Economic impact of Candida colonization and Candida infection in the critically ill patient.

The objective of the study presented here was to assess the economic impact of Candida colonization and Candida infection in critically ill patients admitted to intensive care units (ICUs). For this purpose, a prospective, cohort, observational, and multicenter study was designed. A total of 1,765 patients over the age of 18 years who were admitted for at least 7 days to 73 medical-surgical ICUs in 70 Spanish hospitals between May 1998 and January 1999 were studied. From day 7 of ICU admission to ICU discharge, samples of tracheal aspirates, pharyngeal exudates, gastric aspirates and urine were collected every week for culture. Prolonged length of stay was associated with severity of illness, Candida colonization or infection, infection by other fungi, antifungal therapy, treatment with more than one antifungal agent, and toxicity associated with this therapy. Compared to non-colonized, non-infected patients (n=720), patients with Candida colonization (n=880) had an extended ICU stay of 6.2 days (OR, 1.69; 95%CI, 1.53-1.87; P<0.001) and an extended hospital stay of 8.6 days (OR, 1.27; 95%CI, 1.16-1.40; P<0.001). The corresponding figures for patients with Candida infection (n=105) were 12.7 days for ICU stay (OR, 2.13; 95%CI, 1.72-2.64; P<0.001) and 15.5 days for hospital stay (OR, 1.23; 95%CI, 0.99-1.52; P=0.060). Candida colonization resulted in an additional 8,000 EUR in direct costs and Candida infection almost 16,000 EUR. Both Candida colonization and Candida infection had an important economic impact in terms of cost increases due to longer stays in both the ICU and in the hospital.

Candidemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Study Group of Fungal Infection in the ICU.

OBJECTIVE: To determine the incidence and prognosis of candidemia in non-neutropenic critically ill patients, to define mortality-related factors, and to evaluate the results of systemic antifungal therapy. DESIGN: A prospective multicenter survey in which medical and/or surgical intensive care units (ICUs) in 28 hospitals in Spain participated. PATIENTS: All critically ill patients with positive blood cultures for Candida species admitted to the participating ICUs over a 15-month period were included. INTERVENTIONS: Candidemia was defined as the presence of at least one positive blood culture containing Candida species. The follow-up period was defined as the time elapsed from the first positive blood culture for Candida species to discharge or death during hospitalization. Antifungal therapy was considered to be "early" when it was administered within 48 h of the date when the first positive blood culture was obtained and "late" when it was administered more than 48 h after the first positive blood culture. MEASUREMENTS AND MAIN RESULTS: Candidemia was diagnosed in 46 patients (mean age 59 years), with an incidence of 1 critically ill patient per 500 ICU admissions. The species most frequently isolated were Candida albicans (60%) and C. parapsilosis (17%). Fluconazole alone was given to 27 patients, amphotericin B alone to 10, and sequential therapy to 6. Three patients did not receive antifungal therapy. The overall mortality was 56% and the attributable mortality 21.7%. In the univariate analysis, mortality was significantly associated with a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score at the onset of candidemia (p = 0.04) and with the time elapsed between the episode of candidemia and the start of antifungal therapy 48 h or more later (p < 0.02). Patients with an APACHE II score lower than 21 at the onset of candidemia had a higher probability of survival than patients who were more seriously ill (p = 0.04). Patients with "early" antifungal therapy (< or = 48 h between the onset of candidemia and the start of antifungal therapy) had a higher probability of survival compared with patients with late therapy (p = 0.06). No significant differences were noted between the two groups on different antifungal therapy. CONCLUSIONS: The incidence of candidemia in ICU patients was very low. An APACHE II score > 20 at the time of candidemia was associated with a higher mortality. Further studies with a large number of patients are needed to assess the effect of early antifungal therapy on the decrease in mortality associated with candidemia and to determine the appropriate dosage of fluconazole and duration of treatment.

[Post-mortem study of laryngotracheal lesions produced by prolonged intubation and/or tracheotomy]. / Estudio necrópsico de las lesiones laringotraqueales por intubación prolongada y/o traqueotomía.

Injuries of the laryngotracheal axis caused by prolonged intubation in critically ill patients raise the issue of the timing of tracheotomy in intubated patients. In 1992 a prospective study was begun in intensive care patients with intubation lasting more than 48 hours. Eight months later, post-mortem data on the laryngotracheal axis of deceased patients was added to our prospective study protocol. The study was closed with 125 cases (52 deceased). The clinical data of 73 surviving patients was compared with that of 18 post-mortem cases. The macroscopic results of the post-mortem study are summarized by grading the lesions according to a personal modification of the Lindholm classification. All cases had laryngotracheal injuries. Only 15% of the lesions were located in the tracheal region. Five cases were classified as grade 2, with an average orotracheal intubation of 9 days, 9 cases as grade 3 with 15 days intubation, and 4 cases as grade 4 with 21 days intubation. We concluded that the severity of laryngotracheal injuries in the early post-mortem exploration was related with the duration of intubation.

[Lesions of the laryngotracheal axis due to prolonged intubation and/or tracheotomy. Preliminary data of a follow-up guidelines]. / Lesiones del eje laringotraqueal por intubación prolongada y/o traqueotomía. Datos preliminares de un protocolo de seguimiento.

Lesions caused by prolonged intubation and tracheostomy when performed in critically ill patients to keep the airways opened are a permanent topic of discussion between intensive care professionals and otolaryngologists. We present a prospective study of such complications following the guidelines elaborated by the intensive care unit and the otolaryngology department of our hospital. The outcomes obtained in the first-year follow up allow us to verify a high incidence of such lesions in the initial period (87%) and a markedly decreased frequency in the following twelve months (17%). Results also show the relation between prolonged intubation and the appearance of laryngotracheal lesions. We conclude that it is very important to reduce the intubation period by performing an earlier tracheostomy.

[Candidiasis in an intensive care unit]. / Estudio de candidosis en un servicio de medicina intensiva.

The risk of being infected by candidiasis in an Intensive Care Unit (ICU) is evaluated, using an algorithm which allows the establishment of an early fungicidal treatment. This is a study which includes 34 patients with a mortality of 35%. Yeasts are detected from the second week at ICU, related with the long stay of patients at ICU and the relationship between mortality and age. The first positive sample usually does not indicate disseminate candidiasis (9%) or a positive blood culture (6%). Population defined as high risk for disseminated candidiasis (HRDC) with a negative blood culture has the worst prognosis (18 cases, 50% mortality rate). The six cases with HRDC with positive blood culture showed a mortality of 17%. In seven cases there were no HRDC criteria (mortality of 14%). With said study the existence or not of a HRDC could be determined, establishing the adequate antifungal treatment.

[Cerebral malaria and multiple organ failure. A case report]. / Paludismo cerebral y fallo multiorgánico. Presentación de un caso.

It is discussed the case of cerebral paludism due to Plasmodium falciparum in a patient who travelled frequently to Ivory Coast and who had done an incorrect prophylaxis of paludism. It is underlined the relationship of cerebral presentation with the presence of multisystemic failure, which was characterized by respiratory distress, hyperdynamic shock, acute renal failure and hematological and digestive disorders. Shock forced the administration of vasoactive drugs (such as dopamine, dobutamine and methoxamine), respiratory failure to establish mechanical ventilation and coagulation disorders to transfuse platelets and plasma. Clinical evolution was favorable in few days thanks to an early symptomatic and etiology therapy.

[Acute lithium poisoning. Treatment with continuous arteriovenous hemofiltration. Apropos of a case]. / Intoxicación aguda por litio. Tratamiento con hemofiltración arteriovenosa continua. A propósito de un caso.

We report a suicide attempt with lithium, chlorpromazine and flunitrazepam. In case of intoxication, renal excretion of lithium can be facilitated with forced diuresis by the administration of large volumes of saline solution, peritoneal dialysis or hemodialysis. In the case of our patient, treatment with saline solution was not effective, so continuous arteriovenous hemofiltration (CAVH) was performed achieving a decrease in serum lithium and obtaining a prompt clinical improvement. No secondary effects or serum lithium rebound effect were observed. We have not found any previous record of the use of CAVH in the treatment of acute lithium intoxication.