ABSTRACT
Objective: In intensive care units (ICUs), carbapenem-resistant Enterobacterales (CRE) pose a significant threat. We aimed to examine the distribution, epidemiological characteristics, and risk factors for CRE positivity in ICUs. Materials and methods: This cross-sectional study was conducted in 96 ICUs of 78 hospitals in Henan Province, China. The clinical and microbiological data were collected. A multivariable logistic regression model was used to analyze the risk factors for CRE positivity. Results: A total of 1,009 patients were enrolled. There was a significant difference in CRE positive rate between pharyngeal and anal swabs (15.16 vs. 19.13%, P < 0.001). A total of 297 carbapenem-resistant Klebsiella pneumoniae (CR-KPN), 22 carbapenem-resistant Escherichia coli (CR-ECO), 6 carbapenem-resistant Enterobacter cloacae (CR-ECL), 19 CR-KPN/CR-ECO, and 2 CR-KPN/CR-ECL were detected. Klebsiella pneumoniae carbapenemase (KPC), New Delhi metallo-beta-lactamase (NDM), and a combination of KPC and NDM were detected in 150, 9, and 11 swab samples, respectively. Multivariable logistic regression analysis determined length of ICU stay, chronic neurological disease, transfer from other hospitals, previous infection, and history of antibiotics exposure as independent risk factors for CRE positivity. Age and cardiovascular diseases were independent risk factors for mixed infections of CRE. The occurrence of CRE in secondary and tertiary hospitals was 15.06 and 25.62%, respectively (P < 0.05). Patients from tertiary hospitals had different clinical features compared with those from secondary hospitals, including longer hospital stays, a higher rate of patients transferred from other hospitals, receiving renal replacement therapy, exposure to immunosuppressive drugs, use of antibiotics, and a higher rate of the previous infection. Conclusion: In ICUs in Henan Province, CRE positive rate was very high, mostly KPC-type CR-KPN. Patients with prolonged ICU stay, chronic neurological disease, transfer from other hospitals, previous infection, and history of antibiotic exposure are prone to CRE. Age and cardiovascular diseases are susceptibility factors for mixed infections of CRE. The CRE positive rate in tertiary hospitals was higher than that in secondary hospitals, which may be related to the source of patients, antibiotic exposure, disease severity, and previous infection.
ABSTRACT
OBJECTIVE: To evaluate the sedation and analgesia power and security of sufentanil in intensive care unit (ICU), and to compare the effect with fentanyl. METHODS: A multicenter randomized controlled trial was conducted. Critical adult patients in ICU from 11 hospitals in Henan Province from June 2011 to January 2012 who needed analgesia based sedation were enrolled. These patients were randomly divided into two groups with 300 cases in each group using the envelope method according to the hospital number and time sequence number of inclusion. Exclusion criteria included the time of analgesia duration < 48 hours and who were under continuous renal replacement therapy (CRRT) treatment during analgesia. 544 cases were enrolled finally, and there were 282 cases in sufentanil group and 262 in fentanyl group. Before using the drug, there was no statistically significant difference in age, body weight, acute physiology and chronic health evaluation II (APACHEII) score, Glasgow coma scale (GCS) between sufentanil group and fentanyl group, and were comparable. The goal of analgesia was faces pain scale (FPS)≤2. If the dosage of sufentanil and fentanyl exceeded the upper limited dose (sufentanil 0.3 µg×kg(-1)×h(-1), fentanyl 2 µg×kg(-1)×h(-1)) but FPS could not meet (still>2), and maintained the upper limited doses of sufentanil and fentanyl and added midazolam, and FPS≤2 or Ramsay 3 could meet the standard. The analgesia duration of all cases was 48-168 hours. Related data were collected for statistical analysis. RESULTS: (1) Compared with the data before the analgesia, the mean arterial pressure (MAP) of sufentanil analgesia after analgesia at different time points were significantly decreased (F=6.061, P<0.001) and closed to the normal level, FPS at different time point score were decreased significantly after analgesia (F=259.389, P<0.001), and the changes in pulse oxygen saturation (SpO(2)), respiratory rate and pulse were not found. (2) Compared with before the analgesia, the white blood cell count (WBC), neutrophil percentage (N), platelet count (PLT), aspartate transaminase (AST), creatinine (Cr), arterial partial pressure of carbon dioxide (PaCO(2)), blood lactic acid, blood sugar, C-reactive protein (CRP) were markedly reduced after sufentanil analgesia (WBC: 10.8 ± 4.2 ×10(9)/L vs. 14.2 ± 11.5×10(9)/L, F=49.879, P<0.001; N: 0.806 ± 0.104 vs. 0.815 ± 0.128, F=5.768, P=0.017; PLT: 160.4 ± 77.0 ×10(9)/L vs. 166.1 ± 89.0×10(9)/L, F=6.568, P=0.011; AST: 61.3 ± 10.1 U/L vs. 90.9 ± 26.9 U/L, F=6.706, P=0.010; Cr: 86.7 ± 71.8 µmol/L vs. 119.6 ± 56.0 µmol/L, F=30.303, P<0.001; PaCO(2): 39.4 ± 7.2 mmHg vs. 41.7 ± 22.6 mmHg, F=4.389, P=0.037; blood lactic acid: 1.9 ± 1.2 mmol/L vs. 2.7 ± 2.5 mmol/L, F=4.883, P=0.028; blood sugar: 8.0 ± 5.4 mmol/L vs. 9.7 ± 7.6 mmol/L, F=9.724, P=0.002; CRP: 64.8 ± 20.7 mg/L vs. 114.0 ± 55.9 mg/L, F=4.883, P=0.028). But there were no statistically significant differences in red blood cell count (RBC), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), thrombin time (TT), alanine aminotransferase (ALT), total bilirubin (TBil), albumin (ALB), total protein (TP) blood urea nitrogen (BUN), and arterial partial pressure of oxygen (PaO(2)) before and after sufentanil analgesia (all P>0.05). (3)There was no statistically significant difference in effectiveness of sufentanil and five times dose of fentanyl (P>0.05). There was no statistically significant difference in the proportion of sedative drugs midazolam usage [18.4% (52/282) vs. 24.8% (65/262), χ(2)=1.151, P=0.283] and the rate of analgesia success [44.3% (125/282) vs. 48.9% (128/262), χ(2)=0.571, P=0.450] and analgesia success [16.3% (46/282) vs. 15.3% (40/262), χ(2)=0.066, P=0.798] between sufentanil and fentanyl group. (4) Comparison of adverse reactions: the incidence of hypotension in sufentanil group was significantly lower than that in fentanyl group [3.2% (9/282) vs. 6.9% (18/262), χ(2)=3.900, P=0.048], and other common adverse reactions, such as respiratory depression/pause, nausea/vomiting and dizziness, pruritus, allergy, slow heart beat (bradycardia) and metabolic reactions had no statistically significant difference. Addiction or tetanus of skeletal muscles was not found in both groups. CONCLUSIONS: Compared with fentanyl, the analgesia efficacy of sufentanil is stronger. Sufentanil has less physiological interference and lower incidence of adverse reactions for ICU patients.
