Impact of enteral versus parenteral nutrition on the incidence of fungal infections: a retrospective study in ICU patients on mechanical ventilation with selective digestive decontamination.

BACKGROUND: Infections are an important cause of morbidity and mortality in patients in intensive care units (ICUs). Fungal infections have increased substantially over recent years and fungi have become one of the important pathogens in ICU patients. This study tests the hypothesis that the incidence of fungal infections is lower in critically ill patients under mechanical ventilation receiving enteral rather than total parenteral nutrition. METHODS: By using a prospectively built database, we analyzed retrospectively the charts of 110 critically ill, intubated patients hospitalized in surgical and medical ICUs and receiving selective digestive topical decontamination (SDD), which consisted of administering non-absorbable antibiotics. Patients without contraindications, and expected to be intubated for more than 72 h, received enteral nutrition within 24 h after intubation. Patients with contraindications for enteral nutrition received total parenteral nutrition, which was discontinued when the criteria for enteral nutrition were met. The incidence of fungal infections in both subgroups of patients was compared. RESULTS: Seventy-nine patients received enteral nutrition and 31 total parenteral (10 patients did not meet the inclusion criteria). Both subgroups were similar with regard to their APACHE II score, age, sex distribution and comorbidities at the time of study entry. No difference was observed in the rate of fungal infections between enteral nutrition (5/29) and total parenteral nutrition (7/71) patient groups. CONCLUSION: No significant decrease in the incidence of fungal infections in critically ill patients receiving SDD was observed between those receiving enteral and total parenteral nutrition.

Secular trends of candidemia over 12 years in adult patients at a tertiary care hospital.

The incidence of fungal infections has been increasing for the last 3 decades, especially among neutropenic, cancer, and critically ill patients. These infections are associated with high mortality rates. We retrospectively reviewed medical charts of adult patients with fungemia from 1989 to 2000 at our institution. The characteristics of the population groups served by the hospital were described. Of 328 patients with fungemia, we reviewed 315 (96%) medical records, and focused on those with candidemia (n = 294). The species distribution in patients with candidemia showed that the most commonly identified species were Candida albicans (66%), followed by C. glabrata (17%), and C. parapsilosis (6%). The incidence of candidemia ranged from 0.2 to 0.46 per 10,000 patient-days with the highest incidence in 1993 and the lowest in 1997. Although most studies show an increased incidence of candidemia, we observed a reduction over the study period. Furthermore, we observed no shift from C. albicans to non-albicans Candida species despite a significant increase in the use of fluconazole. The overall mortality among patients with candidemia was 44%, with the highest rate in patients over 65 years (52%). Factors independently associated with higher mortality were patient age greater than 65 years, intensive care unit admission, and underlying cancer.

Incidence, Clinical Features, Risk Factors and Outcome of Bacteremia due to Vancomycin-Resistant and Vancomycin-Sensitive Enterococcus Species Analyzed Over a 7-year Period in a Single Cancer Institution.

The aim of this study was to retrospectively compare the incidence, risk factors, and outcome in patients seen over a 7-year period at the National Cancer Institute in the Slovak Republic, with vancomycin-sensitive or vancomycin-resistant enterococcal bacteremia. The total incidence of enterococcal bacteremia at the National Cancer Institute increased from 5.1% in 1991 to 11.1% in 1993 and then decreased to 4.3% in 1995. Analysis of the 77 episodes of enterococcal bacteremia from 66 patients showed that 69 episodes from 60 patients were due to vancomycin-sensitive Enterococcus faecalis (group 1) and 8 episodes from 8 patients were due to vancomycin-resistant Enterococcus faecium (group 2). The features most frequently associated with enterococcal bacteremia were the insertion of a central venous catheter, neutropenia lasting more than 10 days, previous therapy with cephalosporins or vancomycin, previous prophylaxis with quinolones, and the incidence of superinfections. There was no difference in the clinical course or outcome between the 2 study groups. Previous therapy with aminoglycosides, cephalosporins, vancomycin or imipenem, neutropenia less than 10 days in length, malignancies other than leukemia or solid tumors, and the incidence of breakthrough bacteremia significantly correlated with patients with vancomycin-resistant E. faecium rather than patients with vancomycin-sensitive E. faecalis. The overall mortality was similar in both groups and averaged 32.5% for all enterococcal bacteremic patients. In this study, the major risk factors associated with cancer patients for developing vancomycin-resistant enterococcal bacteremia were previous therapy with aminoglycosides, cephalosporins or vancomycin, superinfections with other organisms and the incidence of breakthrough bacteremia.