Decontamination of the digestive tract and oropharynx in ICU patients.

BACKGROUND: Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) are infection-prevention measures used in the treatment of some patients in intensive care, but reported effects on patient outcome are conflicting. METHODS: We evaluated the effectiveness of SDD and SOD in a crossover study using cluster randomization in 13 intensive care units (ICUs), all in The Netherlands. Patients with an expected duration of intubation of more than 48 hours or an expected ICU stay of more than 72 hours were eligible. In each ICU, three regimens (SDD, SOD, and standard care) were applied in random order over the course of 6 months. Mortality at day 28 was the primary end point. SDD consisted of 4 days of intravenous cefotaxime and topical application of tobramycin, colistin, and amphotericin B in the oropharynx and stomach. SOD consisted of oropharyngeal application only of the same antibiotics. Monthly point-prevalence studies were performed to analyze antibiotic resistance. RESULTS: A total of 5939 patients were enrolled in the study, with 1990 assigned to standard care, 1904 to SOD, and 2045 to SDD; crude mortality in the groups at day 28 was 27.5%, 26.6%, and 26.9%, respectively. In a random-effects logistic-regression model with age, sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, intubation status, and medical specialty used as covariates, odds ratios for death at day 28 in the SOD and SDD groups, as compared with the standard-care group, were 0.86 (95% confidence interval [CI], 0.74 to 0.99) and 0.83 (95% CI, 0.72 to 0.97), respectively. CONCLUSIONS: In an ICU population in which the mortality rate associated with standard care was 27.5% at day 28, the rate was reduced by an estimated 3.5 percentage points with SDD and by 2.9 percentage points with SOD. (Controlled Clinical Trials number, ISRCTN35176830.)

[Less ventilator-associated pneumonia after oral decontamination with chlorhexidine; a randomised trial]. / Minder beademingspneumonieën door orale decontaminatie met chloorhexidine; gerandomiseerde trial.

OBJECTIVE: To determine the effect of oral decontamination with either chlorhexidine (CHX, 2%) or the combination chlorhexidine-colistin (CHX-COL, 2%-2%) on the frequency and the time to onset of ventilator-associated pneumonia in Intensive Care patients. DESIGN: Double blind, placebo-controlled, multicentre, randomised trial. METHODS: Consecutive ICU patients needing at least 48 h of mechanical ventilation were enrolled in a randomized trial with 3 arms: CHX, CHX-COL, and placebo (PLAC). The trial medication was administered in the oral cavity every 6 h. Oropharyngeal swabs were obtained daily and analysed quantitatively for Gram-positive and Gram-negative microorganisms. Endotracheal colonisation was monitored twice weekly. Ventilator-associated pneumonia was diagnosed on the basis of a combination of clinical, radiological and microbiological criteria. RESULTS: Of 385 patients included, 130 received PLAC, 127 CHX and 128 CHX-COL. Baseline characteristics in the three groups were comparable. The daily risk of ventilator-associated pneumonia was reduced in both treatment groups compared to PLAC: 65% (HR= 0.352; 95% CI: 0.160-0.791; p = 0.012) for CHX and 55% (HR= 0.454; 95%/ CI: 0.224-0.925; p = 0.030) for CHX-COL. CHX-COL provided a significant reduction in oropharyngeal colonisation with both Gram-negative and Gram-positive microorganisms, whereas CHX significantly affected only colonisation with Gram-positive microorganisms. There were no differences in the duration of mechanical ventilation, ICU-stay or ICU-survival. CONCLUSION: Oral decontamination of the oropharyngeal cavity with chlorhexidine or the combination chlorhexidine-colistin reduced the incidence and the time to onset ofventilator-associated pneumonia.

Do cultures contribute to optimisation of antibiotic therapy in the intensive care unit?

Obtaining diagnostic microbiological cultures before initiating empirical antimicrobial therapy is part of the diagnostic work-up of intensive care patients with a clinical suspicion of infection. However, it is unknown to what extent these cultures provide a microbiological cause of infection and to what extent antimicrobial therapy is influenced. During a 6-month period, all episodes of suspected clinical infection were analysed and categorised as non-microbiologically proven infection (non-MPI) or MPI. Effects of culture results on antibiotic therapy were analysed for episodes of respiratory tract infection. Invasive diagnostic techniques were not routinely used for diagnosis of respiratory tract infections. Among 212 patients admitted, 147 episodes of clinical suspicion of infection were recorded (104 for respiratory tract infection) and 1147 microbiological cultures were obtained (0.64 culture per patient day). Antibiotics were administered on 1111 (62%) of 1803 patients days. Of the respiratory tract infections, 571 cultures resulted in 49 (47%) MPI. Cover with empirical antibiotics was inappropriate in 7 of 104 cases (8%) of respiratory infections. In 12 cases (11.5%) empirical therapy could have been changed based on culture results. Negative cultures were never followed by cessation of therapy, but the duration of treatment was significantly shorter for non-MPI. Forty-seven percent of respiratory tract infections were microbiologically confirmed and, based on culture results, empirical antimicrobial therapy could have been influenced in 11.5% of cases of respiratory tract infections. These findings provide aspects to evaluate and improve the diagnostic work-up of infections in the ICU.

[Intensive care medicine in the Netherlands, 1997-2001. II. Changes over time and differences between hospitals]. / Intensivecaregeneeskunde in Nederland, 1997-2001. II. Verandering in de tijd en verschillen tussen ziekenhuizen.

OBJECTIVE: To describe efficacy (mortality) and efficiency (length of admission) of intensive care (IC) treatment after admission due to a prior cardiothoracic operation or pneumonia, based on data from the Dutch National Intensive Care Evaluation (NICE) foundation. DESIGN: Descriptive. METHOD: Data for the period 1 January 1997-31 December 2001 were extracted from the NICE databank for patients admitted after cardiothoracic surgery and for patients admitted with pneumonia. The variables changes in time, risk factors for mortality, and differences between hospitals were analysed. RESULTS: There were 25,463 admissions to 5 hospitals following cardiothoracic surgery and 1408 admissions to 18 hospitals due to pneumonia. An increase in valve surgery was noted in the cardiothoracic surgery group: from about 10% to about 25%. In the group undergoing valve operations, there was an increase in the average age of the patients and in the number of patients with comorbidity. No significant differences in mortality between hospitals were detected. However, the length of ICU treatment differed. Hospital mortality in the pneumonia group was 33.9%. Differences between hospitals with respect to mortality (both crude mortality and severity-of-illness adjusted mortality) and length of ICU admission were found. CONCLUSION: With the NICE registration it is possible to detect differences and trends. This is a valuable tool for indicating where and how quality and efficiency in intensive care medicine can be improved.

Guidelines for severe community-acquired pneumonia in the western world.

BACKGROUND: Recently, several guidelines (ATS 1993/IDSA 1998; ERS 1998; SWAB 1998) have been issued for the initial therapy of patients with community-acquired pneumonia. In patients who fulfil the criteria for severe community-acquired pneumonia (SCAP), it was advised to start with a macrolide (active against Legionella spp. and Mycoplasma pneumoniae) in combination with an agent active against both pneumococci and Pseudomonas aeruginosa by the ATS/IDSA guidelines, while the ERS suggested starting with a second or third generation cephalosporin, in combination with either a macrolide or second generation quinolon plus or minus rifampicin. In the SWAB guidelines, no recommendations for SCAP were made. METHODS: Sixty-two cases admitted to the intensive care units of a tertiary-care university hospital with SCAP between 1992 and 1996 were studied retrospectively. The causative pathogens, clinical and laboratory characteristics of severity, antibiotic therapy and mortality were analysed. Immunocompromised patients, patients using immunosuppressive agents and patients with a malignancy were excluded. RESULTS: Indices of severe illness were widely seen and 37% developed shock while 45% required vasoactive drugs. Bilobular or multilobular abnormalities were seen in 34% of the patients. Forty-five patients (73%) required artificial respiration and 54 (87%) had an underlying disease. The overall mortality was 42%. In 41 patients (66%), a pathogen was isolated. The most frequent causes of SCAP in this study were Streptococcus pneumoniae (22 cases or 35%), Haemophilus influenzae (seven cases or 11%), Pseudomonas aeruginosa (four cases or 7%), and other Enterobacteriaceae (twice in combination with pneumococci and once with H. influenzae). Legionella pneumophila was identified in three cases. In patients with severe chronic obstructive pulmonary disease (COPD), pneumococci were the most important pathogens six cases or 27%), followed by P. aeruginosa (14%) and H. influenzae (14%). CONCLUSIONS: The guidelines for the management of SCAP issued by the ATS and IDSA in 1993 are only partially adequate in the Dutch setting. Coverage of P. aeruginosa would seem useful, given the fact that isolation of this pathogen has been shown to be a predictor of mortality, but only in patients with severe COPD or structural disease of the lung, and especially in patients in whom the Gram stain reveals Gram-negative rods, as is also suggested in the revised IDSA guidelines (1998). Risk factors for P. aeruginosa could be added to the ERS guidelines. Including SCAP as a separate entity in the SWAB guidelines may be useful.

[Mild sequelae 12 years following massive aspiration of barium sulfate in the lungs]. / Geringe restverschijnselen 12 jaar na massale bariumsulfaat-aspiratie in de longen.

A twelve-year-old girl, who as a baby underwent an investigation of the oesophagus and stomach with barium roentgen contrast fluid, during which there was massive aspiration of barium contrast into the right lung, at follow-up showed no abnormalities, apart from slight signs of peribronchial granulomatosis or fibrosis. If there is an enhanced risk of aspiration or an oesophago-tracheal fistula is suspected it is better to use an isotonic water-soluble contrast fluid.

[The return of severe infections caused by Streptococcus pyogenes]. / De terugkeer van ernstige infecties door Streptococcus pyogenes.

Two patients with severe group A streptococcal infection associated with a toxic shock-like syndrome are described. Both isolates produced the pyrogenic exotoxin B. Since 1987 there have been many reports of these severe streptococcal infections. In order to know the incidence in the Netherlands, isolates from patients with severe streptococcal infection have to be serotyped (types of M-protein) and tested for streptococcal toxin production, and serum antibody levels have to be determined.

In vitro binding characteristics for cesium of two qualities of prussian blue, activated charcoal and Resonium-A.

The in vitro binding characteristics of radioactive 137Cs to two forms of Prussian blue [colloidally (soluble) K3Fe[Fe(CN)6] and insoluble Fe4[Fe(CN)6]3] and to activated charcoal and sodium polystyrene sulfonate (Resonium-A) were investigated by constructing Langmuir isotherms at pH = 1.0, 6.5 and 7.5 at 37 degrees C. At the three pHs investigated, 137Cs binding to activated charcoal and sodium polystyrene sulfonate was negligible. Binding of 137Cs to insoluble Prussian blue exceeded that for the soluble form and was pH dependent for both formulations. Maximum binding capacities were 87 mg/g (pH = 1.0), 194 mg/g (pH = 6.5) and 238 mg/g (pH = 7.5) for the insoluble form and 48 (pH = 1.0), 73 (pH = 6.5) and 78 (pH = 7.5) for the soluble form. As activated charcoal did not bind 137Cs, charcoal hemoperfusion is of no value. This has been confirmed by an in vitro experiment, using a Gambro Adsorbs 300 C cartridge.

[Histoplasma capsulatum infection, a manifestation of AIDS unusual for The Netherlands]. / Histoplasma capsulatum-infectie, een voor Nederland ongewone manifestatie van de ziekte AIDS.

The history of 29-year-old male from Surinam with antibodies to HIV-1 and long-lasting fever, lymphadenopathy, pain in the right upper abdomen and a granulomatous hepatitis is described. The patient suffered from disseminated histoplasmosis, a fungal disease rare in The Netherlands, which is the indicator disease for the diagnosis of AIDS (CDC-IVCI). It is stressed that in seropositive patients coming from endemic areas, including Surinam, the possibility of this disease should be considered.