already during the first treatment which led to the stop of ECMO after 14 days. FGF (fresh gas flow) had been progressively decreased to the oxygenator. At the same time, lung ventilation has been increased to maintain an adequate CO2 clearance. The patient remained stable at a FGF of 0 L/min for a period of 24 hours;thus only mechanical ventilation was kept. A negative fluid balance has led to a significant patient's clinical conditions improvement to permit VV-ECMO weaning. Conclusion(s): Fluid overload removal is an essential goal to improve gas exchanges and, consequently, outcomes in patients treated with ECMO and its duration can both improve. This goal requires continuous renal replacement therapy (CRRT) because of patient's hemodynamic instability. However, the approach combining CRRT and ECMO is facilitated by several ways to link the different circuits without the necessity of positioning a bilumen CVC and, also, by using the same anticoagulation regimen.