Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients.

OBJECTIVE: To analyze the effect on clinical outcomes of prophylactic positive end expiratory pressure in nonhypoxemic ventilated patients. DESIGN: Multicenter randomized controlled clinical trial. SETTING: One trauma and two general intensive care units in two university hospitals. PATIENTS: One hundred thirty-one mechanically ventilated patients with normal chest radiograph and PaO2/FiO2 above 250. INTERVENTIONS: Patients were randomly allocated to receive mechanical ventilation with 5-8 cm H2O of positive end-expiratory pressure (PEEP) (PEEP group, n = 66) or no-PEEP (control group, n = 65). MEASUREMENTS AND MAIN RESULTS: Primary end-point variable was hospital mortality. Secondary outcomes included microbiologically confirmed ventilator-associated pneumonia, acute respiratory distress syndrome, barotrauma, atelectasis, and hypoxemia (PaO2/FiO2 <175). Both groups were similar at randomization in demographic characteristics, intensive care unit admission diagnoses, severity of illness, and risk factors for ventilator-associated pneumonia. Hospital mortality rate was similar (p = 0.58) between PEEP (29.7%) and control (25.4%) groups. Ventilator-associated pneumonia was detected in 16 (25.4%) patients in the control group and 6 (9.4%) in the PEEP group (relative risk, 0.37; 95% confidence interval = 0.15-0.84; p = 0.017). The number of patients who developed hypoxemia was significantly higher in the control group (34 of 63 patients, 54%) than in the PEEP group (12 of 64, 19%) (p < 0.001), and the hypoxemia developed after a shorter period (median [interquartile range]) in the control group than in the PEEP group (38 [20-70] hrs vs. 77 [32-164] hrs, p < 0.001). Groups did not significantly differ in incidence of acute respiratory distress syndrome (14% in controls vs. 5% in the PEEP group, p = 0.08), barotrauma (8% vs. 2%, respectively, p = 0.12), or atelectasis (27% vs. 19%, respectively, p = 0.26). CONCLUSIONS: These findings indicate that application of prophylactic PEEP in nonhypoxemic ventilated patients reduces the number of hypoxemia episodes and the incidence of ventilator-associated pneumonia.

[Candiduria in patients with urethral catheter admitted in Intensive Care Unit. Etiology and in vitro susceptibility to fluconazole]. / Candiduria en pacientes con sonda uretral ingresados en una unidad de cuidados intensivos. Etiología y sensibilidad in vitro al fluconazol.

BACKGROUND: The isolation of Candida species in urine in patients admitted in intensive care units who bear a vesical catheter is considered as a sign of bad prognosis. The etiological mechanisms and the appropriateness of administering an antifungal treatment in these patients is controversial. PATIENTS AND METHOD: The prevalence of Candida species in urine and the in vitro susceptibility to fluconazole by means of the E-test were determined in 560 patients admitted in an intensive care unit. RESULTS: In 60 patients (11%) Candida species was isolated in urine after catheter replacement. 56.7% of isolates corresponded toC. albicans, 21.7% to C. glabrata, 15% to C.tropicalis, 5% to C. parapsilosis and 1.7% to C.kefyr. Only two isolates (C. albicans and C. glabrata)had a minimal inhibitory concentration (MIC) >= 64 microgram/ml (which was regarded as resistant) and 91% of strains had a MIC between 0.125 and 8 microgram/ml. MIC 90% for C. albicans and C. tropicalis was 1 microgram/ml,while it was 16 microgram/ml for C. glabrata. C. albicans is the most frequent species isolated in urine in these patients. However,over 40% of cases are found to have non-albicans species,especially C. glabrata and C. tropicalis. The majority of Candida isolates (91%) are sensitive in vitro to fluconazole.

Candiduria en pacientes con sonda uretral ingresados en una unidad de cuidados intensivos. Etiología y sensibilidad in vitro al fluconazol / Candiduria in patients with uretral catheter admitted in intensive care unit. Etiology and in vitro susceptibility to fluconazole

FUNDAMENTO: En enfermos graves con sonda vesical el aislamiento de Candida spp. en orina se considera un signo de mal pronóstico. Existen controversias sobre la etiología y el tratamiento antifúngico. PACIENTES Y MÉTODO: En un estudio prospectivo de 560 ingresados en la unidad de medicina intensiva se determinó la prevalencia de las especies de Candida en orina y su sensibilidad in vitro al fluconazol por medio del E-test. RESULTADOS: En 60 pacientes (11 por ciento) se aisló Candida después de cambiar la sonda. El 56,7 por ciento correspondió a Candida albicans, el 21,7 por ciento a C. glabrata, el 15 por ciento a C.tropicalis, el 5 por ciento a C. parapsilosis y el 1,7 por ciento a C. kefyr.Solamente un aislado de C. albicans y otro de C.glabrata presentaron una concentración inhibitoria mínima (CIM) de 64 µg/ml o mayor, considerándose resistentes. El 91 por ciento presentó una CIM de 0,125 a 8 µg/ml. La CIM90 de C. albicans y C. tropicalis resultó de 1 µg/ml, mientras que para C. glabrata fue de 16 µg/ml. CONCLUSIONES: C. albicans sigue siendo la especie más frecuente en orina; no obstante, en más del 40 por ciento de los casos se aíslan otras especie, principalmente C. glabrata y C. tropicalis. La gran mayoría de los aislados de Candida spp. es sensible in vitro al fluconazol (AU)