Risk factors for methicillin-resistant Staphylococcus aureus colonisation or infection in intensive care units and their reliability for predicting MRSA on ICU admission.

Predicting methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs) avoids inappropriate antimicrobial empirical treatment and enhances infection control. We describe risk factors for colonisation/infection related to MRSA (MRSA-C/I) in critically ill patients once in the ICU and on ICU admission, and search for an easy-to-use predictive model for MRSA colonisation/infection on ICU admission. This multicentre cohort study included 69,894 patients admitted consecutively (stay>24h) in April-June in the five-year period 2006-2010 from 147 Spanish ICUs participating in the National Surveillance Study of Nosocomial Infections in ICUs (ENVIN-HELICS). Data from all patients included were used to identify risk factors for MRSA-C/I during ICU stays, from admission to discharge, using uni- and multivariable analysis (Poisson regression) to check that the sample to be used to develop the predictive models was representative of standard critical care population. To identify risk factors for MRSA-C/I on ICU admission and to develop prediction models, multivariable logistic regression analysis were then performed only on those admitted in 2010 (n=16950, 2/3 for analysis and 1/3 for subsequent validation). We found that, in the period 2006-2010, 1046 patients were MRSA-C/I. Independent risk factors for MRSA-C/I in ICU were: age>65, trauma or medical patient, high APACHE-II score, admitted from a long-term care facility, urinary catheter, previous antibiotic treatment and skin-soft tissue or post-surgical superficial skin infections. Colonisation with several different MDRs significantly increased the risk of MRSA-C/I. Risk factors on ICU admission were: male gender, trauma critical patient, urgent surgery, admitted from other ICUs, hospital ward or long-term facility, immunosuppression and skin-soft tissue infection. Although the best model to identify carriers of MRSA had a good discrimination (AUC-ROC, 0.77; 95% CI, 0.72-0.82), sensitivity was 67% and specificity 76.5%. Including more complex variables did not improve prediction capability. Our conclusion is that clinical-demographic risk factors for colonisation/infection related to MRSA should not be used to accurately identify patients who would benefit from empirical anti-MRSA treatment or from specific preventive measures. Independent risk factors for MRSA colonisation/infection during ICU stay and on ICU admission are described. The latter should be considered in future studies for MRSA prediction.

Infección nosocomial en las unidades de cuidados intensivos / Nosocomial infections in intensive care units

Las infecciones nosocomiales (IN) tiene todavía una alta incidencia en las unidades de cuidados intensivos (UCI), convirtiéndose en uno de los problemas más importantes que ocurren. Asimismo se asocian con una alta mortalidad y morbilidad en los pacientes críticos y están asociadas a un aumento en la estancia media de los pacientes y del coste hospitalario. Tomando como base el Estudio Nacional de Vigilancia de Infección Nosocomial en Unidades de Cuidados Intensivos (ENVIN-UCI) se hace una descripción de la etiología de las principales IN, como son la neumonía asociada a ventilación mecánica, la infección urinaria asociada a sondaje uretral y la bacteriemia primaria y relacionada con catéter. Se hace asimismo una revisión del impacto de las IN, incluyendo las infecciones causadas por microorganismos multirresistentes. Finalmente se hace una descripción de medidas y programas de control de infección en la UCI, tales como Bacteriemia Zero y Neumonía Zero, que claramente conllevan una disminución de las tasas de IN

Nosocomial infections (NI) still have a high incidence in intensive care units (ICUs), and are becoming one of the most important problems in these units. It is well known that these infections are a major cause of morbidity and mortality in critically ill patients, and are associated with increases in the length of stay and excessive hospital costs. Based on the data from the ENVIN-UCI study, the rates and aetiology of the main nosocomial infections have been described, and include ventilator-associated pneumonia, urinary tract infection, and both primary and catheter related bloodstream infections, as well as the incidence of multidrug-resistant bacteria. A literature review on the impact of different nosocomial infections in critically ill patients is also presented. Infection control programs such as zero bacteraemia and pneumonia have been also analysed, and show a significant decrease in NI rates in ICUs

[Nosocomial infections in intensive care units]. / Infección nosocomial en las unidades de cuidados intensivos.

Nosocomial infections (NI) still have a high incidence in intensive care units (ICUs), and are becoming one of the most important problems in these units. It is well known that these infections are a major cause of morbidity and mortality in critically ill patients, and are associated with increases in the length of stay and excessive hospital costs. Based on the data from the ENVIN-UCI study, the rates and aetiology of the main nosocomial infections have been described, and include ventilator-associated pneumonia, urinary tract infection, and both primary and catheter related bloodstream infections, as well as the incidence of multidrug-resistant bacteria. A literature review on the impact of different nosocomial infections in critically ill patients is also presented. Infection control programs such as zero bacteraemia and pneumonia have been also analysed, and show a significant decrease in NI rates in ICUs.

Antibiotic prescription patterns in the empiric therapy of severe sepsis: combination of antimicrobials with different mechanisms of action reduces mortality.

INTRODUCTION: Although early institution of adequate antimicrobial therapy is lifesaving in sepsis patients, optimal antimicrobial strategy has not been established. Moreover, the benefit of combination therapy over monotherapy remains to be determined. Our aims are to describe patterns of empiric antimicrobial therapy in severe sepsis, assessing the impact of combination therapy, including antimicrobials with different mechanisms of action, on mortality. METHODS: This is a Spanish national multicenter study, analyzing all patients admitted to ICUs who received antibiotics within the first 6 hours of diagnosis of severe sepsis or septic shock. Antibiotic-prescription patterns in community-acquired infections and nosocomial infections were analyzed separately and compared. We compared the impact on mortality of empiric antibiotic treatment, including antibiotics with different mechanisms of action, termed different-class combination therapy (DCCT), with that of monotherapy and any other combination therapy possibilities (non-DCCT). RESULTS: We included 1,372 patients, 1,022 (74.5%) of whom had community-acquired sepsis and 350 (25.5%) of whom had nosocomial sepsis. The most frequently prescribed antibiotic agents were ß-lactams (902, 65.7%) and carbapenems (345, 25.1%). DCCT was administered to 388 patients (28.3%), whereas non-DCCT was administered to 984 (71.7%). The mortality rate was significantly lower in patients administered DCCTs than in those who were administered non-DCCTs (34% versus 40%; P = 0.042). The variables independently associated with mortality were age, male sex, APACHE II score, and community origin of the infection. DCCT was a protective factor against in-hospital mortality (odds ratio (OR), 0.699; 95% confidence interval (CI), 0.522 to 0.936; P = 0.016), as was urologic focus of infection (OR, 0.241; 95% CI, 0.102 to 0.569; P = 0.001). CONCLUSIONS: ß-Lactams, including carbapenems, are the most frequently prescribed antibiotics in empiric therapy in patients with severe sepsis and septic shock. Administering a combination of antimicrobials with different mechanisms of action is associated with decreased mortality.

[Analysis of treatments used in infections caused by gram-positive multiresistant cocci in critically ill patients admitted to the ICU]. / Análisis de los tratamientos utilizados en las infecciones por cocos grampositivos multirresistentes en pacientes críticos ingresados en UCI.

UNLABELLED: The appearance of new antimicrobials with activity against Gram-positive multiresistant cocci and knowledge of the limitations of glycopeptides has represented an important change in the use of these antibiotics. OBJECTIVE: To analyze at the national level changes in the use of antibiotics with specific activity against Gram-positive multiresistant cocci in critically ill patients admitted to the ICU as well as the characteristics of patients treated with these agents and the forms of administration. MATERIAL AND METHODS: Retrospective cohort study of patients admitted to the ICU for more than 24 hours between 2008 and 2010 in the ENVIN-HELICS national registry. Cases were defined as patients who had received one or more of the following antibiotics: vancomycin, teicoplanin, linezolid or daptomycin. The characteristics of patients who used one or more of these agents were compared with those treated with other antibiotics. Indications and forms of use of each antibiotic were assessed. Descriptive results are presented. RESULTS: A total of 45,757 patients, 27,982 (61.2%) of whom received 63,823 antimicrobials were included in the study. In 6,368 (13.9%) patients, one or more antibiotics specifically active against Gram-positive multiresistant cocci were given. There was a predominance of the use of vancomycin and linezolid and an important increase in the prescription of daptomycin (+320%) and linezolid (+22.4%). In more than 95% of cases, linezolid and daptomycin were prescribed for the treatment of infections, whereas vancomycin and teicoplanin were used for prophylaxis in 20-25% of cases. Between 75% and 80% of indications for treating infections, antibiotics were used empirically except for daptomycin which was used as a directed treatment in 43% of the cases. Only in one third of the indications for empirical treatment, susceptible microorganisms were identified (appropriate treatment). CONCLUSIONS: The use of antibiotics with activity against Gram-positive multiresistant cocci remained stable around 14% of all indications. The use of vancomycin and linezolid predominated and there was a clear trend towards an increase in the use of daptomycin and linezolid and a decrease in the use of glycopeptides. Empirical treatments were considered appropriate in only one third of cases.

Análisis de los tratamientos utilizados en las infecciones por cocos grampositivos multirresistentes en pacientes críticos ingresados en UCI / Analysis of treatments used in infections caused by Gram-positive multiresistant cocci in critically ill patients admitted to the ICU

La aparición de nuevos antibióticos activos frentes a cocos grampositivos multirresistentes (CGP-MR) y el conocimiento de las limitaciones de los glucopéptidos ha supuesto un importante cambio en las tendencias de utilización de estos antibióticos. Objetivo. Analizar las variaciones a nivel nacional en el consumo de antibióticos activos de forma específica frente a CGP-MR en pacientes críticos ingresados en UCI así como las características de los pacientes que los utilizan, y sus formas de empleo. Material y métodos. Análisis retrospectivo, de cohortes que incluye los pacientes ingresados en UCI más de 24 horas entre los años 2008-2010 del registro ENVIN-HELICS. Se define como caso los pacientes que han recibido uno o más de los siguientes antibióticos: vancomicina, teicoplanina, linezolid o daptomicina. Se comparan las características de los pacientes que han utilizado uno o más de dichos antibióticos con los pacientes que han utilizado otros antibióticos. Se describen las indicaciones y formas de utilización de cada uno de ellos. Los resultados se presentan de forma descriptiva. Resultados. Se han incluido 45.757 pacientes de los que 27.982 (61,2%) han utilizado 63.823 antimicrobianos. En 6.368 (13,9%) pacientes se han utilizado uno o más antibióticos activos de forma selectiva frente a CGP-MR. Ha predominado la utilización de vancomicina y linezolid y se observa un importante incremento en la prescripción de daptomicina (+320%) y de linezolid (+22,4%). Mas del 95% de indicaciones de linezolid y daptomicina se realizaron para el tratamiento de infecciones mientras que vancomicina y teicoplanina se utilizó entre el 20-25% de los casos para profilaxis. Entre el 75-80% de las indicaciones de tratamiento se han realizado de forma empírica excepto con daptomicina que se ha utilizado de forma dirigida en el 43% de los casos. Sólo en una tercera parte de las indicaciones para tratamiento empírico se han identificado microorganismos susceptibles (tratamiento apropiado). Conclusiones. El empleo de antibióticos activos frente a CGP-MR se mantiene estable en torno al 14% del total de indicaciones. Existe un predominio en el uso de linezolid y vancomicina y una clara tendencia a incrementar el empleo de daptomicina y linezolid y a disminuir el uso de glucopéptidos. Sólo una tercera parte de los tratamientos empíricos con estos antibióticos se han valorado como apropiados(AU)

The appearance of new antimicrobials with activity against Gram-positive multiresistant cocci and knowledge of the limitations of glycopeptides has represented an important change in the use of these antibiotics. Objetive. To analyze at the national level changes in the use of antibiotics with specific activity against Gram-positive multiresistant cocci in critically ill patients admitted to the ICU as well as the characteristics of patients treated with these agents and the forms of administration. Material and methods. Retrospective cohort study of patients admitted to the ICU for more than 24 hours between 2008 and 2010 in the ENVIN-HELICS national registry. Cases were defined as patients who had received one or more of the following antibiotics: vancomycin, teicoplanin, linezolid or daptomycin. The characteristics of patients who used one or more of these agents were compared with those treated with other antibiotics. Indications and forms of use of each antibiotic were assessed. Descriptive results are presented. Results. A total of 45,757 patients, 27,982 (61.2%) of whom received 63,823 antimicrobials were included in the study. In 6,368 (13.9%) patients, one or more antibiotics specifically active against Gram-positive multiresistant cocci were given. There was a predominance of the use of vancomycin and linezolid and an important increase in the prescription of daptomycin (+320%) and linezolid (+22.4%). In more than 95% of cases, linezolid and daptomycin were prescribed for the treatment of infections, whereas vancomycin and teicoplanin were used for prophylaxis in 20-25% of cases. Between 75% and 80% of indications for treating infections, antibiotics were used empirically except for daptomycin which was used as a directed treatment in 43% of the cases. Only in one third of the indications for empirical treatment, susceptible microorganisms were identified (appropriate treatment). Conclusions. The use of antibiotics with activity against Gram-positive multiresistant cocci remained stable around 14% of all indications. The use of vancomycin and linezolid predominated and there was a clear trend towards an increase in the use of daptomycin and linezolid and a decrease in the use of glycopeptides. Empirical treatments were considered appropriate in only one third of cases(AU)

Corticosteroid therapy in patients with primary viral pneumonia due to pandemic (H1N1) 2009 influenza.

OBJECTIVE: During the first pandemic, some patients with pandemic (H1N1) 2009 influenza were treated with corticosteroids. The objective of this study was to assess the effect on survival of corticosteroid therapy in patients with pandemic (H1N1) 2009 influenza. METHODS: Prospective, observational, multicenter study performed in 148 ICU. Data were recorded in the GTEI/SEMICYUC registry. Adult patients with pandemic (H1N1) 2009 influenza confirmed by rt-PCR were included in the analysis. Database records specified corticosteroid type and reason for corticosteroid treatment. RESULTS: 372 patients with the diagnosis of primary viral pneumonia and completed outcomes treated in an ICU were included in the database. Mechanical ventilation was used in 70.2% of the patients. 136 (36.6%) patients received corticosteroids after a diagnosis of primary viral pneumonia. Obesity (35.6% vs 47.8% p = 0.021) and asthma (7.6% vs 15.4% p = 0.018), were more frequent in the group treated with corticosteroids. A Cox regression analysis adjusted for severity and potential confounding factors found that the use of corticosteroid therapy was not significantly associated with mortality (HR = 1.06, 95% CI 0.626-1.801; p = 0.825). CONCLUSIONS: Corticosteroid therapy in a selected group of patients with primary viral pneumonia due to pandemic (H1N1) 2009 influenza does not improve survival.

Ward mortality after ICU discharge: a multicenter validation of the Sabadell score.

BACKGROUND: Tools for predicting post-ICU patients' outcomes are scarce. A single-center study showed that the Sabadell score classified patients into four groups with clear-cut differences in ward mortality. OBJECTIVE AND DESIGN: To validate the Sabadell score using a prospective multicenter approach. SETTING: Thirty-one ICUs in Spain. PATIENTS AND METHODS: All patients admitted in the 3-month study period. We recorded variables at ICU admission (age, sex, severity of illness, and do-not-resuscitate orders), during the ICU stay (ICU-specific treatments, ICU-acquired infection, and acute renal failure), and at ICU discharge (Sabadell score). Statistical analyses included one-way ANOVA and multiple regression analysis with ward mortality as the dependent variable. RESULTS: We admitted 4,132 patients (mean age 61.5 +/- 16.7 years) with mean predicted mortality of 23.8 +/- 22.7%; 545 patients (13%) died in the ICU and 3,587 (87%) were discharged to the ward. Overall ward mortality was 6.7%; ward mortality was 1.5% (36/2,422) in patients with score 0 (good prognosis), 9% (64/725) in patients with score 1 (long-term poor prognosis), 23% (79/341) in patients with score 2 (short-term poor prognosis), and 64% (63/99) in patients with score 3 (expected hospital death). Variables associated with ward mortality in the multivariate analysis were predicted risk of death (OR 1.016), ICU readmission (OR 5.9), Sabadell score 1 (OR 4.7), Sabadell score 2 (OR 15.7), and Sabadell score 3 (OR 107.2). CONCLUSION: We confirm the ability of the Sabadell score at ICU discharge to define four groups of patients with very different likelihoods of hospital survival.