Combined antibiotic stewardship and infection control measures to contain the spread of linezolid-resistant Staphylococcus epidermidis in an intensive care unit.

BACKGROUND: The unrestricted use of linezolid has been linked to the emergence of linezolid-resistant Staphylococcus epidermidis (LRSE). We report the effects of combined antibiotic stewardship and infection control measures on the spread of LRSE in an intensive care unit (ICU). METHODS: Microbiological data were reviewed to identify all LRSE detected in clinical samples at an ICU in southwest Germany. Quantitative data on the use of antibiotics with Gram-positive coverage were obtained in defined daily doses (DDD) per 100 patient-days (PD). In addition to infection control measures, an antibiotic stewardship intervention was started in May 2019, focusing on linezolid restriction and promoting vancomycin, wherever needed. We compared data from the pre-intervention period (May 2018-April 2019) to the post-intervention period (May 2019-April 2020). Whole-genome sequencing (WGS) was performed to determine the genetic relatedness of LRSE isolates. RESULTS: In the pre-intervention period, LRSE were isolated from 31 patients (17 in blood cultures). The average consumption of linezolid and daptomycin decreased from 7.5 DDD/100 PD and 12.3 DDD/100 PD per month in the pre-intervention period to 2.5 DDD/100 PD and 5.7 DDD/100 PD per month in the post-intervention period (p = 0.0022 and 0.0205), respectively. Conversely, vancomycin consumption increased from 0.2 DDD/100 PD per month to 4.7 DDD/100 PD per month (p < 0.0001). In the post-intervention period, LRSE were detected in 6 patients (4 in blood cultures) (p = 0.0065). WGS revealed the predominance of one single clone. CONCLUSIONS: Complementing infection control measures by targeted antibiotic stewardship interventions was beneficial in containing the spread of LRSE in an ICU.

Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial.

BACKGROUND: Vocal cord injuries, postoperative hoarseness, and sore throat are common complications after general anesthesia. One-lung ventilation can be achieved via two techniques: double-lumen endotracheal tube or endobronchial blocker such as the Arndt blocker. The current study was designed to assess the impact of these techniques for one-lung ventilation on the incidence and severity of postoperative hoarseness, vocal cord lesions, and sore throat. METHODS: In this prospective trial, 60 patients were randomly assigned to two groups. One-lung ventilation was achieved with either an endobronchial blocker (blocker group) or a double-lumen-tube (double-lumen group). Postoperative hoarseness and sore throat were assessed at 24, 48, and 72 h after surgery. Bronchial injuries and vocal cord lesions were examined by bronchoscopy immediately after surgery. RESULTS: In 56 included patients, postoperative hoarseness occurred significantly more frequently in the double-lumen group compared with the blocker group: 44% versus 17%, respectively (P = 0.046). Similar findings were observed for vocal cord lesions: 44% versus 17%, respectively (P = 0.046). The incidence of bronchial injuries was comparable between groups (P = 0.540). Cumulative number of days with hoarseness and sore throat were significantly increased in the double-lumen group compared with the blocker group (P < 0.01). No major complications such as bronchial ruptures were observed. CONCLUSIONS: Clinicians should be aware of an increased incidence of minor airway injuries that may impair patient satisfaction when using a double-lumen tube instead of an endobronchial blocker for one-lung ventilation.

Rocuronium is not associated with more vocal cord injuries than succinylcholine after rapid-sequence induction: a randomized, prospective, controlled trial.

Postoperative hoarseness (PH), sore throat (ST), and vocal cord injuries (VCI) are common complications after general anesthesia. Excellent endotracheal intubating conditions are associated with less laryngeal morbidity than good or poor intubating conditions. Thus, we tested the hypothesis that a rapid-sequence induction (RSI) with succinylcholine would lead to less PH and VCI than with rocuronium. In this prospective trial, 160 patients were randomized in 2 groups to receive thiopental 5.0 mg/kg, fentanyl 3.0 microg/kg, succinylcholine 1.0 mg/kg, or rocuronium 0.6 mg/kg during RSI. PH and ST were assessed at 24, 48, and 72 h after surgery, VCI were examined by stroboscopy in those patients who had PH >3 days. Excellent and clinically acceptable intubating conditions were significantly increased in the succinylcholine group compared with the rocuronium group: 57% versus 21% and 89% versus 59%, respectively (P < 0.001). The incidence and severity of PH, and VCI between the succinylcholine and the rocuronium groups did not differ significantly: PH: 50% versus 51% (P = 0.99) and VCI: 3% versus 1% (P = 0.98), respectively. Similar findings were found for ST, 39% versus 28% (P = 0.22), and postoperative myalgia, 39% versus 29% (P = 0.25), respectively. Intubating conditions were significantly better in the succinylcholine group compared with the rocuronium group. The incidence and severity of ST and myalgia were not increased in the patients receiving succinylcholine. However, the rate of PH and VCI was similar to the rocuronium group.

Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial.

Vocal cord injuries (VCI) and postoperative hoarseness (PH) are common complications after general anesthesia. Poor muscle relaxation at the moment of tracheal intubation may result in VCI. There is a large interindividual variation in neuromuscular depression after administration of neuromuscular blocking drugs. Therefore, the optimal individual timing of tracheal intubation based on neuromuscular monitoring (monitoring) may decrease VCI. In this prospective trial, 60 patients were randomized into 2 groups: Monitoring group: tracheal intubation at maximum block based on monitoring after atracurium 0.5 mg/kg and 2-min group: tracheal intubation 2 min after injection of atracurium 0.5 mg/kg. Intubating conditions were evaluated with the Copenhagen score. VCI were examined by stroboscopy before and 24 and 72 h after surgery. PH was assessed at 24, 48, and 72 h after surgery by a standardized interview. Excellent intubating conditions were significantly increased in the monitoring group compared with the 2-min group: 8 versus 2 patients, respectively (P = 0.036). The incidence of PH between the study groups was comparable: 7 (monitoring) versus 8 patients (2-min) (P = 0.860). Similar findings were observed for VCI: 9 versus 5 patients; respectively (P = 0.268); type of VCI: thickening of the vocal cords: 8 (monitoring) versus 5 (2-min) patients (P = 0.423), hematomas: 2 patients in each group (not significant). The present study demonstrated that neuromuscular monitoring improved endotracheal intubating conditions. However, tracheal intubation at maximum intensity of neuromuscular block was not associated with a decrease in vocal cord injuries.