Effect of selective flora suppression on colonization, infection, and mortality in critically ill patients: a one-year, prospective consecutive study.

OBJECTIVE: To study the effect of enterally administered polymyxin E, tobramycin, and amphotericin B (selective flora suppression) on bacterial colonization, infection, resistance, and mortality rate. DESIGN: Prospective, consecutive crossover controlled study. SETTING: Two surgical ICUs in a university hospital; ICU I with ten beds, ICU II with eight beds. PATIENTS: Two hundred patients entered the 1-yr trial. Fifty of 111 patients received selective flora suppression during the first 6 months in ICU I (test group), while 61 of 111 patients served as the control group in the following 6 months. In ICU II, 49 of 89 patients received no selective flora suppression in the first 6 months (control group), followed by 40 of 89 patients receiving selective flora suppression during the second 6-month period (test group). INTERVENTIONS: The test group got a mixture of nonabsorbable antibiotics (paste and suspension) in the digestive tract. The control group received paste and suspension without antimicrobial agents. All 200 patients received cefotaxime during the first 4 days. MEASUREMENTS AND MAIN RESULTS: With the use of selective flora suppression, colonization with aerobic Gram-negative bacilli was significantly (p less than .01) reduced. There was also a significant reduction in nosocomial bronchopulmonary (ICU I and II; p less than .001) and urinary tract (ICU II; p less than .001) infections. The difference in mortality was not significant. There was no development of resistance against the antibiotics used during the limited period evaluated. CONCLUSIONS: Selective flora suppression is effective in reducing secondary colonization by aerobic Gram-negative bacilli. Reduction of bronchopulmonary and urinary tract infections most likely occurs with colonization prevention.

Comparative clinical trial of ceftazidime and imipenem/cilastatin in patients with severe nosocomial pneumonias and septicaemias.

The efficacy and safety of ceftazidime and imipenem in patients with severe infections was compared in a randomized multi-centre trial. Patients on assisted respiration with clinical signs of pneumonia or septicaemia who had been in hospital for at least 3 days were studied. Twenty-one patients were treated with ceftazidime, 24 with imipenem. The mean duration of treatment was 9 days in both groups. At the end of the trial 17 patients (81%) of the ceftazidime group and 16 patients (67%) in the imipenem group were clinically cured or showed marked improvement. The bacteriological results showed an eradication of the causative pathogens in 17 of 21 cases in the ceftazidime group and 13 of 19 in the imipenem group.

[Nosocomial infections in surgical intensive medicine. Results of a 5-year prospective study]. / Nosokomiale Infektionen in der operativen Intensivmedizin. Ergebnisse einer 5jährigen prospektiven Erhebung.

All the ICU patients were continuously studied during the first quarter of 5 consecutive years for infections according to a standard protocol. The investigators--the infection control officer and a well-trained infection control nurse--decided if the patient was infected by referring to medical and nursing record, temperature charts, laboratory and x-ray reports and, where necessary, by clinical examination. Definitions and criteria for infections comply with the CDC and the algorithms of the Senic Project. Only the first quarter of each year from 1980-1984 was analysed. The first quarter of 1980 was analysed retrospectively, the following years were examined prospectively. In 1984 a new ICU (ICU I) in addition to the old ICU (ICU II) was opened. The two ICUs differ in building construction but have similar patients, nursing staff and medical standards. The frequency of nosocomial infection was not affected by the different building constructions. The number of patients surveyed was 1009, 60% were males and 40% females. The average age was 45.5 years and the average period of stay about 4 days. 733 patients (72.6%) were intubated and artificially ventilated for 3 days. A fatal outcome resulted in 13.2% of all patients. 1129 nosocomial infections were registered in 311 patients, which means an infection rate of 32.8%. The most frequent nosocomial infections were those of the respiratory tract. Wound infections developed in 16.6%. The urinary tract was affected in 8.8%. Nosocomial septicaemias were observed in 8.7%. Catheter-associated infections were noticed in 6.7% of the patients. A fatal outcome resulted in 26% of the patients with nosocomial infections and in 6.9% of the non-infected patients, respectively.

Infection surveillance and selective decontamination of the digestive tract (SDD) in critically ill patients--results of a controlled study.

All ICU patients were continuously monitored for infections according to a standard protocol by the physician in charge and an infection control nurse during the first quarter of five consecutive years (1980-1984). The number of patients surveyed was 1,009. The average age was 45.5 years and the average period of stay about four days. 733 patients (72.6%) were intubated and artificially ventilated for three days. A fatal outcome resulted in 13.2% of all patients, 1,129 nosocomial infections were registered in 331 patients, which means an infection rate of 32.8%. The most frequent nosocomial infections were those of the respiratory tract (24.3%). Wound infections developed in 16.6%. The urinary tract was affected in 8.8%. Nosocomial septicaemias were observed in 8.7%. Catheter-associated infections were found in 6.7% of the patients. A fatal outcome resulted in 26% of the patients with nosocomial infections and in 6.9% of the non-infected patients, respectively. There was no significant reduction in nosocomial infections over the five-year period in our ICU. Therefore, a study was designed to evaluate the concept of selective decontamination of the digestive tract (SDD) in critically ill patients in our two surgical/traumatological ICUs. A prospective, consecutive, placebo-controlled study in two ICUs was carried out during four six-month periods. 200 patients who were intubated for at least three days, required intensive care for a minimum of five days, and belonged to either class III or IV according to the "Therapeutic Intervention Scoring System" were included in the study. They received either placebo or a prophylaxis regimen, consisting of polymyxin E, tobramycin and amphotericin B.(ABSTRACT TRUNCATED AT 250 WORDS)

[Selective flora suppression for control of infection in surgical intensive care medicine]. / Selektive Florasuppression zur Infektionskontrolle in der operativen Intensivmedizin.

The question to be answered in this study was: Is prophylactic selective florasuppression advantageous compared to conventional antibiotic policy as far as microbial colonisation, infection, mortality and development of resistance are concerned? A prospective, consecutive, placebo-controlled study in two ICU's was carried out during four 6-months periods. 200 patients who were intubated for at least 3 days, required intensive care for a minimum of 5 days, and belonged to either class III or IV according to the "Therapeutic Intervention Scoring System" were included in the study. They received either placebo or the prophylaxis regimen described by Stoutenbeek et al., consisting of polymyxin E, tobramycin and amphotericin B. Oropharyngeal, tracheobronchial and rectal colonisation with aerobic gram-negative bacilli markedly decreased in the test groups. The rates of nosocomial bronchopulmonary infections (ICU I and II) and urinary tract infections (ICU II) were significantly reduced. There was no significant reduction in wound infection, septicaemia and mortality rates. No development of resistance and no increase of multi-resistant strains occurred. Selective florasuppression is effective in reducing infection rates in critically ill patients without development of resistant strains.

[Monitoring infection at the intensive care unit--a multicenter pilot study]. / Infektionsüberwachung an Intensivstationen--eine multizentrische Pilotstudie.

During a period of 3 months an infection survey was carried out in 4 intensive care units (ICUs), 2 in Vienna, Austria, and one each in Ulm and Münster, Federal Republic of Germany, using a common protocol. A total of 329 patients was monitored prospectively. This pilot study was performed to evaluate the usefulness of parameters included in the monitoring form. It was attempted to characterize the patient populations of the four units. Mean duration of stay (1-12 days), mortality (8-26%), leading diagnosis upon admission, intubation rate (41-91%) and use of pulmonary artery catheter (12-35%) were distinctly different. The rate of patients admitted already with an infection was 9-43%, septicemia was diagnosed in up to 27% of the diseased. The rate of infection acquired in the unit was between 12 and 37%, the most frequent types were bronchopneumonia, septicemia and urinary tract infection. When septicemia patients were compared to non-septicemia patients who had been admitted for more than 3 days, it appeared that the latter stayed significantly shorter at the ICU and showed less frequently bronchopneumonia or urinary tract infection at the time of admission. Septicemia patients acquired more frequently additional infections like broncho-pneumonia or urinary tract infection while staying at the ICU. The median day of onset of septicemia was the fifth day and only in a quarter of cases diagnosis could be supported by a positive blood culture. The use of antibiotics in the 4 ICUs is compared and shows marked differences. Based upon experience with this type of infection survey a new modified protocol is introduced, which displays the time course of documented events.

[Partial remission of fulminant thrombotic-thrombopenic purpura (Moschcowitz syndrome) by infusion of fresh plasma]. / Partielle Remission der fulminanten thrombotisch-thrombozytopenischen Purpura (Moschcowitz-Syndrom) unter Infusion von Frischplasma.

In addition to the typical manifestations of thrombotic-thrombocytopenic purpura like thrombocytopenia, haemolysis, fever, coma and renal failure, signs of a beginning DIC could be seen in a patient after abdominal surgery. Haemostatic, cardiovascular and respiratory data are presented. Pulmonary angiography by using a Swan-Ganz-catheter revealed multiple filling defects reversible with therapy. Treatment with fresh whole blood aggravated thrombocytopenia. Daily infusions of fresh frozen plasma combined with heparinisation and antithrombin III because of DIC, induced haematologic remission. Renal failure and cerebral symptoms could not be influenced. Diagnosis, monitoring and therapy are discussed.

["Intensive lungs"--possibilities for quality improvement]. / "Intensivlungen"--Möglichkeiten zur Qualitätsverbesserung.

X-ray lung diagnosis in an intensive-care unit makes special demands on technique, imaging and on the physician's experience. The quality of image interpretation and evaluation is considerably improved by superimposing the technical data on the x-ray image and by using an antiscatter grid cassette. Proper evaluation of the parameters important for diagnosis is improved by registration of the data on the x-ray film; taking a maximum possible score of 100 as reference value, quality of evaluation is improved from 66.5 points to 71.8 points by data registration on the film itself, whereas the simultaneous use of an antiscatter grid cassette improves the score still further, namely, to 84.3 points. The importance of the clinical condition of the patient, and of the type of breathing chosen, for assessing the chest x-ray, is emphasised.

[X-Ray diagnosis of pneumothorax in intensive care units (author's transl)]. / Röntgendiagnostik des Pneumothorax auf Intensivstationen.

Pneumothorax is the most severe manifestation of pulmonary barotrauma which occurs in mechanical ventilation. Diagnosis of pneumothorax in intensive care radiology is of particular difficulty. Chest radiographs in supine position show a variety of signs which may be helpful but are not conclusive. There are different techniques for verification of ventrally located pneumothorax. 45 degrees tangential radiographs of the hemithorax in question are most conclusive for demonstration of extrapulmonary air located inside the pleural cavity. This 45 degrees technique ist easy to carry out without changing the patients position.

[Posttraumatic fat embolism of the retina (author's transl)]. / Die posttraumatische Fettembolie der Netzhaut.

Following a description of the clinical course of general fat embolism two cases of fat embolism with eye involvement seen by the authors are described. The course of the disease as well as the ophthalmoscopic picture are discussed and the condition is differentiated from traumatic angiopathy of the retina (Purtscher's disease).

[A new portable device for ventilatory support (author's transl)]. / Ein neues transportables Beatmungsgerät.

Transportation of patients requiring continuous ventilatory support and increased inspired oxygen concentrations may be troublesome for the physician and the nursing staff and dangerous for the patients. A new portable ventilator requiring oxygen of three atm. pressure as gas supply was tested for use during in-hospital transportation of more than 300 critically ill patients. Ventilator operation was simple, the machine was resistant to rude handling and the patients were ventilated reliably.

Hemodynamic changes in pulmonary circulation following fat embolism.

Hemodynamic effects in pulmonary circulation were measured in three young patients having proved fat embolism following trauma. The increase of pulmonary artery pressure, even in the early phase, was typical. The direction of the therapy to normalise the hemodynamic changes was the most important part of the therapeutic management.