Jávea consensus guidelines for the treatment of Candida peritonitis and other intra-abdominal fungal infections in non-neutropenic critically ill adult patients / Documento de consenso de Jávea para el tratamiento de la candidiasis peritoneal y otras formas de infecciones fúngicas intraabdominales en pacientes adultos críticos no neutropénicos

Background. Although the management of the invasive candidiasis has improved in the last decade, controversial issues yet remain, especially in the diagnostic and therapeutic approaches to Candida peritonitis and other forms of intra-abdominal fungal infections. Aims. We sought to identify core clinical knowledge about intra-abdominal fungal infections and to achieve high-agreement recommendations required to care for critically ill adult patients with Candida peritonitis and other forms of intra-abdominal fungal infection. Methods. A biregional Spanish survey, to elucidate the consensus about the already mentioned fungal infections by means of the Delphi technique, was conducted anonymously by e-mail with 29 multidisciplinary experts in invasive fungal infections from 14 hospitals in the Valencia and Murcia communities during 2014. Respondents included intensivists, anesthesiologists, microbiologists, pharmacologists, and infectious disease specialists, who answered 31 questions prepared by a coordination group after a strict review of the literature from the 5 previous years. The educational objectives spanned 6 categories: epidemiology, microbiological diagnosis, clinical diagnosis, antifungal treatment, de-escalation therapy, and special situations. The agreement required among the panelists for each item to be selected had to be higher than 70%. After extracting the recommendations from the selected items, a meeting at which the experts were asked to validate the previously selected recommendations in a second round of scoring took place. Results. After the second round, 36 recommendations were validated according to the following distribution: epidemiology (5), microbiological diagnosis (4), clinical diagnosis (4), antifungal treatment (3), de-escalation therapy (4), and special situations (16). Conclusions. Treatment of Candida peritonitis and other forms of intra-abdominal fungal infections in ICU patients requires a broad range of knowledge application and skills that our recommendations address. Based on the DELPHI methodology, these recommendations might help to optimize the therapeutic management of these patients in special situations and in various scenarios to improve their outcome (AU)

Antecedentes. Aunque en la última década se ha observado una mejoría en el manejo de la candidiasis invasora todavía existe controversia, especialmente en la aproximación diagnóstico-terapéutica de la candidiasis peritoneal y otras formas de infección fúngica invasora intraabdominal en el paciente crítico no neutropénico. Objetivos. Identificar los principales conocimientos clínicos sobre las infecciones fúngicas intraabdominales y elaborar recomendaciones con un alto nivel de consenso, necesarias para el diagnóstico y el tratamiento de la candidiasis peritoneal y otras infecciones fúngicas intraabdominales en pacientes adultos críticos no neutropénicos. Métodos. Se realizó un cuestionario prospectivo en dos comunidades autónomas para estimar mediante la técnica Delphi el consenso en el diagnóstico y tratamiento de las infecciones mencionadas. El cuestionario se realizó en el año 2014, de forma anónima y por correo electrónico, con 29 expertos de varias disciplinas, especialistas en infecciones fúngicas invasivas de 14 hospitales de la Comunidad Valenciana y Murciana, entre los que se incluían intensivistas, anestesistas, microbiólogos, farmacéuticos y especialistas en enfermedades infecciosas, que respondieron a 31 preguntas preparadas por el grupo de coordinación, tras una revisión exhaustiva de la literatura de los 5 años previos. Los objetivos educativos contemplaron 6 categorías que incluían epidemiología, diagnóstico microbiológico, diagnóstico clínico, tratamiento antifúngico, desescalado del tratamiento farmacológico y situaciones especiales. El nivel de acuerdo alcanzado entre los expertos en cada una de las categorías debía superar el 75% para ser seleccionada. En un segundo término, después de extraer las recomendaciones de los temas seleccionados, se celebró una reunión presencial con 29 especialistas y se les solicitó la validación de las recomendaciones preseleccionadas. Resultados. Después de la segunda ronda, 36 recomendaciones fueron validadas siguiendo la siguiente distribución: epidemiología (5), diagnóstico microbiológico (4), diagnóstico clínico (4), tratamiento antifúngico, (3), desescalado (4) y situaciones especiales (16). Conclusiones. El manejo de la peritonitis candidiásica en pacientes de UCI requiere la aplicación de los conocimientos y destrezas que se detallan en nuestras recomendaciones. Estas recomendaciones, basadas en la metodología DELPHI, ayudan a optimizar el tratamiento de los pacientes críticos con candidiasis invasiva en distintos escenarios y situaciones clínicas y a mejorar su pronóstico (AU)

Jávea consensus guidelines for the treatment of Candida peritonitis and other intra-abdominal fungal infections in non-neutropenic critically ill adult patients.

BACKGROUND: Although the management of the invasive candidiasis has improved in the last decade, controversial issues yet remain, especially in the diagnostic and therapeutic approaches to Candida peritonitis and other forms of intra-abdominal fungal infections. AIMS: We sought to identify core clinical knowledge about intra-abdominal fungal infections and to achieve high-agreement recommendations required to care for critically ill adult patients with Candida peritonitis and other forms of intra-abdominal fungal infection. METHODS: A biregional Spanish survey, to elucidate the consensus about the already mentioned fungal infections by means of the Delphi technique, was conducted anonymously by e-mail with 29 multidisciplinary experts in invasive fungal infections from 14 hospitals in the Valencia and Murcia communities during 2014. Respondents included intensivists, anesthesiologists, microbiologists, pharmacologists, and infectious disease specialists, who answered 31 questions prepared by a coordination group after a strict review of the literature from the 5 previous years. The educational objectives spanned 6 categories: epidemiology, microbiological diagnosis, clinical diagnosis, antifungal treatment, de-escalation therapy, and special situations. The agreement required among the panelists for each item to be selected had to be higher than 70%. After extracting the recommendations from the selected items, a meeting at which the experts were asked to validate the previously selected recommendations in a second round of scoring took place. RESULTS: After the second round, 36 recommendations were validated according to the following distribution: epidemiology (5), microbiological diagnosis (4), clinical diagnosis (4), antifungal treatment (3), de-escalation therapy (4), and special situations (16). CONCLUSIONS: Treatment of Candida peritonitis and other forms of intra-abdominal fungal infections in ICU patients requires a broad range of knowledge application and skills that our recommendations address. Based on the DELPHI methodology, these recommendations might help to optimize the therapeutic management of these patients in special situations and in various scenarios to improve their outcome.

A randomized, placebo-controlled trial of preemptive antifungal therapy for the prevention of invasive candidiasis following gastrointestinal surgery for intra-abdominal infections.

BACKGROUND: Patients undergoing emergency gastrointestinal surgery for intra-abdominal infection are at risk of invasive candidiasis (IC) and candidates for preemptive antifungal therapy. METHODS: This exploratory, randomized, double-blind, placebo-controlled trial assessed a preemptive antifungal approach with micafungin (100 mg/d) in intensive care unit patients requiring surgery for intra-abdominal infection. Coprimary efficacy variables were the incidence of IC and the time from baseline to first IC in the full analysis set; an independent data review board confirmed IC. An exploratory biomarker analysis was performed using logistic regression. RESULTS: The full analysis set comprised 124 placebo- and 117 micafungin-treated patients. The incidence of IC was 8.9% for placebo and 11.1% for micafungin (difference, 2.24%; [95% confidence interval, -5.52 to 10.20]). There was no difference between the arms in median time to IC. The estimated odds ratio showed that patients with a positive (1,3)-ß-d-glucan (ßDG) result were 3.66 (95% confidence interval, 1.01-13.29) times more likely to have confirmed IC than those with a negative result. CONCLUSIONS: This study was unable to provide evidence that preemptive administration of an echinocandin was effective in preventing IC in high-risk surgical intensive care unit patients with intra-abdominal infections. This may have been because the drug was administered too late to prevent IC coupled with an overall low number of IC events. It does provide some support for using ßDG to identify patients at high risk of IC. CLINICAL TRIALS REGISTRATION: NCT01122368.

Bugs, hosts and ICU environment: Countering pan-resistance in nosocomial microbiota and treating bacterial infections in the critical care setting / Gérmenes, huéspedes y el entorno de la Unidad de Cuidados Intensivos: contrarrestando la panresistencia en la microbiota nosocomial para tratar las infecciones bacterianas en cuidados críticos

ICUs are areas where resistance problems are the largest, and these constitute a major problem for the intensivist's clinical practice. Main resistance phenotypes among nosocomial microbiota are (I) vancomycin-resistance/heteroresistance and tolerance in grampositives (MRSA, enterococci) and (II) efflux pumps/enzymatic resistance mechanisms (ESBLs, AmpC, metallo-betalactamases) in gramnegatives. These phenotypes are found at different rates in pathogens causing respiratory (nosocomial pneumonia/ventilator-associated pneumonia), bloodstream (primary bacteremia/catheter-associated bacteremia), urinary, intraabdominal and surgical wound infections and endocarditis in the ICU. New antibiotics are available to overcome non-susceptibility in grampositives; however, accumulation of resistance traits in gramnegatives has led to multidrug resistance, a worrisome problem nowadays. This article reviews microorganism/infection risk factors for multidrug resistance, suggesting adequate empirical treatments. Drugs, patient and environmental factors all play a role in the decision to prescribe/recommend antibiotic regimens in the specific ICU patient, implying that intensivists should be familiar with available drugs, environmental epidemiology and patient factors (AU)

UCIs son las áreas donde los problemas de resistencia son los más grandes, y éstos constituyen un problema importante para la práctica clínica de los intensivistas . Fenotipos de resistencia principales entre la microbiota nosocomial son ( I ) vancomycin-resistance/heteroresistance y tolerancia en grampositives ( MRSA, enterococos ) y ( II ) las bombas de flujo / mecanismos enzimáticos de resistencia ( BLEE , AmpC , metalo- betalactamasas ) en gramnegativos . Estos fenotipos se encuentran en diferentes tipos de patógenos causantes de las vías respiratorias (neumonía / pulmonía nosocomial asociada a ventilación mecánica), el torrente sanguíneo ( bacteremia primaria / bacteriemia asociada a catéter ) , urinario, infecciones de las heridas quirúrgicas intraabdominales y endocarditis y en la UCI. Nuevos antibióticos están disponibles para superar la no - susceptibilidad in grampositives, sin embargo, la acumulación de rasgos de resistencia en gramnegativos ha dado lugar a la resistencia a múltiples fármacos, un problema preocupante en la actualidad. Este artículo revisa los factores de riesgo microorganismo / infección de la resistencia a múltiples fármacos, lo que sugiere tratamientos empíricos adecuados. Las drogas, el paciente y los factores ambientales juegan un papel en la decisión de prescribir / recomendar regímenes de antibióticos en el paciente en la UCI específica, lo que implica que los intensivistas deben familiarizarse con los fármacos disponibles, epidemiología ambiental y los factores del paciente (AU)

Bugs, hosts and ICU environment: countering pan-resistance in nosocomial microbiota and treating bacterial infections in the critical care setting.

ICUs are areas where resistance problems are the largest, and these constitute a major problem for the intensivist's clinical practice. Main resistance phenotypes among nosocomial microbiota are (i) vancomycin-resistance/heteroresistance and tolerance in grampositives (MRSA, enterococci) and (ii) efflux pumps/enzymatic resistance mechanisms (ESBLs, AmpC, metallo-betalactamases) in gramnegatives. These phenotypes are found at different rates in pathogens causing respiratory (nosocomial pneumonia/ventilator-associated pneumonia), bloodstream (primary bacteremia/catheter-associated bacteremia), urinary, intraabdominal and surgical wound infections and endocarditis in the ICU. New antibiotics are available to overcome non-susceptibility in grampositives; however, accumulation of resistance traits in gramnegatives has led to multidrug resistance, a worrisome problem nowadays. This article reviews microorganism/infection risk factors for multidrug resistance, suggesting adequate empirical treatments. Drugs, patient and environmental factors all play a role in the decision to prescribe/recommend antibiotic regimens in the specific ICU patient, implying that intensivists should be familiar with available drugs, environmental epidemiology and patient factors.

Bugs, hosts and ICU environment: countering pan-resistance in nosocomial microbiota and treating bacterial infections in the critical care setting.

ICUs are areas where resistance problems are the largest, and they constitutes a major problem for the intensivist's clinical practice. Main resistance phenotypes among nosocomial microbiota are: i) vancomycin-resistance/heteroresistance and tolerance in grampositives (MRSA, enterococci) and ii) efflux pumps/enzymatic resistance mechanisms (ESBLs, AmpC, metallobetalactamases) in gramnegatives. These phenotypes are found at different rates in pathogens causing respiratory (nosocomial pneumonia/ventilator-associated pneumonia), bloodstream (primary bacteremia/catheter-associated bacteremia), urinary, intraabdominal and surgical wound infections and endocarditis in the ICU. New antibiotics are available to overcome non-susceptibility in grampositives; however, accumulation of resistance traits in gramnegatives has lead to multidrug resistance, a worrisome problem nowadays. This article reviews by microorganism/infection risk factors for multidrug resistance, suggesting adequate empirical treatments. Drugs, patient and environmental factors all play a role in the decision to prescribe/recommend antibiotic regimens in the specific ICU patient, implying that intensivists should be familiar with available drugs, environmental epidemiology and patient factors.

Magnetic resonance imaging in patients with spinal neurostimulation systems.

BACKGROUND: The safety of performing magnetic resonance imaging (MRI) in patients with spinal cord stimulation (SCS) systems needs to be documented. A prospective in vivo study in patients with SCS, exploring the changes produced by MRI and the associated side effects, was performed. METHODS: After ethics committee approval and patient consent, 31 consecutive patients with SCS at different spinal levels requiring a scheduled MRI evaluation were studied during an 18-month period. All MRIs were performed with a 1.5-T clinical use magnet and a specific absorption rate of no more than 0.9 W/kg. Frequency tables were used for the descriptive study, whereas comparative evaluations were made with the chi-square test for qualitative variables and single-factor analysis of variance for quantitative variables. RESULTS: The mean patient age was 49 +/- 9.5 yr; 67.7% were women (n = 21), and 32.3% were men (n = 10). None of the patients experienced hemodynamic, respiratory, or neurologic alterations. Reported changes were as follows: increased temperature in the generator's area (n = 2, 6.5%); increased in the intensity of the stimulation (n = 1, 3.2%); impedance greater than 4,000 Omega on several of the electrodes in the leads (n = 1, 3.2%); telemetry not possible (n = 2, 6.5%). Radiologic evaluation after MRI revealed no spatial displacements of the SCS leads in any case. CONCLUSION: Under the conditions of the described protocol, MRI in patients with SCS systems resulted in few complications. None of the recorded problems were serious, and in no case were patients harmed or the systems reprogrammed. Maximum patient satisfaction was reported in all cases.

Palliative treatment of dyspnea with epidural methadone in advanced emphysema.

STUDY OBJECTIVES: This study investigated whether epidural methadone perfusion at the thoracic level can mitigate dyspnea in patients with advanced emphysema. DESIGN: Open-label clinical trial without a control group. SETTING: University hospital. PATIENTS: The inclusion criteria were a diagnosis of emphysema, basal dyspnea index (Mahler scale) < or = 3, FEV(1) < or = 35%, and no indication for pneumoreduction or lung transplantation surgery. INTERVENTIONS: An epidural catheter was inserted at the thoracic level connected to a perfusion pump for administering methadone (6 mg/24 h). Assessments were made at baseline, 1 week, and 1 month after catheter insertion. MEASUREMENTS: Pulmonary function tests were performed, and determinations were made of arterial blood gas levels, respiratory control data, dyspnea quantification by Mahler transitional dyspnea index (TDI), and the Borg scale change with inspiratory resistive loading, 6-min walk (6MW) distance, and health-related quality of life using the Chronic Respiratory Disease Questionnaire. RESULTS: Of the nine patients studied, infection and catheter migration lead to suspension of treatment before the end of the study in two cases. A significant improvement in dyspnea occurred by 1 week: mean TDI, 3.77 (SD, 1.98) [p < 0.01]. After 1 month of treatment, there were significant improvements in the 6MW distance (mean, 35.33 m; SD, 17.03; p < 0.05), health-related quality of life (mean, 1.63; SD, 0.36; p < 0.05), and dyspnea (mean TDI, 5.33; SD, 2.16; p < 0.05). In addition, after 1 month, Paco(2) fell by 6.67 mm Hg (p < 0.05) and rapid shallow breathing index decreased from 38 to 27 (p < 0.05). These changes occurred without any alteration in the subject's ability to perceive or respond to inspiratory loading. CONCLUSION: Epidural methadone perfusion at chest level can effectively palliate dyspnea and improve exercise capacity and quality of life in patients with advanced emphysema, without deterioration in respiratory control or lung function. These data suggest that modulation of spinal cord afferent signaling is an appropriate novel target for dyspnea control in chronic respiratory disease.

Tratamiento del fenómeno de Raynaudmediante electroestimulación medular / Treatment of Raynaud´s phenomenon through medullary electrostimulation

Introducción: En el tratamiento del dolor asociado al síndrome de Raynaud se han probado numerosos tratamientos médicos o quirúrgicos. La electroestimulación medular es un tratamiento que ha mostrado su eficacia en la enfermedad isquémica periférica y en la isquemia cardíaca. También se ha usado con éxito en algunos casos de fenómeno de Raynaud. Material y método: Entre 1993 y 2001, se trataron mediante electroestimulación medular (EEM) 6 pacientes con fenómeno de Raynaud que no habían respondido a los tratamientos habituales. Tres de los pacientes presentaban una esclerodermia sistémica limitada tipo CREST (acrónimo de Calcinosis, síndrome de Raynaud, alteraciones esofágicas, esclerodactilia y telangiectasias) uno un lupus eritematoso sistémico, otro una enfermedad mixta del tejido conjuntivo y otro una enfermedad de Buerger. Se consideraba que había tenido éxito en el tratamiento, si había una mejoría del 50% del dolor medido con la escala analógica visual. Resultados: En 5 pacientes la electroestimulación mejoró de forma significativa el dolor. Sólo uno de los pacientes, afectado de enfermedad de Buerger, no respondió al tratamiento. Discusión. La electroestimulación medular es una opción terapéutica eficaz y segura en pacientes con fenómeno de Raynaud refractario a otros tratamientos. Otras opciones terapéuticas y las posibles complicaciones del tratamiento se discuten en este artículo (AU)