Risk of Multidrug-Resistant Pathogens in Severe Community-Acquired Pneumonia.

Severe community-acquired pneumonia (SCAP) is difficult to treat when caused by difficult-to-treat (DTR) pathogens because of limited treatment options and poorer clinical outcomes. Over time, several predictive scoring systems based on risk factors for infection with multidrug resistant pathogens have been developed. We reviewed the available tools for identifying DTR pathogens as the cause of SCAP, both predictive scoring systems and rapid diagnostic methods, to develop management strategies aimed at early identification of DTR pathogens, reducing broad-spectrum antibiotic use and improving clinical outcomes. The scoring systems reviewed show considerable heterogeneity among them at the level of the region studied, the definition of risk factors, as well as which DTR pathogens are the target pathogens. The models described have shown limited effectiveness in reducing inappropriate antibiotic treatment or improving patient outcomes by themselves. However, predictive models could serve as a first step in identifying DTR pathogen infections as part of a larger detection algorithm. Rapid diagnostic tools, such as multiplex polymerase chain reaction, would be useful for the rapid identification of pneumonia-causing pathogens and their resistance mechanisms. In resource-limited settings, rapid tests should be limited to patients at high risk of developing SCAP due to DTR pathogens. We propose an integrative algorithm based on the different scores, taking into account local epidemiological data, where ideally each center should have an antimicrobial stewardship program.

Mesenchymal stem/stromal cell-based therapies for severe viral pneumonia: therapeutic potential and challenges.

Severe viral pneumonia is a significant cause of morbidity and mortality globally, whether due to outbreaks of endemic viruses, periodic viral epidemics, or the rarer but devastating global viral pandemics. While limited anti-viral therapies exist, there is a paucity of direct therapies to directly attenuate viral pneumonia-induced lung injury, and management therefore remains largely supportive. Mesenchymal stromal/stem cells (MSCs) are receiving considerable attention as a cytotherapeutic for viral pneumonia. Several properties of MSCs position them as a promising therapeutic strategy for viral pneumonia-induced lung injury as demonstrated in pre-clinical studies in relevant models. More recently, early phase clinical studies have demonstrated a reassuring safety profile of these cells. These investigations have taken on an added importance and urgency during the COVID-19 pandemic, with multiple trials in progress across the globe. In parallel with clinical translation, strategies are being investigated to enhance the therapeutic potential of these cells in vivo, with different MSC tissue sources, specific cellular products including cell-free options, and strategies to 'licence' or 'pre-activate' these cells, all being explored. This review will assess the therapeutic potential of MSC-based therapies for severe viral pneumonia. It will describe the aetiology and epidemiology of severe viral pneumonia, describe current therapeutic approaches, and examine the data suggesting therapeutic potential of MSCs for severe viral pneumonia in pre-clinical and clinical studies. The challenges and opportunities for MSC-based therapies will then be considered.

Impacto en el manejo diagnóstico/terapéutico de la ecocardiografía básica dirigida a objetivos concretos en una UCI de cirugía cardíaca / Impact of goal directed basic echocardiography on diagnostic and therapeutic management in an ICU of cardiac surgery

OBJETIVO: Pocos estudios han evaluado el impacto en el diagnóstico y tratamiento de la ecocardiografía transtorácica básica en los pacientes postoperados de cirugía cardíaca. El objetivo de nuestro estudio fue valorar el impacto de la ecocardiografía transtorácica básica en el manejo diagnóstico y terapéutico de estos pacientes. DISEÑO: Durante 18 meses se estudiaron prospectivamente todos los pacientes postoperados de cirugía cardíaca que ingresaron en el Servicio de Medicina Intensiva de un hospital universitario. Se realizó una valoración clínica a todos ellos para establecer un diagnóstico y un tratamiento inicial. Se realizó una ecocardiografía transtorácica básica para valoración diagnóstica, que se comparó con la valoración clínica. En caso de discrepancia, se valoró cambiar el tratamiento en función a la ecocardiografía y se evaluó la respuesta terapéutica. Se realizó un análisis descriptivo de los hallazgos. RESULTADOS: Se incluyeron 136 pacientes y se realizaron 203 ecocardiografías. La ecocardiografía transtorácica difería del diagnóstico inicial en 101 (49,8%) ecocardiografías. En 56 de estas (55,44%) se obtuvo un diagnóstico alternativo, lo que comportó un cambio en el tratamiento en 30pacientes (53,6%). Encontramos mejoría clínica significativa en 26 de estos pacientes (86,76%) en los siguientes 30-60min. CONCLUSIONES: La ecocardiografía transtorácica básica es útil en el manejo diagnóstico y terapéutico de los pacientes postoperados de cirugía cardíaca. En la mitad de las ecocardiografías realizadas no se pudo confirmar el diagnóstico clínico. En la mayoría de los pacientes en que observamos cambio en el diagnóstico debido a la ecocardiografía, se observó mejoría clínica tras el cambio de tratamiento

OBJECTIVE: Few studies have evaluated the impact in diagnosis and therapeutic management of basic transthoracic echocardiography in postoperated cardiac surgery. The aim of our study was to evaluate the impact of basic transthoracic echocardiography in the management of this kind of patients. DESIGN: Over an 18-month period, we prospectively studied all patients admitted to a university hospital Intensive Care Unit following heart surgery. We evaluated clinically all of them to establish a diagnosis and an initial treatment. We performed basic transthoracic echocardiography for a diagnosis evaluation that was compared with clinical diagnosis. If they differed, we assessed to change treatment and evaluate the therapeutic response. We performed a descriptive analysis. RESULTS: We included 136 patients and performed 203 echocardiographies. Transthoracic echocardiography differed of initial diagnosis in 101 (49.8%) echocardiographies. In 56 of these echocardiographies (55.44%), we could give an alternative diagnosis with a change in the treatment in 30patients (53,6%). We found clinical improvement in 26 patients (86.76%) in the following 30-60minutes. CONCLUSIONS: Basic transthoracic echocardiography is useful in diagnostic and therapeutic management of postoperative cardiac surgery patients. We could not confirm the clinical diagnosis in half of the performed echocardiographies. In most patients in whom we observe a change in the diagnosis due to echocardiography, we observed a clinical improvement after changing the treatment

Efficacy of Telavancin in Comparison to Linezolid in a Porcine Model of Severe Methicillin-Resistant Staphylococcus aureus Pneumonia.

Current guidelines recommend vancomycin and linezolid as first-line agents against methicillin-resistant Staphylococcus aureus (MRSA) nosocomial pneumonia. Telavancin is a potential new therapeutic alternative, specifically in monomicrobial MRSA pneumonia. This study compared the efficacies of telavancin versus linezolid in a porcine model of severe MRSA pneumonia. In 18 mechanically ventilated pigs (32.11 ± 1.18 kg), 75 ml of 106 CFU/ml of MRSA was administered into each pulmonary lobe. After the onset of pneumonia, pigs were randomized into three groups: a control group, a group receiving 22.5 mg/kg of body weight every 24 h (q24h) of telavancin, and a group receiving 10 mg/kg q12h of linezolid intravenously. Tracheal aspirate and bronchoalveolar lavage (BAL) fluids were cultured every 24 h. After 48 h of treatment, tissue samples were collected from the ventral and dorsal sections of each lobe. Microbiological and histopathological analyses were performed. Lung tissue concentrations differed among the groups (P = 0.019), with the lowest MRSA lung burden in the telavancin group (P < 0.05 versus the control). MRSA was detected in 46.7%, 40.0%, and 21.7% of the lung tissue samples from the control, linezolid, and telavancin groups, respectively (P < 0.001). MRSA concentrations differed among the groups in tracheal aspirate fluid (P = 0.011) but not in BAL fluid. Furthermore, there was no increased risk of kidney injury during telavancin use. Thus, telavancin has higher bactericidal efficacy than linezolid during the first 48 h of treatment in a porcine model of severe MRSA pneumonia. However, studies are needed to confirm the benefits of telavancin in treating MRSA nosocomial pneumonia.

Código Sepsis Interhospitalario en Catalunya: modelo organizativo territorial para la atención inicial al paciente con sepsis / Interhospital Sepsis Code in Catalonia (Spain): Territorial model for initial care of patients with sepsis

La sepsis es una entidad sindrómica de elevada prevalencia y mortalidad. Su manejo está estandarizado y tiene una eficacia dependiente del tiempo. Sin embargo, el manejo de los pacientes con sepsis es complejo. La heterogeneidad de las formas de presentación puede dificultar su detección y manejo, así como las diferencias en formación, competencias o disponibilidad de recursos sanitarios. La Comisión Asesora para la Atención al PAciente con Sepsis (CAAPAS), formada por 7 sociedades científicas, el Sistema de Emergencias Médicas (SEM) y el Servei Català de la Salut (CatSalut), han desarrollado en Catalunya el Código Sepsis Interhospitalario (CSI). El objetivo general del CSI es facilitar la detección precoz, la atención inicial y la coordinación interhospitalaria para optimizar el tratamiento de los pacientes con sepsis o shock séptico en formato código de riesgo vital, de forma homogénea a lo largo de todo el territorio catalán

Sepsis is a syndromic entity with high prevalence and mortality. The management of sepsis is standardized and exhibits time-dependent efficiency. However, the management of patients with sepsis is complex. The heterogeneity of the forms of presentation can make it difficult to detect and manage such cases, in the same way as differences in training, professional competences or the availability of health resources. The Advisory Commission for Patient Care with Sepsis (CAAPAS), comprising 7 scientific societies, the Emergency Medical System (SEM) and the Catalan Health Service (CatSalut), have developed the Interhospital Sepsis Code (CSI) in Catalonia (Spain). The general objective of the CSI is to increase awareness, promote early detection and facilitate initial care and interhospital coordination to attend septic patients in a homogeneous manner throughout Catalonia

Impact of goal directed basic echocardiography on diagnostic and therapeutic management in an ICU of cardiac surgery. / Impacto en el manejo diagnóstico/terapéutico de la ecocardiografía básica dirigida a objetivos concretos en una UCI de cirugía cardíaca.

OBJECTIVE: Few studies have evaluated the impact in diagnosis and therapeutic management of basic transthoracic echocardiography in postoperated cardiac surgery. The aim of our study was to evaluate the impact of basic transthoracic echocardiography in the management of this kind of patients. DESIGN: Over an 18-month period, we prospectively studied all patients admitted to a university hospital Intensive Care Unit following heart surgery. We evaluated clinically all of them to establish a diagnosis and an initial treatment. We performed basic transthoracic echocardiography for a diagnosis evaluation that was compared with clinical diagnosis. If they differed, we assessed to change treatment and evaluate the therapeutic response. We performed a descriptive analysis. RESULTS: We included 136 patients and performed 203 echocardiographies. Transthoracic echocardiography differed of initial diagnosis in 101 (49.8%) echocardiographies. In 56 of these echocardiographies (55.44%), we could give an alternative diagnosis with a change in the treatment in 30patients (53,6%). We found clinical improvement in 26 patients (86.76%) in the following 30-60minutes. CONCLUSIONS: Basic transthoracic echocardiography is useful in diagnostic and therapeutic management of postoperative cardiac surgery patients. We could not confirm the clinical diagnosis in half of the performed echocardiographies. In most patients in whom we observe a change in the diagnosis due to echocardiography, we observed a clinical improvement after changing the treatment.

Interhospital Sepsis Code in Catalonia (Spain): Territorial model for initial care of patients with sepsis. / Código Sepsis Interhospitalario en Catalunya: modelo organizativo territorial para la atención inicial al paciente con sepsis.

Sepsis is a syndromic entity with high prevalence and mortality. The management of sepsis is standardized and exhibits time-dependent efficiency. However, the management of patients with sepsis is complex. The heterogeneity of the forms of presentation can make it difficult to detect and manage such cases, in the same way as differences in training, professional competences or the availability of health resources. The Advisory Commission for Patient Care with Sepsis (CAAPAS), comprising 7 scientific societies, the Emergency Medical System (SEM) and the Catalan Health Service (CatSalut), have developed the Interhospital Sepsis Code (CSI) in Catalonia (Spain). The general objective of the CSI is to increase awareness, promote early detection and facilitate initial care and interhospital coordination to attend septic patients in a homogeneous manner throughout Catalonia.

Evaluation of intensivist basic training in transthoracic echocardiography in the postoperative period of heart surgery / Evaluación de la formación de intensivistas en ecocardiografía transtorácica básica en el postoperatorio de cirugía cardíaca

Background: Transthoracic echocardiography can significantly change the management of many critical patients, and is being incorporated into many Intensive Care Units (ICU). Very few studies have examined the feasibility and impact of intensivists performing basic transthoracic echocardiography upon the management of critical patients after cardiac surgery. The present study therefore evaluates the quality of acquisition and accuracy of intensivist interpretation of basic transthoracic echocardiograms in the postoperative period of heart surgery. Methods: Over an 8-month period we prospectively studied 148 patients within 24h after admission to a university hospital ICU following heart surgery. We performed basic transthoracic echocardiography to evaluate ventricular function, pericardial effusion, hypovolemia and mitral regurgitation. Cohen's Kappa was used to compare transthoracic echocardiograms obtained by intensivists with basic versus advanced training. Concordance on image acquisition and interpretation was evaluated. Results: We analyzed data of adequate transthoracic echocardiograms in 148 patients (92.5%). Apical four-chamber view and advanced trainees obtained better quality images. Concordance was good for right and left ventricular function (kappa=0.7±0.14 and 0.87±0.05, respectively), and moderate for the remaining parameters. Interpretation concordance between basic and advanced training intensivists was good (kappa=0.73±0.05). Conclusions: Intensivists with basic training in echocardiography are capable of performing and interpreting echocardiograms in most patients during the postoperative period of heart surgery

Objetivo: La ecocardiografía transtorácica puede cambiar significativamente el manejo en muchos pacientes críticos y se está incorporando dentro de muchas unidades de cuidados intensivos (UCI). Pocos estudios han examinado la factibilidad y el impacto de la ecocardiografía transtorácica básica realizada por intensivistas en el manejo de los pacientes críticos después de una cirugía cardíaca. Por ello, nosotros evaluamos la calidad de adquisición y la precisión en la interpretación de la ecocardiografía básica realizada por intensivistas en los pacientes postoperados de cirugía cardíaca. Métodos: Durante 8 meses, estudiamos prospectivamente 148 pacientes postoperados de cirugía cardíaca dentro de las primeras 24h de ingreso en una UCI de un hospital universitario. Realizamos una ecocardiografía transtorácica básica para evaluar función ventricular, líquido pericárdico, hipovolemia y regurgitación mitral. Utilizamos el coeficiente kappa de Cohen para comparar las ecocardiografías transtorácicas realizadas por los intensivistas con formación básica versus avanzada. Evaluamos la concordancia en la adquisición de imágenes y su interpretación. Resultados: Analizamos los datos de las ecocardiografías transtorácicas de 148 pacientes (92,5%). La visión apical cuatro-cámaras y los intensivistas con formación avanzada obtuvieron mayor calidad de imagen. La concordancia fue buena para la función ventricular derecha e izquierda (kappa=0,7±0,14 y 0,87±0,05, respectivamente), y moderada para el resto de parámetros. La concordancia de la interpretación entre los intensivistas con formación básica y avanzada fue buena (kappa=0,73±0,05). Conclusiones: Los intensivistas formados en ecocardiografía transtorácica básica son capaces de obtener e interpretar las ecocardiografías en la mayoría de postoperados programados de cirugía cardíaca

Fragilidad en pacientes mayores de 65 años ingresados en cuidados intensivos (FRAIL-ICU) / Frailty in patients over 65 years of age admitted to Intensive Care Units (FRAIL-ICU)

Objetivo: Estimar la prevalencia de fragilidad en pacientes ingresados en cuidados intensivos (UCI) y su impacto sobre la mortalidad intra UCI, al mes y a los 6 meses. Diseño: Estudio de cohorte prospectiva. Ámbito: UCI polivalentes españolas. Intervención: Ninguna. Pacientes y métodos: Pacientes≥65 años ingresados en UCI>24horas. Se recogieron las variables al ingreso y la situación basal por teléfono al mes y a los 6 meses del alta de UCI. Variables de interés principal: Edad, sexo, fragilidad (escala FRAIL), situación basal (Barthel, Lawton, Clinical Dementia Rating y Nutric Score), días de ventilación mecánica (VM), escalas de gravedad (APACHE II y SOFA), mortalidad UCI, al mes y a los 6 meses del alta. Resultados: Ciento treinta y dos pacientes, 46 frágiles (34,9%). Pacientes frágiles vs. no frágiles: 78,8±7,2 vs. 78,6±6,4 años (p=0,43), varones 43,8% vs. 56,3% (p=0,10), SOFA 4,7±2,9 vs. 4,6±2,9 (p=0,75), VM 33.3% vs. 66,7% (p=0,75), días de VM 5,6±15 vs. 4,3±8,1 (p=0,57), mortalidad UCI 13% versus 6% (p = 0,14), mortalidad al mes 24% versus 8% (p = 0,01), mortalidad 6 meses 32% versus 15% (p = 0,03). La fragilidad se asocia con la mortalidad al mes (OR = 3,5; p <0,05, IC del 95% (1,22-10,03) y a los 6 meses del alta de UCI (OR = 2,62; p <0,05, IC del 95% (1,04-6,56). Conclusiones: La fragilidad está presente en el 35% de los pacientes ingresados en UCI, asociándose a la mortalidad

Objective: To estimate the prevalence of frailty in patients admitted to the Intensive Care Unit (ICU) and its impact upon ICU mortality at 1 and 6 months. Design: A prospective observational cohort study was carried out. Setting: Spanish ICU. Intervention: None. Patients and methods: Patients≥65 years of age admitted to the ICU for>24hours. Variables were registered upon admission, and functional status was assessed by telephone calls 1 and 6 months after discharge from the ICU. Main study variables: Age, gender, frailty (FRAIL scale), functional status (Barthel, Lawton, Clinical Dementia Rating and NUTRIC score), days of mechanical ventilation (MV), functional score (APACHE II and SOFA), ICU mortality, and mortality 1 and 6 months after ICU discharge. Results: A total of 132 patients were evaluated, of which 46 were frail (34.9%). Age of the frail versus non-frail patients: 78.8±7.2 and 78.6±6.4 years, respectively (P=.43); male gender: 43.8% versus 56.3% (P=.10); SOFA score: 4.7±2.9 versus 4.6±2.9 (P=.75); MV: 33.3% versus 66.7% (P=.75); days of MV: 5.6±15 versus 4.3±8.1 (P=.57); ICU mortality 13% versus 6% (P = .14), mortality at 1 month 24% versus 8% (P = .01), mortality 6 months 32% versus 15% (P = .03). Frailty is associated with mortality at one month (OR = 3.5, P <.05, 95% CI (1.22-10.03) and at 6 months after discharge from the ICU (OR = 2.62, P <.05, 95% CI (1.04-6.56). Conclusions: Frailty was present in 35% of the patients admitted to the ICU, and was associated with mortality

Frailty in patients over 65 years of age admitted to Intensive Care Units (FRAIL-ICU). / Fragilidad en pacientes mayores de 65 años ingresados en cuidados intensivos (FRAIL-ICU).

OBJECTIVE: To estimate the prevalence of frailty in patients admitted to the Intensive Care Unit (ICU) and its impact upon ICU mortality at 1 and 6 months. DESIGN: A prospective observational cohort study was carried out. SETTING: Spanish ICU. INTERVENTION: None. PATIENTS AND METHODS: Patients≥65 years of age admitted to the ICU for>24hours. Variables were registered upon admission, and functional status was assessed by telephone calls 1 and 6 months after discharge from the ICU. MAIN STUDY VARIABLES: Age, gender, frailty (FRAIL scale), functional status (Barthel, Lawton, Clinical Dementia Rating and NUTRIC score), days of mechanical ventilation (MV), functional score (APACHE II and SOFA), ICU mortality, and mortality 1 and 6 months after ICU discharge. RESULTS: A total of 132 patients were evaluated, of which 46 were frail (34.9%). Age of the frail versus non-frail patients: 78.8±7.2 and 78.6±6.4 years, respectively (P=.43); male gender: 43.8% versus 56.3% (P=.10); SOFA score: 4.7±2.9 versus 4.6±2.9 (P=.75); MV: 33.3% versus 66.7% (P=.75); days of MV: 5.6±15 versus 4.3±8.1 (P=.57); ICU mortality 13% versus 6% (P = .14), mortality at 1 month 24% versus 8% (P = .01), mortality 6 months 32% versus 15% (P = .03). Frailty is associated with mortality at one month (OR = 3.5, P <.05, 95% CI (1.22-10.03) and at 6 months after discharge from the ICU (OR = 2.62, P <.05, 95% CI (1.04-6.56). CONCLUSIONS: Frailty was present in 35% of the patients admitted to the ICU, and was associated with mortality.

Evaluation of intensivist basic training in transthoracic echocardiography in the postoperative period of heart surgery.

BACKGROUND: Transthoracic echocardiography can significantly change the management of many critical patients, and is being incorporated into many Intensive Care Units (ICU). Very few studies have examined the feasibility and impact of intensivists performing basic transthoracic echocardiography upon the management of critical patients after cardiac surgery. The present study therefore evaluates the quality of acquisition and accuracy of intensivist interpretation of basic transthoracic echocardiograms in the postoperative period of heart surgery. METHODS: Over an 8-month period we prospectively studied 148 patients within 24h after admission to a university hospital ICU following heart surgery. We performed basic transthoracic echocardiography to evaluate ventricular function, pericardial effusion, hypovolemia and mitral regurgitation. Cohen's Kappa was used to compare transthoracic echocardiograms obtained by intensivists with basic versus advanced training. Concordance on image acquisition and interpretation was evaluated. RESULTS: We analyzed data of adequate transthoracic echocardiograms in 148 patients (92.5%). Apical four-chamber view and advanced trainees obtained better quality images. Concordance was good for right and left ventricular function (kappa=0.7±0.14 and 0.87±0.05, respectively), and moderate for the remaining parameters. Interpretation concordance between basic and advanced training intensivists was good (kappa=0.73±0.05). CONCLUSIONS: Intensivists with basic training in echocardiography are capable of performing and interpreting echocardiograms in most patients during the postoperative period of heart surgery.

Identification and validation of distinct biological phenotypes in patients with acute respiratory distress syndrome by cluster analysis.

RATIONALE: We hypothesised that patients with acute respiratory distress syndrome (ARDS) can be clustered based on concentrations of plasma biomarkers and that the thereby identified biological phenotypes are associated with mortality. METHODS: Consecutive patients with ARDS were included in this prospective observational cohort study. Cluster analysis of 20 biomarkers of inflammation, coagulation and endothelial activation provided the phenotypes in a training cohort, not taking any outcome data into account. Logistic regression with backward selection was used to select the most predictive biomarkers, and these predicted phenotypes were validated in a separate cohort. Multivariable logistic regression was used to quantify the independent association with mortality. RESULTS: Two phenotypes were identified in 454 patients, which we named 'uninflamed' (N=218) and 'reactive' (N=236). A selection of four biomarkers (interleukin-6, interferon gamma, angiopoietin 1/2 and plasminogen activator inhibitor-1) could be used to accurately predict the phenotype in the training cohort (area under the receiver operating characteristics curve: 0.98, 95% CI 0.97 to 0.99). Mortality rates were 15.6% and 36.4% (p<0.001) in the training cohort and 13.6% and 37.5% (p<0.001) in the validation cohort (N=207). The 'reactive phenotype' was independent from confounders associated with intensive care unit mortality (training cohort: OR 1.13, 95% CI 1.04 to 1.23; validation cohort: OR 1.18, 95% CI 1.06 to 1.31). CONCLUSIONS: Patients with ARDS can be clustered into two biological phenotypes, with different mortality rates. Four biomarkers can be used to predict the phenotype with high accuracy. The phenotypes were very similar to those found in cohorts derived from randomised controlled trials, and these results may improve patient selection for future clinical trials targeting host response in patients with ARDS.

The status of intensive care medicine research and a future agenda for very old patients in the ICU.

The "very old intensive care patients" (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years.

Declining mortality due to severe sepsis and septic shock in Spanish intensive care units: A two-cohort study in 2005 and 2011 / Disminución de la mortalidad de la sepsis grave y shock séptico en las ucis españolas: un estudio de dos cohortes en 2005 y 2011

OBJECTIVE: To analyze the evolution of sepsis-related mortality in Spanish Intensive Care Units (ICUs) following introduction of the Surviving Sepsis Campaign (SSC) guidelines and the relationship with sepsis process-of-care. DESIGN: A prospective cohort study was carried out, with the inclusion of all consecutive patients presenting severe sepsis or septic shock admitted to 41 Spanish ICUs during two time periods: 2005 (Edusepsis study pre-intervention group) and 2011 (ABISS-Edusepsis study pre-intervention group). Scope: Patients with severe sepsis or septic shock admitted to Spanish ICUs. PATIENTS: All ICU admissions from the emergency department or wards and all ICU patients with a diagnosis of severe sepsis or septic shock. A total of 1348 patients were included: 630 in the 2005 group and 718 in the 2011 group. Intervention: None. Primary endpoints: ICU mortality, 28-day mortality and Hospital mortality, hospital length of stay, ICU length of stay and compliance with the resuscitation bundle. RESULTS: Compliance with the resuscitation bundle was significantly greater in the 2011 group (5.7% vs. 9.9%; p = 0.005), and was associated to lower mortality (OR 0.602 [0.365-0.994]; p = 0.048). The 2011 group had lower absolute in-hospital mortality (44.0% vs. 32.6%; p = 0.01), 28-day mortality (36.5% vs. 23.0%; p = 0.01), and adjusted mortality (OR 0.64 [0.49-0.83], p = 0.001). CONCLUSIONS: Mortality related to severe sepsis or septic shock in Spain decreased between two patient cohorts in 2005 and 2011, and was attributable to earliness and improvement in sepsis care

OBJETIVO: Analizar la evolución de la mortalidad relacionada con la sepsis en las unidades de cuidados intensivos (UCI) españolas desde la introducción de las directrices Surviving Sepsis Campaing y la relación con el proceso de atención de la sepsis. DISEÑO: Estudio prospectivo de cohortes. Se incluyeron de manera consecutiva, todos los pacientes con sepsis grave o shock séptico ingresados en 41 UCI españolas durante 2 periodos de tiempo: en 2005 (grupo pre-intervención en el estudio Edusepsis) y en 2011 (grupo pre-intervención en el estudio ABISS-Edusepsis). Ámbito: Pacientes con sepsis grave o shock séptico ingresados en las UCI españolas. PACIENTES: Todos los ingresos en UCI procedentes de Urgencias o planta y todos los pacientes de UCI con diagnóstico de sepsis grave/shock séptico. Se incluyeron 1348 pacientes: 630 del grupo de 2005 y 718 del grupo de 2011. Intervención: Ninguna. Variables de interés principal: Mortalidad en UCI, a 28 días y hospitalaria, estancia en la UCI y en el hospital y cumplimiento con el bundle de reanimación. RESULTADOS: El cumplimiento del bundle de reanimación fue significativamente mayor en el grupo de 2011 (5,7 frente a 9,9%, p = 0,005) y se asoció con una menor mortalidad (OR 0,602 [0,365 a 0,994], p = 0,048). El grupo de 2011 tuvo una menor mortalidad absoluta hospitalaria (44,0 frente a 32,6%, p = 0,01), mortalidad a los 28 días (36,5 frente a 23,0%, p = 0,01) y mortalidad ajustada (OR 0,64 [0,49 a 0,83], p = 0,001). CONCLUSIONES: La mortalidad relacionada con la sepsis grave y el shock séptico en España disminuyó entre las 2 cohortes de pacientes de 2005 y 2011, atribuible a la precocidad y las mejoras en la atención de la sepsis

Toward a personalized response approach in sepsis 4.0 / Hacia una estrategia de respuesta personalizada en sepsis 4.0

No disponible

Declining mortality due to severe sepsis and septic shock in Spanish intensive care units: A two-cohort study in 2005 and 2011.

OBJECTIVE: To analyze the evolution of sepsis-related mortality in Spanish Intensive Care Units (ICUs) following introduction of the Surviving Sepsis Campaign (SSC) guidelines and the relationship with sepsis process-of-care. DESIGN: A prospective cohort study was carried out, with the inclusion of all consecutive patients presenting severe sepsis or septic shock admitted to 41 Spanish ICUs during two time periods: 2005 (Edusepsis study pre-intervention group) and 2011 (ABISS-Edusepsis study pre-intervention group). SCOPE: Patients with severe sepsis or septic shock admitted to Spanish ICUs. PATIENTS: All ICU admissions from the emergency department or wards and all ICU patients with a diagnosis of severe sepsis or septic shock. A total of 1348 patients were included: 630 in the 2005 group and 718 in the 2011 group. INTERVENTION: None. PRIMARY ENDPOINTS: ICU mortality, 28-day mortality and Hospital mortality, hospital length of stay, ICU length of stay and compliance with the resuscitation bundle. RESULTS: Compliance with the resuscitation bundle was significantly greater in the 2011 group (5.7% vs. 9.9%; p=0.005), and was associated to lower mortality (OR 0.602 [0.365-0.994]; p=0.048). The 2011 group had lower absolute in-hospital mortality (44.0% vs. 32.6%; p=0.01), 28-day mortality (36.5% vs. 23.0%; p=0.01), and adjusted mortality (OR 0.64 [0.49-0.83], p=0.001). CONCLUSIONS: Mortality related to severe sepsis or septic shock in Spain decreased between two patient cohorts in 2005 and 2011, and was attributable to earliness and improvement in sepsis care.

A new experimental model of acid- and endotoxin-induced acute lung injury in rats.

The majority of the animal models of acute lung injury (ALI) are focused on the acute phase. This limits the studies of the mechanisms involved in later phases and the effects of long-term treatments. Thus the goal of this study was to develop an experimental ALI model of aspiration pneumonia, in which diffuse alveolar damage continues for 72 h. Rats were intratracheally instilled with one dose of HCl (0.1 mol/l) followed by another instillation of one dose of LPS (0, 10, 20, 30, or 40 µg/g body weight) 2 h later, which models aspiration of gastric contents that progresses to secondary lung injury from bacteria or bacterial products. The rats were euthanized at 24, 48, and 72 h after the last instillation. The results showed that HCl and LPS at all doses caused activation of inflammatory responses, increased protein permeability and apoptosis, and induced mild hypoxemia in rat lungs at 24 h postinstillation. However, this lung damage was present at 72 h only in rats receiving HCl and LPS at the doses of 30 and 40 µg/g body wt. Mortality (∼50%) occurred in the first 48 h and only in the rats treated with HCl and LPS at the highest dose (40 µg/g body wt). In conclusion, intratracheal instillation of HCl followed by LPS at the dose of 30 µg/g body wt results in severe diffuse alveolar damage that continues at least 72 h. This rat model of aspiration pneumonia-induced ALI will be useful for testing long-term effects of new therapeutic strategies in ALI.

Evolution over a 15-year period of the clinical characteristics and outcomes of critically ill patients with severe community-acquired pneumonia / Evolución durante un período de 15 años de las características clínicas y resultados de los pacientes críticamente enfermos con neumonía comunitaria grave

OBJECTIVES: To study the characteristics and outcomes of patients in the ICU with severe community-acquired pneumonia (SCAP) over a 15-year surveillance period. METHODS: We conducted a retrospective cohort study of episodes of SCAP, and assessed the epidemiology, etiology, treatment and outcomes of patients admitted to the ICU, comparing three periods (1999-2003, 2004-2008 and 2009-2013). RESULTS: A total of 458 patients were diagnosed with SCAP. The overall cumulative incidence was 37.4 episodes/1000 admissions, with a progressive increase over the three periods (P < 0.001). Patients fulfilling the two major IDSA/ATS criteria at admission increased from 64.2% in the first period to 82.5% in the last period (P = 0.005). Streptococcus pneumoniae was the prevalent pathogen. The incidence of bacteremia was 23.1%, and a progressive significant reduction in overall incidence was observed over the three periods (P = 0.02). Globally, 91% of the patients received appropriate empiric antibiotic treatment, increasing from 78.3% in the first period to 97.7% in the last period (P < 0.001). Combination antibiotic therapy (betalactam+macrolide or fluoroquinolone) increased significantly from the first period (61%) to the last period (81.3%) (P < 0.001). Global ICU mortality was 25.1%, and decreased over the three periods (P = 0.001). CONCLUSIONS: Despite a progressively higher incidence and severity of SCAP in our ICU, crude ICU mortality decreased by 18%. The increased use of combined antibiotic therapy and the decreasing rates of bacteremia were associated to improved patient prognosis

OBJETIVOS: Estudiar las características y el pronóstico de los pacientes con neumonía grave adquirida en la comunidad ingresados en una unidad de cuidados intensivos (UCI) durante un período de 15 años. MATERIAL Y MÉTODOS: Estudio retrospectivo de una cohorte de pacientes con neumonía grave comunitaria en los que se analizó la evolución en la epidemiología, etiología, tratamiento y pronóstico durante un período de 15 años, comparando 3 períodos (1999-2003, 2004-2008 y 2009-2013). RESULTADOS: Un total de 458 pacientes fueron diagnosticados de neumonía. La incidencia media global durante el período estudiado fue de 37,4 episodios/1.000 ingresos, encontrándose un incremento progresivo durante los 3 períodos estudiados (p < 0,001). Los pacientes que cumplían con los 2 criterios mayores de neumonía grave de la ATS/IDSA aumentaron de un 64,2% en el primer período a un 82,5% en el último período (p = 0,005). Streptococcus pneumoniae fue el microorganismo más frecuente aislado. La incidencia de bacteriemia fue del 23,1%, encontrándose una reducción significativa y progresiva en la incidencia a lo largo de los 3 períodos (p = 0,02). El 91% de los pacientes recibió tratamiento antibiótico empírico apropiado, encontrándose un incremento entre el primer y el último período del 78,3% al 97,7% (p < 0,001). El tratamiento combinado (betalactámico+macrólido o quinolona) aumentó de un 61% en el primer período a un 81,3% en el último (p < 0,001). La mortalidad en la unidad de cuidados intensivos durante todo el período fue del 25,1%, encontrándose una disminución progresiva durante los 3 períodos (p=0,001). CONCLUSIONES: A pesar de un incremento progresivo en la incidencia y gravedad de las neumonías ingresadas en unidad de cuidados intensivos, la mortalidad se redujo en un 18%. El incremento en la utilización de tratamiento combinado y la disminución en la incidencia de bacteriemia se asociaron a una mejoría en el pronóstico

Evolution over a 15-year period of the clinical characteristics and outcomes of critically ill patients with severe community-acquired pneumonia.

OBJECTIVES: To study the characteristics and outcomes of patients in the ICU with severe community-acquired pneumonia (SCAP) over a 15-year surveillance period. METHODS: We conducted a retrospective cohort study of episodes of SCAP, and assessed the epidemiology, etiology, treatment and outcomes of patients admitted to the ICU, comparing three periods (1999-2003, 2004-2008 and 2009-2013). RESULTS: A total of 458 patients were diagnosed with SCAP. The overall cumulative incidence was 37.4 episodes/1000 admissions, with a progressive increase over the three periods (P<0.001). Patients fulfilling the two major IDSA/ATS criteria at admission increased from 64.2% in the first period to 82.5% in the last period (P=0.005). Streptococcus pneumoniae was the prevalent pathogen. The incidence of bacteremia was 23.1%, and a progressive significant reduction in overall incidence was observed over the three periods (P=0.02). Globally, 91% of the patients received appropriate empiric antibiotic treatment, increasing from 78.3% in the first period to 97.7% in the last period (P<0.001). Combination antibiotic therapy (betalactam+macrolide or fluoroquinolone) increased significantly from the first period (61%) to the last period (81.3%) (P<0.001). Global ICU mortality was 25.1%, and decreased over the three periods (P=0.001). CONCLUSIONS: Despite a progressively higher incidence and severity of SCAP in our ICU, crude ICU mortality decreased by 18%. The increased use of combined antibiotic therapy and the decreasing rates of bacteremia were associated to improved patient prognosis.