ABSTRACT
INTRODUCTION: De-escalation of antimicrobial therapy is often advocated to reduce the use of broad-spectrum antibiotics in critically ill patients. However, little data are available on the application of this strategy in daily clinical practice. METHODS: This is a retrospective analysis of all meropenem prescriptions in a surgical intensive care unit (ICU) during 1 year. Age, Acute Physiology and Chronic Health Evaluation II score on admission to the ICU, site of infection, causative organism, duration of meropenem administration, other antibiotic prescription for the same infectious episode for which meropenem was administered, and ICU mortality were recorded. De-escalation was defined as the administration of an antibiotic with a narrower spectrum within 3 days of the start of meropenem. RESULTS: Data from 113 meropenem prescriptions were available for analysis. Pulmonary (46%) and complicated intraabdominal (31%) infections were the most frequent infections. In 37 patients, meropenem was used after identification of a multiresistant gram-negative organism (MRGN), whereas in 76 patients, empirical treatment with meropenem was started. Empirical prescription of meropenem was de-escalated in 42% of the patients. In the majority of the patients in whom de-escalation was not done, no conclusive cultures were available to guide treatment; also, colonization with MRGN at other sites was frequently associated with non-de-escalation. Patients in whom antibiotics were de-escalated had a trend toward a lower mortality rate (7% vs 21%, P = .12). CONCLUSIONS: De-escalation after empirical treatment with meropenem was performed in less than half of the patients. Reasons for not de-escalating included the absence of conclusive microbiology and colonization with MRGN.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Critical Care , Practice Patterns, Physicians'/statistics & numerical data , Respiratory Tract Infections/drug therapy , Surgical Wound Infection/drug therapy , Thienamycins/therapeutic use , Adult , Aged , Critical Illness , Drug Administration Schedule , Drug Resistance, Microbial , Empirical Research , Hospital Mortality , Humans , Intensive Care Units , Meropenem , Middle Aged , Retrospective StudiesABSTRACT
BACKGROUND AND AIMS: The abdominal compartment syndrome (ACS) is associated with organ dysfunction and mortality in critically ill patients. Furthermore, the deleterious effects of increased IAP have been shown to occur at levels of intra-abdominal pressure (IAP) previously deemed to be safe. The aim of this article is to provide an overview of all aspects of this underrecognized pathological syndrome for surgeons. METHODS AND CONTENTS: This review article will focus primarily on the recent literature on ACS as well as the definitions and recommendations published by the World Society for the Abdominal Compartment Syndrome. The definitions regarding increased IAP will be listed, followed by a brief but comprehensive overview of the different mechanisms of organ dysfunction associated with intra-abdominal hypertension (IAH). Measurement techniques for IAP will be discussed, as well as recommendations for organ function support in patients with IAH. Finally, surgical treatment and management of the open abdomen are briefly discussed, as well as some minimally invasive techniques to decrease IAP. CONCLUSIONS: The ACS was first described in surgical patients with abdominal trauma, bleeding, or infection, but in recent years ACS has also been described in patients with other pathologies such as burn injury and sepsis. Some of these so-called nonsurgical patients will require surgery to treat their ACS. This review article is intended to provide surgeons with a clear insight into the current state of knowledge regarding IAH, ACS, and the impact of IAP on the critically ill patient.
Subject(s)
Abdomen/surgery , Compartment Syndromes/surgery , Algorithms , Bandages , Combined Modality Therapy , Compartment Syndromes/diagnosis , Compartment Syndromes/etiology , Compartment Syndromes/mortality , Critical Care/methods , Critical Illness , Decompression, Surgical/methods , Gastrointestinal Tract/blood supply , Hemodynamics/physiology , Hydrostatic Pressure , Ischemia/complications , Manometry/methods , Multiple Organ Failure/diagnosis , Multiple Organ Failure/etiology , Multiple Organ Failure/mortality , Multiple Organ Failure/surgery , Multiple Trauma/complications , Multiple Trauma/surgery , Practice Guidelines as Topic , Reoperation , Reperfusion Injury/complications , Resuscitation/methods , Risk Factors , Suction , Suture TechniquesABSTRACT
The superior vena cava (SVC) syndrome is an uncommon complication due to permanent transvenous pacemaker electrodes. Infection of the leads is a risk factor for its occurrence. After being treated for SVC syndrome, due to multiple pacemaker leads, with thrombolysis and coumarine therapy, our patient was diagnosed with repetitive positive blood cultures. Because of relapsing SVC syndrome all pacemaker material was surgically removed. Recovery was complete and the patient remained pacemaker-independent. Culture of the leads showed the same coagulase-negative staphylococci as in the blood cultures. The indications for pacemaker implantation should always be rigorously defined and complications thoroughly investigated and treated.
