Outcomes of 23 patients diagnosed with New Delhi metallo-beta-lactamase (NDM)-producing Klebsiella pneumoniae infection treated with ceftazidime/avibactam and aztreonam at a single center in Poland.

PURPOSE: Amongst all etiologic hospital-acquired infection factors, K. pneumoniae strains producing New Delhi metallo-ß-lactamase (KP-NDM) belong to pathogens with the most effective antibiotic resistance mechanisms. Clinical guidelines recommend using ceftazidime/avibactam with aztreonam (CZA + AT) as the preferred option for NDM-producing Enterobacterales. However, the number of observations on such treatment regimen is limited. This retrospective study reports the clinical and microbiological outcomes of 23 patients with KP-NDM hospital-acquired infection treated with CZA + AT at a single center in Poland. METHODS: The isolates were derived from the urine, lungs, blood, peritoneal cavity, wounds, and peritonsillar abscess. In microbiological analysis, mass spectrometry for pathogen identification, polymerase chain reaction, or an immunochromatographic assay for detection of carbapenemase, as well as VITEK-2 system, broth microdilution, and microdilution in agar method for antimicrobial susceptibility tests were used, depending of the pathogens' nature. CZA was administered intravenously (IV) at 2.5 g every eight hours in patients with normal kidney function, and aztreonam was administered at 2 g every eight hours IV. Such dosage was modified when renal function was reduced. RESULTS: KP-NDM was eradicated in all cases. Four patients (17.4%) died: three of them had a neoplastic disease, and one - a COVID-19 infection. CONCLUSION: The combination of CZA + AT is a safe and effective therapy for infections caused by KP-NDM, both at the clinical and microbiological levels. The synergistic action of all compounds resulted in a good agreement between the clinical efficacy of CZA + AT and the results of in vitro susceptibility testing.

Bacteraemia caused by Lactobacillus casei in a patient after cardiac surgery. A case report.

BACKGROUND: Bacteria of the Lactobacillus family are a part of the physiological flora of the oral cavity, gastrointestinal tract, and urinary tract. We have used them in the food industry as probiotics and supplements. In some settings, rod-shaped lactic acid bacteria may become pathogenic. It may occur in immunocompromised or heart disease patients after cardiac surgery, patients with disturbed intestinal wall permeability, or those treated with broad-spectrum antibiotics. CASE PRESENTATION: We present rare bacteraemia induced by the probiotic bacterium Lactobacillus casei in a 63-year-old patient after the attempted removal of ICD electrodes, complicated by acute regurgitation of the tricuspid valve. The patient underwent urgent cardiac surgery, the electrode elements were removed, and the tricuspid valve was replaced with a biological prosthesis. After surgery, the patient required intensive, multidisciplinary treatment with mechanical ventilation, continuous renal replacement therapy, broad-spectrum empirical antibiotic therapy, parenteral nutrition, and blood product transfusion because of multiple organ failure. On the 14th day of hospitalisation, the clinical symptoms of septic shock were observed. The microbiological investigation was performed, and Lactobacillus casei was cultured from a dialysis catheter sample. Dedicated antimicrobials were administered, and the patient was discharged home in good overall condition. CONCLUSIONS: The present case shows that the promoted use of probiotics must be cautiously administered to patients in severe conditions, especially when accompanied by reduced immune system efficiency symptoms.

Preliminary trial of 24 vs 72 hour perioperative meropenem in patients with ESBL-producing Enterobacterales bacteriuria scheduled for urological procedures.

Introduction: Antimicrobial prophylaxis is an important issue in positive urine culture patients undergoing endourological procedures or extracorporeal shock wave lithotripsy (ESWL). It is especially recognized in asymptomatic bacteriuria patients of alarm pathogen etiology. We designed a preliminary study to determine optimal duration of antibiotic prophylaxis in patients undergoing endourological procedures or ESWL with asymptomatic bacteriuria caused by Enterobacterales with extended spectrum beta-lactamase positive (ESBL+) type resistance. Material and methods: A total of 60 patients with confirmed ESBL+ Enterobacterales bacteriuria were admitted for endourological procedures or ESWL. The patients were randomized into two groups - a one-day (n = 33) and a three-day (n = 27) period of perioperative antibiotic prophylaxis with meropenem. In both groups on the following day after the procedure (24 hours after the procedure) and 7 days after the procedure serum inflammation markers were assessed. Results: Values of white blood count, C-reactive protein and procalcitonin prior to, 24 hours and seven days after the procedure clearly showed no statistically significant differences between groups that have received a one-day and three-day antibiotic regimen. Conclusions: In patients with ESBL+ Enterobacterales asymptomatic bacteriuria undergoing endourological procedures or ESWL a 72-hour perioperative meropenem prophylaxis showed no superiority over a 24-hour regimen. Further studies will be carried out to establish optimal prophylaxis for specific endourological procedures and to test safety of a single dose regimen.

Bloodstream Infections in the Intensive Care Unit: a Single-Center Retrospective Bacteriological Analysis Between 2007 and 2019.

Hospital-acquired bloodstream infections are a severe worldwide problem associated with significant morbidity and mortality. This retrospective, single-center study aimed to analyze bloodstream infections in patients hospitalized in the intensive care unit of the Military Institute of Medicine, Poland. Data from the years 2007-2019 were analyzed. When the infection was suspected, blood samples were drawn and analyzed microbiologically. When bacterial growth was observed, an antimicrobial susceptibility/resistance analysis was performed. Among 12,619 analyzed samples, 1,509 were positive, and 1,557 pathogens were isolated. In 278/1,509 of the positive cases, a central line catheter infection was confirmed. Gram-negative bacteria were the most frequently (770/1,557) isolated, including Acinetobacter baumannii (312/770), Klebsiella pneumoniae (165/770; 67/165 were the isolates that expressed extended spectrum beta-lactamases (ESBL), 5/165 isolates produced the New Delhi metallo-ß-lactamases (NDM), 4/165 isolates expressed Klebsiella pneumoniae carbapenemase (KPC), and 1/165 isolate produced OXA48 carbapenemase), Pseudomonas aeruginosa (111/770; 2/111 isolates produced metallo-ß-lactamase (MBL), and Escherichia coli (69/770; 11/69 - ESBL). Most Gram-positive pathogens were staphylococci (545/733), mainly coagulase-negative (368/545). Among 545 isolates of the staphylococci, 58 represented methicillin-resistant Staphylococcus aureus (MRSA). Fungi were isolated from 3.5% of samples. All isolated MRSA and methicillin-resistant coagulase-negative Staphylococcus (MRCNS) strains were susceptible to vancomycin, methicillin-sensitive Staphylococcus aureus (MSSA) isolates - to isoxazolyl penicillins, and vancomycin-resistant Enterococcus (VRE) - to linezolid and tigecycline. However, colistin was the only therapeutic option in some infections caused by A. baumannii and KPC-producing K. pneumoniae. P. aeruginosa was still susceptible to cefepime and ceftazidime. Echinocandins were effective therapeutics in the treatment of fungal infections.

The Clinical Manifestation of SARS-CoV-2 in Critically Ill Patients with Klebsiella pneumoniae NDM Hospitalized in the ICU of a Modular Hospital during the Third Wave of the Pandemic in Poland-An Observational Cohort Study.

There is limited information on the clinical characteristics of critically ill patients infected with SARS-CoV-2 and Klebsiella pneumoniae NDM. The objective of this study was to describe such a group of patients hospitalised in the intensive care unit of a large academic hospital during the third wave of the COVID-19 pandemic in Poland. Between 1 March and 30 June 2021, 103 patients were hospitalised, of whom 23 (22.3%) were positive for K. pneumoniae NDM; 14 (61%) of those patients died. Their hospitalisation time varied between 9 and 47 days. Five of the 23 patients (21.7%) were otherwise healthy. In contrast, the others suffered from cardiovascular problems (11, 47.8%), obesity (6, 26.1%), diabetes (5, 21.7%), neurological problems (4, 17.4%), or kidney disease (1, 4.3%); 4 (17.4%) were heavy smokers, and 1 (4.3%) had a history of alcohol abuse. K. pneumoniae NDM was isolated from urine samples of all patients. In 17 patients (73.9%), it was also isolated from other sources: from the respiratory tract in 10 (43.8%), from the blood in 2 (8.7%), and the central venous catheter was contaminated in 1 case (4.3%). Fourteen of the patients (60.9%) were colonised K. pneumoniae NDM. In four patients (17.4%), bacterial and fungal coinfection occurred. In one case (4.4%), two fungal species, Candida albicans and Candida glabrata, were isolated simultaneously. The most frequently administered antimicrobial agent was colistin (60.9%), followed by meropenem (47.8%), vancomycin (47.8%), ceftriaxone (34.8%), linezolid (30.4%), piperacillin/tazobactam (30.4%), and trimethoprim/sulfamethoxazole (30.4%). Other less-frequently administered agents included amikacin, amoxicillin/clavulanate, tigecycline, ciprofloxacin, fosfomycin, clindamycin, and cloxacillin. Fluconazole was administered in 14 patients (60.7%) and micafungin was administered in 2 (8.7%).

Infective endocarditis - can we treat it more effectively?

Infective endocarditis (IE), despite the diagnostic and therapeutic advances, still remains a serious disease associated with high mortality and serious complications. The present guidelines of the European Cardiology Society of 2015 recommend administration of the antibiotics indicated in empirical therapy for multiple weeks and in targeted treatment often for 6-8 weeks. This is associated with a risk of adverse effects of antibiotic therapy in the form of nephro- and/or hepatotoxicity and an increased risk of infections with Clostridioides difficile, while long-term hospitalisation is associated with high non-drug costs. The recommendations developed by the Austrian Society for Infectious Diseases and Tropical Medicine list dalbavancin among the new antibiotics that may find application in the treatment of IE of staphylococcal aetiology. This antibiotic is a lipoglycopeptide antibiotic alternative to vancomycin in the treatment of Staphylococcus aureus MRSA infections, especially in a situation where the minimum inhibitory concentration for vancomycin is high but below the breakpoint. Dalbavancin has very good pharmacokinetic and pharmacodynamic properties, with a long duration of action of up to 14 days after administration of a single dose (1500 mg in a 30-minute infusion). This antibiotic is characterised by high clinical efficacy with good treatment tolerance and safety profile, without causing toxic effects in internal organs in comparison with vancomycin. In view of its safety, clinical efficacy and convenient dosing, dalbavancin may prove a useful therapeutic option in the treatment of IE.

The Polish Prevalence of Infection in Intensive Care (PPIC): A one-day point prevalence multicenter study.

BACKGROUND: Infections in critically ill patients are the main reasons for a lack of therapeutic success and increased mortality in intensive care units (ICUs). There have been many analyses of the incidence of infections in ICUs; however, no large studies of this kind have been conducted either in Poland or in Eastern and Central Europe. OBJECTIVES: The aim of the research was to undertake a one-day study of the prevalence of infections in ICUs in Warszawa and the Mazovian region of Poland. MATERIAL AND METHODS: A prospective questionnaire survey analysis - a one-day prevalence study of infections - was carried out on June 25, 2014, in 28 ICUs in Poland. RESULTS: Among 205 ICU patients (193 adults and 12 children), 134 infections were found in 101 patients (99/193 adults (51.30%) and 2/12 children (16.70%)), and bacterial colonization in 19/205 (9.3%) patients. In 66.42% of the cases, more than 1 site of infection was diagnosed. On the day of the study, 75.40% of the diagnosed infections had positive microbiological results. The most frequent were respiratory tract infections (53.73%), wound infections (18.65%) and bloodstream infections (14.92%). Most of the infections (64.10%) were caused by Gram-negative bacteria (GN), followed by Gram-positive bacteria (GP; 31.80%) and fungi (4.10%). The most frequently reported GN microorganisms were Enterobacteriaceae (44.7%). Methicillin-resistant Staphylococcus aureus (MRSA) infections were found in 8.80% of the patients. Antibiotics were administered to 75.60% of the adult patients, in 69.20% as targeted treatment. Mechanical ventilation, central vein catheterization and urinary bladder catheterization were used in 67.80%, 85.85% and 94.63% of the patients, respectively. CONCLUSIONS: On the day of the study, more than half of the patients had infections, mostly from GN bacteria. Respiratory tract infections were the main type found. In about 2/3 of the patients, antibiotics were administered, mainly as targeted therapy.

Regional Cerebral Oxygen Saturation Decreases During Primary Hip Arthroplasty: An Analysis of Perioperative Regional Cerebral Oxygenation (rSO2), S100 Calcium-Binding Protein B (S100B) and Glial Fibrillary Acidic Protein (GFAP) Values. A Pilot Study.

BACKGROUND The incidence of postoperative cognitive dysfunction (POCD) after major joint arthroplasty is high. In the etiology of POCD, many factors have been cited, including thromboembolic complications. The incidence of cerebral embolization after lower extremity arthroplasty may be as high as 40-60%. The potential events of cerebral embolization could lead to a decrease in the regional cerebral oxygenation (rSO2) and increased serum levels of biochemical markers of brain damage. The objective of the study was to test whether there are any changes in the rSO2 values and serum markers of brain damage in patients who underwent total hip arthroplasty. MATERIAL AND METHODS Fifteen patients who underwent primary hip arthroplasty under spinal anesthesia were analyzed. The rSO2 was monitored using infrared spectroscopy. Biochemical analyses of S100 calcium-binding protein B (S100B) protein and fibrillary acidic protein (GFAP) serum concentrations were performed using immunoassay methods. RESULTS The values of rSO2 decreased during the surgery, but this was not related to mean arterial pressure variations or hemoglobin saturation. The concentration of S100B was increased compared to its preoperative values, and there were no changes in GFAP values. The changes in rSO2 readings correlated with the biomarkers' levels just after the surgery. CONCLUSIONS Our results suggest that S100B may be a more specific marker of astroglial damage in patients after primary total hip arthroplasty. The decrease in rSO2 readings may be due to micro-thromboembolic events that occurred during the surgery. However, the results of this study are preliminary, and further studies are needed to establish its clinical efficacy.

In vitro analysis of the minimal inhibitory concentration values of different generations of anti-methicillin-resistant Staphylococcus aureus antibiotics.

Methicillin-resistant Staphylococcus aureus (MRSA) resistance to antimicrobials may result in the increased risk of treatment failure. The objective of the study was to analyse in vitro MRSA susceptibility to vancomycin, linezolid, daptomycin, tigecycline, ceftaroline, dalbavancin, clindamycin, ciprofloxacin and trimethoprim/sulfamethoxazole. All MRSA strains isolated from hospitalised patients were analysed according to the current microbiological recommendations. Finally, a total of 124 MRSA strains were analysed; all were susceptible to tested antibiotics. Dalbavancin had the lowest minimum inhibitory concentration (MIC), and vancomycin the highest MIC value. There were 28/124 strains of MRSA susceptible for clindamycin, 36/124 for ciprofloxacin and 121/124 for trimethoprim/sulfamethoxazole. Dalbavancin was the most effective antimicrobial in our study.

Non-instrumental clinical monitoring does not guarantee an adequate course of general anesthesia. A prospective clinical study.

BACKGROUND: Clinical monitoring is the most common method of adjusting the appropriate level of general anesthesia. However, episodes of intraoperative awareness (AWR) are still reported, suggesting that clinical observations may not be sufficient in some cases. The objective of this study was to compare the efficacy of clinical and instrumental neuromonitoring with auditory evoked potentials (AEP) in an intraoperative analysis of the proper level of general anesthesia. METHODS: Patients scheduled for elective surgery were randomly divided into two groups. Subjects in the first group underwent intravenous, in the second group volatile anesthesia. The adequacy of anesthesia was analyzed using clinical parameters. All the participants were instrumentally monitored with the autoregressive AEP index (AAI). After the anesthesia, patients filled out a questionnaire on possible AWR. RESULTS: Data of 208 patients (87 in the first, and 121 in the second group) were analyzed. Before surgery there were no changes in AAI values between groups (80 vs. 78, P=0.5192). The mean values of clinical parameters changed, but five minutes after the nociceptive stimuli. The mean values of AAI at analyzed time points were specific for general anesthesia. In patients under intravenous anesthesia, we found more episodes of too low (46/608 vs.15/847, P<0.000) anesthesia. One case of AWR was found in the TIVA group. CONCLUSIONS: AAI index is good indicator of patients' level of consciousness during general anesthesia. Standard clinical monitoring provides appropriate level of the procedure. However, it is insufficient during TIVA and does not prevent episodes of AWR.

Dalbavancin treatment in a deep sternal wound MRSA infection after coronary artery bypass surgery: a case report.

BACKGROUND: A deep sternal wound infection (DSWI) can become a severe complication after cardiac surgery, with in-hospital mortality rates reaching up to 35%. Staphylococci, particularly methicillin resistant Staphylococcus aureus (MRSA), play important roles in its etiology. CASE PRESENTATION: This case report presents a patient who underwent coronary artery bypass surgery, and suffered postoperatively from a DSWI caused by MRSA. The pathogen was susceptible to vancomycin and rifampicin in vitro; however, this therapy was clinically ineffective. Both clinical improvement and MRSA eradication were achieved after surgical debridement of the wound and the intravenous administration of dalbavancin. CONCLUSIONS: We decided to administer dalbavancin because of its convenient pharmacological profile. The patient's tolerance of the antimicrobial was good, the biochemical markers of inflammation returned to the normal ranges, and the microbiological results one week after the dalbavancin administration were negative. A good clinical outcome was achieved with both the surgery and antimicrobial administration. In this case, dalbavancin was more effective in the treatment of the sternal and surrounding tissue infections caused by MRSA, when compared to vancomycin.

Changes in bacterial flora and antibiotic resistance in clinical samples isolated from patients hospitalized in the Military Institute of Medicine in Warsaw, Poland, between 2005-2012

BACKGROUND: Hospital infections have become an important problem. Knowledge of microbiological situations both helps in ensuring that the optimal choice of antibacterial treatment is made, and in improving the results of the selected therapy. OBJECTIVE: In this paper, both the changes in the bacterial flora of patients hospitalized in the Military Institute of Medicine, and the bacterial resistance to antimicrobials were analyzed. MATERIAL AND METHODS: Data were collected between 2005 and 2012. The identification and testing of pathogens, susceptibility tests, and analysis of bacterial resistance mechanisms to antibiotics were performed according to current guidelines. RESULTS: A total number of 28,066 bacterial strains were isolated. The most frequently isolated pathogens were Gram-negative bacteria (n=18,021; 64% of all isolated bacteria), including Enterobacteriaceae (71%) and non-Enterobacteriaceae (29%). The total number of isolated Gram-positive bacteria (n=10,045; 36% of all isolates) included Staphylococcus spp. (65%) and Enterococcus spp. (35%). The highest increase in the number of infections was caused by Enterobacteriaceae. The number of Staphylococcus aureus and coagulase negative Staphylococcus resistant to methicillin decreased. Analyzed alert pathogens with resistance phenotypes were highly susceptible to a single type of antibiotic. All multidrug resistant Gram-negative bacteria (except those naturally resistant to colistin) were susceptible to colistin. All methicillin resistant S. aureus and methicillin resistant coagulase negative Staphylococci were susceptible to vancomycin and linezolid. All MSSA strains were susceptible to cloxacillin, all Enterococcus faecium strains to ampicillin, and all VRE strains were susceptible to linezolid and tigecycline.

Etomidate, but not thiopental, decreases serum cortisol concentration in morbidly obese patients. A randomized controlled trial.

BACKGROUND: The effect of etomidate administration on the adrenal cortex in obese patients is still unclear. The objective of the study was to determine the influence of a single dose of etomidate on cortisol secretion in the morbidly obese. METHODS: 127 healthy patients were enrolled into the study. Data from 82 patients scheduled for elective laparoscopic surgery were analyzed. 62 of them were morbidly obese, while 20 had normal body mass. The participants were divided equally into etomidate and thiopental groups, depending on the kind of intravenous anaesthetic used for the induction of anaesthesia. Each patient's serum cortisol concentration was measured five times: on the day before surgery (sample A), two hours after the induction of anaesthesia (sample B), after a short tetracosactide test (sample C), 24 hours after the induction of anaesthesia (sample D), and after a second short stimulation test (sample E). RESULTS: The mean cortisol concentration in obese patients in the etomidate group was lower two hours after the induction of anaesthesia (sample B, P < 0.001), and 30 minutes after the first tetracosactide test (sample C, P < 0.001) compared to obese patients in the thiopental group. There were no differences between the groups in sample A (P = 0.833), D (P = 0.614) and E (P = 0.769). We found no changes in haemodynamic parameters between both groups. CONCLUSIONS: Etomidate decreased serum cortisol concentration and decreased reactivity to tetracosactide both in morbidly obese and in normal weight patients. This effect was reversible within 24 hours.

Effectivity of antiseptics against some pathogens.

INTRODUCTION: The efficacy of antiseptics against bacteria and fungi is different. The choice of optimal antiseptic solution is very important in prophylaxis of hospital infections. MATERIAL AND METHODS: In this study the efficacy of different antiseptics against some pathogens (Klebsiella pneumoniae ESBL (+), Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus MRSA, Candida dublinensis) was analyzed. The disc diffusion, similar to the method used in antibiotic sensitivity testing was applied. We assumed that the size of inhibition zone of bacterial growth corresponds with the efficacy of antiseptic. RESULTS AND CONCLUSION: The 2% alcoholic solution of chlorhexidine was the most effective antiseptic in our study.

Intraoperative awareness during general anaesthesia: results of the observational survey.

BACKGROUND: Intraoperative awareness is a rare but extremely unfavourable phenomenon affecting 0.1-0.2% of patients who undergo surgery under general anaesthesia. The event exposes patients to stress and its remote, severe outcomes. The aim of the present study was to determine the incidence of intraoperative awareness in patients undergoing general anaesthesia. METHODS: The observational questionnaire-based study was carried out in patients treated in one centre during a period of 8 months. Anaesthesia depth was monitored clinically using measurements of end-tidal concentration of volatile anaesthetic agent. After anaesthesia, accounts of patients regarding possible intraoperative awareness were analysed. Awareness was defined as recall events are confirmed or have a high likelihood of occuring in the intraoperative period. RESULTS: Data from 199 patients were analysed. None of them experienced awareness during general anaesthesia (category A). Possible intraoperative awareness was observed in one patient (0.5%) (category B), and 17 patients (8.5%) experienced intraoperative dreaming. CONCLUSION: The incidence of intraoperative awareness in our study was low. The intraoperative monitoring including clinical analysis of anaesthetized patient as well as measurement of end-tidal concentration of volatile anaesthetic agent seems to be sufficient for prevention of episodes of awareness during general anaesthesia.

Comparison of in vitro efficacy of ertapenem, imipenem and meropenem in the infections caused by the Enterobacteriaceae strains family.

BACKGROUND: The members of the bacterial Enterobacteriaceae family play an important role in the aetiology of many hospital infections. Some of them are able to produce ß-lactamase, an enzyme which induces the resistance of those bacteria to penicillins, cephalosporins and, in severe infections, to penicillins with ß-lactamase inhibitors. In this situation, the carbapenems become the drugs of choice. The objective of this study was to analyse the in vitro efficacy of three carbapenems: ertapenem, imipenem and meropenem against bacterial species of the Enterobacteriaceae family. METHODS: A total of 99 bacterial species (including ten bacterial species producing the ESBL mechanism), isolated between September 2011 and March 2012 from diagnostic material collected from patients of surgical clinics in the department of motoskeletal system infections and the critical care unit, hospitalised in the Military Institute of Medicine in Warsaw, were analysed. The values of MIC 50 and MIC 90 were recorded. RESULTS: All isolated bacterial species were susceptible to meropenem. One strain of Morganella morganii was resistant to imipenem, while one strain of Enterobacter cloaceae and one strain of Klebsiella pneumoniae were resistant to ertapenem. In the Enterobacteriaceae ESBL(-) group, the values of MIC 50 were 0.006 µg mL-1 for ertapenem, 0.19 µg mL⁻¹ for imipenem, and 0.032 µg mL⁻¹ for meropenem, and the MIC 90 values were: 0.25 µg mL⁻¹, 0.5 µg mL⁻¹ and 0.125 µg mL⁻¹, respectively. In the Enterobacteriaceae ESBL(+) group, the values of MIC 50 were 0.38 µg mL⁻¹, 0.25 µg mL⁻¹, 0.064 µg mL⁻¹, and the values of MIC 90 were 0.5 µg mL⁻¹, 0.25 µg mL⁻¹ and 0.125 µg mL⁻¹, respectively. CONCLUSIONS: All analysed carbapenems had high in vitro efficacy against both Enterobacteriaceae ESBL(-) and Enterobacteriaceae ESBL(+) bacterial species.

Recommendations for the management of trauma or surgery-related massive blood loss.

UNLABELLED: Exsanguination is an underestimated cause of treatment failures in patients with severe trauma or undergoing surgery. In some patients the primary dysfunction of blood clot formation is a direct cause of a massive blood loss. Patients without previous coagulation disorders are at risk of coagulopathy following intraoperative or post-traumatic bleeding, where the local haemostasis does not warrant bleeding cessation. THE AIM OF THE STUDY: was to assess the therapeutic value of various components of a complex interdisciplinary approach, based on the opinion of the experts treating patients with massive bleeding. MATERIAL AND METHODS: The study was conducted by anonymous questionnaire, using the analogue representation of the argument strength. The results were analyzed based on the techniques of descriptive statistics. The argument was considered a key parameter, when the median value of strength was located in the highest quartile. RESULTS: It was found that the arguments of the highest strength for the risk of developing the posthaemorrhagic coagulation disorders are: loss of more than one third of blood volume, fluid therapy in an amount greater than 35 ml/kg, administration of more than 5 units of packed red blood cells, insufficient supply of fresh frozen plasma and platelets in proportion to packed red blood cells, severe acidosis and hypothermia. The most important tests for post-haemorrhage coagulopathy are: anatomically non-localized bleed, abnormal values of the standard coagulation parameters and fibrinogen level below 1 g/L. In the treatment of post-haemorrhagic coagulopathy the team of experts pointed out the benefits of antifibrinolytic drugs, concentrates of prothrombin complex and recombinant activated coagulation factor VII. CONCLUSIONS: Multidisciplinary therapeutic management of bleeding patients is associated with employment of appropriate treatment methods to achieve the best possible outcome. Factors influencing the development of coagulopathy, the methods of diagnosis and proposed techniques of treatment may facilitate therapeutic decisions in bleeding patients requiring massive transfusion of blood components.

[The comparison of different bronchial aspirate culturing methods in patients with ventilator-associated pneumonia (VAP)]. / Porownanie roznych sposobow pobierania materialu z drzewa oskrzelowego do badan mikrobiologicznych.

BACKGROUND: Although broncho-alveolar lavage (BAL) culture and protected specimen brush (PSB) are regarded as the most effective methods in the diagnosis of VAP, a simple endotracheal aspiration (EA) is frequently performed during routine care, because of its simplicity and low cost. We compared the effectiveness of EA with BAL and PSB in VAP patients. METHODS: Sixty-one adult VAP patients, ventilated for longer than 48 h, were cultured with all three methods. RESULTS: Positive cultures were obtained from 63.9% of patients, with Acinetobacter baumannii being the most common pathogen. There was a high positive correlation between simple aspirates and BAL (k 0.817, CI 0.664-0.840, p <0.001) and aspirates and PSB (k 0.667, CI 0.483-0.871, p <0.001). CONCLUSION: Because of the high sensitivity of bronchial aspirate culturing, compared to BAL and PSB, it can be used successfully in most cases.

[Antimicrobial therapy of severe infections in critically ill patients]. / Antybiotykoterapia ciezkich zakazen u chorych leczonych w oddzialach intensywnej terapii.

Antimicrobial therapy of severe infections in critically ill patients becomes an important clinical problem. One of the reason is increasing resistance of pathogens to antibiotics. In this paper the current problems of the treatment of severe infections in Intensive Care Units' patients were discussed as well as benefits of modern antimicrobial agents were presented.

Translumbar inferior vena cava cannulation.

BACKGROUND: The aim of the study was to review our three year experience with translumbar insertion of dialysis catheters. METHODS: In five adult patients (4 males and one female, mean age 45 yr), requiring dialysis due to end-stage chronic renal failure, the inferior vena cava was cannulated because of the impossibility of using any other approach. All procedures were performed under fluoroscopy. After visualisation of the inferior vena cava by injection of contrast medium into a peripheral vein, the vena cava was punctured with a 20 cm long needle, at the L3 level. The position of the needle was confirmed by injection of contrast medium, and the vein was then cannulated with a peel-away cannula, using a standard Seldinger technique. Subsequently, a pre-tunneled silastic catheter was introduced and secured. RESULTS: The catheters were used for from 3 to 10 months. No case of permanent catheter dysfunction was noted. Three episodes of temporary thrombosis, in two patients, were successfully treated with heparin and urokinase. Three catheters became contaminated, but they were treated without the necessity for catheter removal. CONCLUSION: The described method is a safe and effective way of securing haemodialysis access in patients where a standard approach is not possible.