Invasive device-related infections after heart surgery.

OBJECTIVE: To analyze postoperative infections in critically ill patients undergoing heart surgery. SETTING: Intensive care units (ICUs). DESIGN: An observational, prospective, multicenter study was carried out. PATIENTS: Patients in the postoperative period of heart surgery admitted to the ICU and included in the ENVIN-HELICS registry between 2005 and 2011. MAIN OUTCOME VARIABLES: Mechanical ventilation associated pneumonia (MVP), urinary catheter-related infection (UCI), primary bacteremia (PB), PB related to vascular catheters (PB-VC) and secondary bacteremia. RESULTS: Of a total of 97,692 patients included in the study, 9089 (9.3%) had undergone heart surgery. In 440 patients (4.8%), one or more infections were recorded. Infection rates were 9.94 episodes of MVP per 1000 days of mechanical ventilation, 3.4 episodes of UCI per 1000 days of urinary catheterization, 3.10 episodes of BP-VC per 1000 days of central venous catheter, and 1.84 episodes of secondary bacteremia per 1000 days of ICU stay. Statistically significant risk factors for infection were ICU stay (odds ratio [OR] 1.18, 95%CI 1.16-1.20), APACHE II upon admission to the ICU (OR 1.05, 95%CI 1.03-1.07), emergency surgery (OR 1.67, 95%CI 1.13-2.47), previous antibiotic treatment (OR 1.38, 95%CI 1.04-1.83), and previous colonization by Pseudomonas aeruginosa (OR 18.25, 95%CI 3.74-89.06) or extended spectrum beta-lactamase producing enterobacteria (OR 16.97, 95%CI 5.4-53.2). The overall ICU mortality rate was 4.1% (32.2% in patients who developed one or more infections and 2.9% in uninfected patients) (P < .001). CONCLUSIONS: Of the patients included in the ENVIN-HELICS registry, 9.3% were postoperative heart surgery patients. The overall mortality was low but increased significantly in patients who developed one or more infection episodes.

[Impact of primary and intravascular catheter-related bacteremia due to coagulase-negative staphylococci in critically ill patients]. / Impacto de la bacteriemia primaria y relacionada con catéter intravascular causada por Staphylococcus coagulasa negativo en pacientes críticos.

OBJECTIVE: To study the impact of coagulase-negative staphylococcal (CNS) primary and intravascular catheter-related bloodstream infection (PBSI/CRBSI) on mortality and morbidity in critically-ill patients. DESIGN: We performed a double analysis using data from the ENVIN-HELICS registry data (years 1997 to 2008): 1) We studied the clinical characteristics and outcomes of patients with CNS-induced PBSI/CRBSI and compared them with those of patients with PBSI/CRBSI caused by other pathogens; and 2) We analyzed the impact of CNS-induced PBSI/CRBSI using a case-control design (1:4) in patients without other nosocomial infections. SETTING: 167 Spanish Intensive Care Units. PATIENTS: Patients admitted to ICU for more than 24 hours. RESULTS: 2,252 patients developed PBSI/CRBSI, of which 1,133 were caused by CNS. The associated mortality for PBSI/CRBSI caused by non-CNS pathogens was higher than that of the CNS group (29.8% vs. 25.9%; P=.039) due exclusively to the mortality of patients with candidemia (mortality: 45.9%). In patients without other infections, PBSI/CRBSI caused by CNS (414 patients) is an independent risk factor for a higher than average length of ICU stay (OR: 5.81, 95% CI: 4.31-7.82; P<.001). CONCLUSION: Crude mortality of patients with CNS-induced BPSI/CRBSI is similar to that of patients with BPSI/CRBSI caused by other bacteria, but lower than that of patients with candidemia. Compared to patients without nosocomial infections, CNS-induced PBSI/CRBSI is associated with a significant increase in length of ICU stay.

[Use of antibiotics for the treatment of multiresistant gram positive cocci infections in critical patients]. / Utilización de antibióticos en el tratamiento de infecciones por cocos grampositivos multirresistentes en pacientes críticos.

INTRODUCTION: This study has been designed to know the use of these antibiotics (ATB) in Intensive Care Units (ICUs). DESIGN AND PATIENTS: A multicentric, prospective, observational study was conducted. In cluded as cases were the indications of vancomycin (VAN), teicoplanin (TPN), quinupristin/dalfopristin (Q/D) and linezolid (LZD). RESULTS: A total of 826 indications (VAN 52.1%, TPN 36.6%, LZD 11.6% and Q/D 0%) were analyzed, 793 (96%) as treatment and 33 (4%) as prophylaxis in 818 patients. Serious sepsis or septic should occurred in 55.9% of the patients treated. The most common infections were pneumonia and catheter-related bacteremia, 48.3% of all the infections being acquired in ICUs. LZD was used mostly in mechanical-ventilation related pneumonia (p = 0.001), VAN in community Central Nervous System infections (p = 0.01) and in catheter-related bacteremia (p = 0.001), TPN in community pneumonia (p = 0.01) and in catheter-related bacteremia (p = 0.001). Treatments were empirical in 65.8% and diagnosis of gram positive cocci was confirmed in 48.3% of them. Staphylococcus aureus was isolated more in the LZD-treated group. Initial treatment was modified 224 times, this occurring more frequently in the VAN-treated group. The reason for this change was clinical failure 59 times, this being more frequent in the TPN group and less frequent in the patients treated with LZD, which was the drug used the most in rescue therapies (43/69, 62.3%). Adverse events, probably related to the ATB, were identified in 36/826 (4.4%) cases. CONCLUSIONS: The most common use of this ATB was to treat ICU-acquired infections. VAN was the most frequently used drug. Treatments with LZD were modified less frequently for clinical failure and this drug was the one most used in rescue therapies. This information indicates an appropriate use of these ATB in an important percentage of critically patients.

Utilización de antibióticos en el tratamiento de infecciones por cocos grampositivos multirresistentes en pacientes críticos / Use of antibiotics for the treatment of multiresistant gram positive cocci infections in critical patients

Introducción. Este estudio se ha diseñado paraconocer el uso de antibióticos (ATB) específicosfrente a cocos grampositivos multirresistentes enCuidados Intensivos.Diseño y pacientes. Estudio observacional, prospectivo y multicéntrico. Se incluyeron como casos las indicaciones de vancomicina (VAN), teicoplanina (TPN), quimipristina/dalfopristina (Q/D) y linezolid (LZD).Resultados. Se analizaron 826 indicaciones (VAN 52,1%; TPN 36,6%; LZD 11,6% y Q/D 0%), 793 (96%) como tratamiento y 33 (4%) como profilaxis en 818 pacientes. El 55,9% de las infecciones se presentaron con sepsis grave o shock séptico. Las más frecuentes fueron neumonías y bacteriemias relacionadas con catéter, y el48,3% fueron adquiridas en la Unidad de Cuidados Intensivos (UCI). LZD fue más utilizado en neumonías relacionadas con ventilación mecánica (p = 0,001), VAN en infecciones del sistema nervioso central (p = 0,01) y en bacteriemias relacionadas con catéter (p = 0,001) y TPN en neumonías comunitarias (p = 0,01) y en bacteriemias relacionadas con catéter (p = 0,001). El 65,8% de los tratamientos fueron empíricos. Staphylo cocus aureus resistente a meticilina fue el más aisladoen el grupo de pacientes tratados con LZD.El tratamiento inicial se modificó en 224 ocasiones,circunstancia más frecuente en tratados con VAN. El motivo de esta modificación fue por fracaso clínico en 59 ocasiones, siendo más frecuente en el grupo tratado con TPN y menos en el tratado con LZD, que además fue el fármaco más utilizado en los tratamientos de rescate(43/69, 62,3%). Se han identificado efectos adversosprobablemente relacionados con los ATB en 36/826 (4,4%) casos.Conclusiones. Las indicaciones más frecuentesfueron para tratar infecciones adquiridas en laUCI. VAN fue el fármaco más utilizado. El tratamientocon LZD se modificó en menos ocasiones por fracaso clínico y fue el más empleado como tratamiento de rescate. El conjunto de la información muestra un empleo adecuado de estos ATB en un importante porcentaje de pacientes críticos

Introduction. This study has been designed toknow the use of these antibiotics (ATB) in Intensive Care Units (ICUs).Design and patients. A multicentric, prospective,observational study was conducted. Included as cases were the indications of vancomycin(VAN), teicoplanin (TPN), quinupristin/dalfopristin (Q/D) and linezolid (LZD).Results. A total of 826 indications (VAN 52.1%,TPN 36.6%, LZD 11.6% and Q/D 0%) were analyzed,793 (96%) as treatment and 33 (4%) as prophylaxis in 818 patients. Serious sepsis or septic should occurred in 55.9% of the patients treated.The most common infections were pneumonia and catheter- related bacteremia, 48.3% of all the infections being acquired in ICUs. LZD was used mostly in mechanical-ventilation related pneumonia (p = 0.001), VAN in community Central Nervous System infections (p = 0.01) and in catheter-related bacteremia (p = 0.001), TPN in community pneumonia (p = 0.01) and in catheter-related bacteremia (p = 0.001). Treatments were empirical in65.8% and diagnosis of gram positive cocci wasconfirmed in 48.3% of them. Staphylococcus aureuswas isolated more in the LZD-treated group.Initial treatment was modified 224 times, this occurringmore frequently in the VAN-treated group.The reason for this change was clinical failure 59times, this being more frequent in the TPN groupand less frequent in the patients treated with LZD,which was the drug used the most in rescue therapies(43/69, 62.3%). Adverse events, probably relatedto the ATB, were identified in 36/826 (4.4%)cases.Conclusions. The most common use of this ATBwas to treat ICU-acquired infections. VAN was themost frequently used drug. Treatments with LZDwere modified less frequently for clinical failureand this drug was the one most used in rescuetherapies. This information indicates an appropriateuse of these ATB in an important percentageof critically patients

Tratamiento antibiótico para la profilaxis de la infección de la necrosis pancreática en la pancreatitis aguda / Antibiotic treatment for prophylaxis of infected pancreatic necrosis in acute pancreatitis

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Efficacy and tolerability of piperacillin/tazobactam versus ceftazidime in association with amikacin for treating nosocomial pneumonia in intensive care patients: a prospective randomized multicenter trial.

OBJECTIVE: To compare clinical and bacteriological efficacy as well as tolerability of two regimens of broad-spectrum antibiotics (ceftazidime versus piperacillin/tazobactam) combined with amikacin in the treatment of nosocomial pneumonia in intensive care patients. DESIGN: Open label, prospective, multicenter, and randomized phase III clinical trial. SETTING: Medical or surgical intensive care units (ICUs) of nine acute-care teaching hospitals in Spain. PATIENTS AND PARTICIPANTS: One hundred and twenty-four ICU patients with nosocomial pneumonia and requiring mechanical ventilation were included. They were randomized to receive amikacin (15 mg/day divided into two doses) combined with either piperacillin (4 g every 6 h) and tazobactam (0.5 g every 6 h) (n = 88) or ceftazidime (2 g every 8 h) (n = 36). MEASUREMENTS AND RESULTS: The causative pathogen was determined in 60.2% of patients in the group of amikacin plus piperacillin/tazobactam and in 76.9% in the group of amikacin plus ceftazidime. A total of 94 bacterial organisms were isolated among which gram-negative bacilli predominated, Pseudomonas aeruginosa being the most frequent. Clinical response at the end of antibiotic therapy was considered satisfactory (cure and/or improvement) in 63.9% of patients in the amikacin plus piperacillin/tazobactam group and in 61.5% in the amikacin plus ceftazidime (odds ratio 1.1; 95% confidence interval 0.44-2.75). Eradication or presumptive eradication rates for each pathogen and for either gram-negative or gram-positive bacteria were similar in both antibiotic combinations (odds ratio 1.2; 95% confidence interval 0.39-3.66). A total of 21 adverse effects (23.9%) occurred in the amikacin plus piperacillin and tazobactam group and six (16.7%) in the amikacin plus ceftazidime group, thrombocytosis, renal dysfunction, and hepatic cytolysis being the most common. The efficacy and tolerability of the two therapeutic regimens were similar not only in the whole study population, but also in the subset of P. aeruginosa-related pneumonia (odds ratio 1; 95% confidence interval 0.08-13.37). CONCLUSIONS: Amikacin associated with either ceftazidime or piperacillin and tazobactam has shown comparable efficacy and tolerability in the treatment of ICU patients with nosocomial pneumonia.

Treatment of severe nosocomial pneumonia: a prospective randomised comparison of intravenous ciprofloxacin with imipenem/cilastatin.

BACKGROUND: A prospective multicentre study was undertaken to compare the efficacy of intravenous ciprofloxacin or imipenem in the treatment of severe nosocomial pneumonia requiring mechanical ventilation. METHODS: Patients with a clinical suspicion of pneumonia were randomised to receive either ciprofloxacin (800-1200 mg/day) or imipenem (2-4 g/day) in doses adjusted for renal function and specimens of the lower respiratory tract were taken. Patients were included in the study when specimens showed significant growth for potentially pathogenic microorganisms in quantitative bacterial cultures (n = 75, ciprofloxacin 41/75 (55%); imipenem 34/75 (45%)). The clinical and bacteriological success rates were the primary and secondary efficacy variables. An intent-to-treat analysis was performed for all randomised patients who received at least one dose of the study medication (n = 149, ciprofloxacin 72/149 (48%), imipenem 77/149 (52%)). RESULTS: The success rates were generally good, but neither the clinical success rates (ciprofloxacin, 29/41 (71%), imipenem, 27/34 (79%); 95% CI -10.8 to 28.1; p = 0.435) nor the bacteriological response rate (ciprofloxacin, 20/41 (49%), imipenem, 17/34 (50%); 95% CI -21.5 to 23.9; p = 1.0) were significantly different between the study arms. Pseudomonas aeruginosa was recovered in 26/75 patients (35%) and clinical (ciprofloxacin, 10/14 (71%), imipenem, 8/12 (67%); 95% CI -40.4 to 30.9; p = 1.0) and bacteriological response rates (ciprofloxacin, 7/14 (50%), imipenem, 3/12 (25%), 95% CI -60.9 to 10.9, p = 0.247) were not significantly different in this subgroup of patients. Resistance of Pseudomonas aeruginosa developed in 5/26 cases (19%), 1/14 (7%) to ciprofloxacin and 4/12 (33%) to imipenem (p = 0.147), and the mortality was 12/75 (16%) with no difference between treatment groups (ciprofloxacin, 8/41(24%), imipenem 4/34 (17%); p = 0.362). The clinical response was evaluable in 109/149 patients (73%) in the intent-to-treat analysis and was successful in 74/109 patients (68%). The clinical response rates were also not significantly different in the intent-to-treat analysis (ciprofloxacin, 34/52 (65%), imipenem, 40/57 (70%); 95% CI -12.8 to 22.3; p = 0.746). CONCLUSIONS: Treatment with either ciprofloxacin or imipenem was effective in a selected group of patients with microbiologically confirmed, severe nosocomial pneumonia requiring mechanical ventilation. Although no differences between the study medication could be documented in this trial, smaller differences between treatment arms may have been missed because of sample size limitations.

Endogenous endotoxemia of intestinal origin during cardiopulmonary bypass. Role of type of flow and protective effect of selective digestive decontamination.

OBJECTIVE: To evaluate the possible related factors to endotoxemia and cytokine activation during the ischemic phase of extracorporeal surgery, and the effect of selective digestive decontamination (SDD) as a preventive measure. DESIGN: Prospective, open, randomized trial. SETTING: Two multidisciplinary ICUs (tertiary care hospitals). PATIENTS: One hundred consecutive patients undergoing cardiopulmonary bypass (CPB), randomly allocated to two groups; gut decontamination (group I = 50 cases) and controls (group II = 50 cases). INTERVENTIONS: Preoperative administration of oral non-absorbable antibiotics (polymyxin E, tobramycin and amphotericin B) versus no administration. MEASUREMENTS AND RESULTS: The assessment of decontamination by means of the bacteriologic control of rectal swabs. Determinations of gastric intramucosal pH (gastric pHi) and plasma endotoxin, tumor necrosis factor (TNF) aNd interleukin-6 (IL-6) before surgery and during the ischemic and reperfusion phases of bypass. Rectal aerobic Gram-negative bacilli (AGNB) were significantly reduced in the treated patients and in 56% total eradication was achieved. Endotoxin, TNF and IL-6 plasma levels were significantly lower in this group. By contrast, both endotoxin and TNF/IL-6 levels and gastric pHi correlated with the type of surgical flow (pulsatile versus non-pulsatile). CONCLUSIONS: SDD reduces the gut content of enterobacteria. This may explain the lower endotoxin and cytokine levels detected in decontaminated patients. In addition to SDD, the type of flow employed during bypass seems to influence endotoxemia and cytokine levels.

Can selective digestive decontamination avoid the endotoxemia and cytokine activation promoted by cardiopulmonary bypass?

OBJECTIVE: To evaluate the effect of selective digestive decontamination on endotoxemia and cytokine activation during the ischemic phase of cardiopulmonary bypass surgery. DESIGN: Prospective, open, randomized, controlled trial. SETTING: Two multidisciplinary intensive care units in tertiary care hospitals. PATIENTS: Eighty consecutive patients randomly allocated to two groups: selective digestive decontamination (group 1, n = 40) and controls (group 2, n = 40). INTERVENTIONS: Preoperative administration of oral antibiotics (polymyxin E, tobramycin, and amphotericin B) vs. untreated controls. MEASUREMENTS AND MAIN RESULTS: Assessment of decontamination by bacteriologic evaluation of rectal swabs (colony-forming units [cfu]/mL) were made in each group, along with circulating endotoxin, tumor necrosis factor and interleukin-6 (IL-6) determinations before surgery, during ischemic and reperfusion phases of bypass, and at 4 hrs and at 24 hrs after surgery. Group 1 patients showed that rectal bacteria decreased ten-fold after treatment for 24 hrs, thousand-fold after 48 hrs, and registered 0 cfu/mL after digestive decontamination was administered for > 72 hrs. Endotoxin and IL-6 assays showed significantly lower values in this latter group vs. those circulating concentrations of control patients. On the other hand, both endotoxin and IL-6 concentrations correlated positively with the duration of surgical ischemia. CONCLUSIONS: Selective digestive decontamination reduces the gut content of enterobacteria, with complete elimination after 3 days of treatment. This fact could explain the lower endotoxin and cytokine concentrations found in the blood samples of patients who had been fully decontaminated. Duration of aortic cross-clamping is an important factor in generating endotoxemia and in the activation of cytokines.

Role of selective digestive decontamination (SDD) in the prevention of nosocomial pneumonia (NP): is gastric decontamination necessary?

In the course of a prospective selective digestive decontamination (SDD) trial to prevent nosocomial pneumonia (NP) during mechanical ventilation (MV), we carried out serial cultures of gastric aspirate to assess the importance of gastric colonization for potential respiratory pathogens and its relationship to the simultaneous gastric pH, to whether the patients were receiving Sucralfate or Ranitidine and to the nutritional biochemical parameters. If NP developed, a bronchial sample was taken by fibreoptic bronchoscopy to determine the causal organisms and its relationship to the previous gastric isolated. Results show: 1) Increase in aerobic Gram negative bacilli colonization during hospitalization. 2) Direct relationship between colonization level and gastric pH. 3) Greater pH in ranitidine vs sucralfate group. 4) Low incidence of NP (11%), the majority of these (66%) being early. 5) No bacteriological correlation between gastric colonization and aetiological agents of NP. 6) Close relationship between pharyngeal colonization and causative germs of pulmonary infection (40%).

Prevention of nosocomial lung infection in ventilated patients: use of an antimicrobial pharyngeal nonabsorbable paste.

A comparative, prospective study was made of the incidence of infection in the lower airway (purulent tracheobronchitis and pneumonia) in long-term patients who were mechanically ventilated due to respiratory failure of noninfectious origin. Twenty-eight patients were randomly allocated into a study group (A, n = 13) in which a nonabsorbable paste containing 2% tobramycin, 2% amphotericin B, and 2% polymyxin E was administered locally to decontaminate the oropharynx, and a control group (B, n = 15) in which a paste without antibiotics was also applied to the oropharynx. We studied the effectiveness of the prophylactic technique in decontaminating the oropharynx and trachea of organisms potentially pathogenic for the respiratory system. Decontamination was successful in ten of 13 patients in group A vs. one of 15 patients in group B (p less than .001). The results demonstrated a lower rate of infection in the lower respiratory tract in the study group (three patients with tracheobronchitis and no pneumonias) than in the control group (three patients with tracheobronchitis and 11 with pneumonia), the difference between both being highly significant (p less than .001). Two (15%) patients in group B developed sepsis of pulmonary origin. None of the patients on prophylactic treatment developed this complication. Although the overall mortality was similar in both groups (group A, 30% vs. group B, 33%), we believe that infection contributed to a great extent to the death of two of five patients in group B. We conclude that nosocomial pneumonia, which is a frequent complication in critically ill patients on mechanical ventilation, could be prevented by local application of nonabsorbable antibiotics to the oropharynx.