Adult patients with tetanus in Slovenia 2006-2021 : Results of a national cohort study.

INTRODUCTION: The aim of the present study was to determine the demographic, epidemiological and clinical characteristics of adult patients with tetanus in Slovenia between 2006 and 2021, as well as to determine the therapeutic approaches which have been successfully used in the intensive care unit (ICU) of the Infectious Diseases Department in the University Medical Centre Ljubljana (UMC). METHODS: We included all adult patients who were treated for tetanus in the ICU of the Department of Infectious Diseases Ljubljana between January 1st, 2006, and December 31th, 2021, in the retrospective study. Available epidemiological and clinical characteristics were reviewed from the medical documentation. RESULTS: There were 31 patients included in the study, four (12.9%) males and 27 (87.1%) females. The vast majority of patients required mechanical ventilation (MV) (87.1%) which lasted (±â€¯SD) on average 35.4 ±â€¯16.0 days. Autonomic dysfunction was present in 29 (93.5%) patients and was statistically significantly associated with shorter disease evolution (p = 0.005) and presence of healthcare-associated infection (p = 0.020). During the hospitalization, 27 (87.1%) patients acquired at least one healthcare-associated infection, most commonly ventilator-associated pneumonia. The average length of stay in the ICU (±â€¯SD) was 42.5 ±â€¯21.3 days. With increasing age, MV lasted statistically significantly longer (p = 0.001), length of stay was longer (p = 0.015), and healthcare-associated infections occurred (p = 0.003) more frequently. Four patients (12.9%) died. CONCLUSIONS: Although the tetanus incidence rate in Slovenia is high in comparison to other European countries on average, our therapeutic approach resulted in a good survival rate and low mortality.

STRESS ULCER PROPHYLAXIS AS A RISK FACTOR FOR TRACHEAL COLONIZATION AND HOSPITAL-ACQUIRED PNEUMONIA IN INTENSIVE CARE PATIENTS: IMPACT ON LATENCY TIME FOR PNEUMONIA.

Stress ulcer prophylaxis is associated with bacterial colonization of respiratory tract. The aims of our study were to determine risk factors for trachea colonization (TC), colonization of pharynx (CP) or stomach (CD) and hospital-acquired pneumonia (HAP), and divide the factors into those with high risk and low risk. The study population (ventilated intensive care unit (ICU) patients eligible to receive stress ulcer prophylaxis) was randomized to receive one of three different treatment protocols: ranitidine, sucralfate, and no stress ulcer prophylaxis (control group). Clinical data relative to pre-specified risk factors for TC or HAP were recorded, as follows: APACHE II score (second risk factor), duration of intubation or tracheotomy (third risk factor), duration of mechanical ventilation (fourth risk factor) and duration of hospitalization in the ICU (fifth risk factor). Gastric pH was recorded and microbiological data regarding stomach, pharynx and trachea were collected on the 1st, 2nd, 3rd and 5th day. Fifty-eight out of 81 patients developed HAP (including ventilator-associated pneumonia), which occurred later in patients with gastric content pH <4 or those that were tracheotomized. Stress ulcer prophylaxis was not associated with HAP; however, it was proved as a risk factor for TC. TC was detected in tracheotomized patients and was caused by gram-negative pathogens. CP was associated with TC, since the majority of patients had CP before TC. A combination of risk factors (APACHE II >18, age >65, mechanical ventilation and sedation) caused a higher incidence of HAP and lower incidence of TC. HAP was more frequent in patients staying in the ICU for >10 days and those with cardiovascular disease as the underlying disorder. Sedation and previous antibiotic therapy correlated with longer latent period (LAT), while higher values of gastric content pH were related to shorter LAT. The longest LAT was found in patients colonized with Acinetobacter spp. Risk factors that accelerated the occurrence of HAP were found to have caused previous colonization. A combination of risk factors increased the likelihood of TC and HAP, and shortened LAT between TC and HAP.

Orotracheal tube as a risk factor for lower respiratory tract infection: preliminary data from a randomised trial.

PURPOSE: The aim of the study was to investigate whether polyurethane (PU) endotracheal tubes, continuous measurements of cuff pressure and aspiration of the subglottic space as a bundle of parameters could reduce patients' risk for developing ventilator associated pneumonia (VAP). METHODS: Two groups of patients that differed only in terms of endotracheal tubes and intubation intervention were compared. Group A was ventilated using PU tubes a with conical cuff; they also had continuous cuff pressure measurement and continuous subglottic aspiration. Group B was ventilated using PVC tubes with a cylindrical cuff; the patients underwent intermittent cuff pressure measurement and intermittent subglottic aspiration. RESULTS: Seven patients in group A (13.2%) and 18 in group B (36.0%) out of 103 were diagnosed with VAP. VAP patients were in general older, stayed longer in the ICU and were ventilated significantly longer compared with the patients with no VAP. Eight more patients in group B died compared with group A. Moreover, subjects in group A survived longer. Patient age, hours on mechanical ventilation, and days on an ICU were all positively associated with the occurrence of VAP. CONCLUSIONS: Prevention parameters in ventilation (PU cuff, conical cuff, continuous subglottic drainage and continuous cuff pressure measurement) could prevent the incidence of VAP in ICU patients.

CD64 index on neutrophils can diagnose sepsis and predict 30-day survival in subjects after ventilator-associated pneumonia.

INTRODUCTION: Sepsis associated with ventilator-associated pneumonia (VAP) causes mortality in intensive care unit (ICU) patients. The time of diagnosis is crucial, and microbiological cultures take time. In this study, the diagnostic accuracy of CD64 index to predict VAP-induced sepsis and survival time in subjects requiring mechanical ventilation were evaluated and compared to conventional biomarkers and culturing methods. METHODOLOGY: A total of 32 subjects with VAP were included. Sepsis after VAP was diagnosed in 25 (78.1%) patients according to clinical signs, radiographic examination, and samples of blood and trachea taken for culturing. Simultaneously with cultures, CD64 index on neutrophils, C-reactive protein (CRP), procalcitonin (PCT), and count of leucocytes and neutrophils were determined. RESULTS: Biomarker values were evaluated in both groups of subjects (with and without sepsis after VAP). The values of CD64 index and CRP were significantly higher in the sepsis group. Receiver operating characteristic (ROC) curve analysis revealed an area under curve (AUC) of 0.929 for CD64 index in differentiating subjects with VAP-induced sepsis from those without sepsis. The biomarkers CRP and PCT showed comparable results (AUC of 0.869 and 0.909, respectively). Blood cultures were positive in 12 subjects, endotracheal aspirate in 19. CD64 index and isolation of pathogen with positive blood cultures or from endotracheal aspirate (positive in 24 cases) could predict survival time before application of more targeted antibiotic therapy. CONCLUSIONS: CD64 index may be used as a useful diagnostic tool to recognize VAP-induced sepsis; moreover, accompanied with an identified pathogen, can predict survival for ICU patients.

Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial.

BACKGROUND: Intensive care units (ICUs) are high-risk areas for transmission of antimicrobial-resistant bacteria, but no controlled study has tested the effect of rapid screening and isolation of carriers on transmission in settings with best-standard precautions. We assessed interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in European ICUs. METHODS: We did this study in three phases at 13 ICUs. After a 6 month baseline period (phase 1), we did an interrupted time series study of universal chlorhexidine body-washing combined with hand hygiene improvement for 6 months (phase 2), followed by a 12-15 month cluster randomised trial (phase 3). ICUs were randomly assigned by computer generated randomisation schedule to either conventional screening (chromogenic screening for meticillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]) or rapid screening (PCR testing for MRSA and VRE and chromogenic screening for highly resistant Enterobacteriaceae [HRE]); with contact precautions for identified carriers. The primary outcome was acquisition of resistant bacteria per 100 patient-days at risk, for which we calculated step changes and changes in trends after the introduction of each intervention. We assessed acquisition by microbiological surveillance and analysed it with a multilevel Poisson segmented regression model. We compared screening groups with a likelihood ratio test that combined step changes and changes to trend. This study is registered with ClinicalTrials.gov, number NCT00976638. FINDINGS: Seven ICUs were assigned to rapid screening and six to conventional screening. Mean hand hygiene compliance improved from 52% in phase 1 to 69% in phase 2, and 77% in phase 3. Median proportions of patients receiving chlorhexidine body-washing increased from 0% to 100% at the start of phase 2. For trends in acquisition of antimicrobial-resistant bacteria, weekly incidence rate ratio (IRR) was 0·976 (0·954-0·999) for phase 2 and 1·015 (0·998-1·032) for phase 3. For step changes, weekly IRR was 0·955 (0·676-1·348) for phase 2 and 0·634 (0·349-1·153) for phase 3. The decrease in trend in phase 2 was largely caused by changes in acquisition of MRSA (weekly IRR 0·925, 95% CI 0·890-0·962). Acquisition was lower in the conventional screening group than in the rapid screening group, but did not differ significantly (p=0·06). INTERPRETATION: Improved hand hygiene plus unit-wide chlorhexidine body-washing reduced acquisition of antimicrobial-resistant bacteria, particularly MRSA. In the context of a sustained high level of compliance to hand hygiene and chlorhexidine bathings, screening and isolation of carriers do not reduce acquisition rates of multidrug-resistant bacteria, whether or not screening is done with rapid testing or conventional testing. FUNDING: European Commission.

Severe human granulocytic anaplasmosis transmitted by blood transfusion.

A 36-year-old woman acquired severe human granulocytic anaplasmosis after blood transfusion following a cesarean section. Although intensive treatment with mechanical ventilation was needed, the patient had an excellent recovery. Disease caused by Anaplasma phagocytophilum infection was confirmed in 1 blood donor and in the transfusion recipient.

Severe tick-borne encephalitis in Slovenia in the years 2001-2005: time for a mass vaccination campaign?

The aim of this retrospective study was to assess some clinical, epidemiological and laboratory parameters of severe tick-borne encephalitis in Slovenia in the last five years, to compare them with published data, and to estimate need for providing a policy of active immunization. Thirty-three adult patients with a severe course of the disease, admitted to the intensive care unit of the Department of Infectious Diseases, University Medical Centre Ljubljana, Slovenia during a five year period, participated. All the patients had specific serum IgM antibodies against tick-borne encephalitis virus at admissions and IgG antibodies were present in 29 out of 33 patients. Twenty-two patients were admitted because of severe consciousness disturbances, nine suffered from spinal nerve paralysis, in two patients cranial nerve paralysis was observed, and one suffered from generalized tonic-clonic seizures. Ten patients were mechanically ventilated and three died. Leukocytosis in peripheral veins was found in twenty-one patients and nine had a C-reactive protein serum concentration over 50 mg/l. Nineteen patients had a cerebrospinal fluid leukocyte count exceeding 100 x 10(6)/l and a cerebrospinal fluid protein concentration was over the cut-off value of 0.45 g/l in majority. The findings of the present study confirmed some previous reports about clinical, epidemiological and laboratory characteristics of patients with severe tick-borne encephalitis. We have found that tick-borne encephalitis in Slovenia has a relatively low fatality rate. However, the severe course with long-lasting sequelae of the disease justifies vaccination of a risk population in endemic areas.

Clinical review: Severe malaria.

Malaria represents a medical emergency because it may rapidly progress to complications and death without prompt and appropriate treatment. Severe malaria is almost exclusively caused by Plasmodium falciparum. The incidence of imported malaria is increasing and the case fatality rate remains high despite progress in intensive care and antimalarial treatment. Clinical deterioration usually appears 3-7 days after onset of fever. Complications involve the nervous, respiratory, renal, and/or hematopoietic systems. Metabolic acidosis and hypoglycemia are common systemic complications. Intravenous quinine and quinidine are the most widely used drugs in the initial treatment of severe falciparum malaria, whereas artemisinin derivatives are currently recommended for quinine-resistant cases. As soon as the patient is clinically stable and able to swallow, oral treatment should be given. The intravascular volume should be maintained at the lowest level sufficient for adequate systemic perfusion to prevent development of acute respiratory distress syndrome. Renal replacement therapy should be initiated early. Exchange blood transfusion has been suggested for the treatment of patients with severe malaria and high parasitemia. For early diagnosis, it is paramount to consider malaria in every febrile patient with a history of travel in an area endemic for malaria.

Severe tick-borne encephalitis in Slovenia: epidemiological, clinical and laboratory findings.

The aim of this retrospective study was to determine epidemiological, clinical and laboratory characteristics in adult patients with the severe form of tick-borne encephalitis. Thirty-one patients with a severe course of disease admitted to the intensive care unit of the Department of Infectious Diseases at the University Medical Centre Ljubljana, Slovenia, between 1996 and 2000 were included in the study. Tick-borne encephalitis virus infection was confirmed by the demonstration of specific IgM and IgG antibodies in serum using routine serological screening tests. All the patients had specific IgM antibodies at admission and IgG antibodies were present in 90.3%. Nineteen patients suffered from severe meningoencephalitis, 11 from meningoencephalomyelitis, and dysfunction of the autonomic nervous system was found in one patient. The mortality rate was 3.3%. Tick bite was recorded in 58% and a characteristic biphasic course of the disease was found in 16 patients. The median cerebrospinal fluid leukocyte count was 112 x 10(6)/l, and in 93.5% of patients the cerebrospinal fluid protein concentration was greater than the cut-off value of 0.45 g/l. The findings of the present study indicate some clinical, epidemiological and laboratory distinctions between published data on the mild or moderately severe form of tick-borne encephalitis and our patients with severe disease.