Epidemiology of intra-abdominal infection and sepsis in critically ill patients: “AbSeS”, a multinational observational cohort study and ESICM Trials Group Project

Purpose: To describe the epidemiology of intra-abdominal infection in an international cohort of ICU patients according to a new system that classifies cases according to setting of infection acquisition (community-acquired, early onset hospital-acquired, and late-onset hospital-acquired), anatomical disruption (absent or present with localized or diffuse peritonitis), and severity of disease expression (infection, sepsis, and septic shock). Methods: We performed a multicenter (n = 309), observational, epidemiological study including adult ICU patients diagnosed with intra-abdominal infection. Risk factors for mortality were assessed by logistic regression analysis. Results: The cohort included 2621 patients. Setting of infection acquisition was community-acquired in 31.6%, early onset hospital-acquired in 25%, and late-onset hospital-acquired in 43.4% of patients. Overall prevalence of antimicrobial resistance was 26.3% and difficult-to-treat resistant Gram-negative bacteria 4.3%, with great variation according to geographic region. No difference in prevalence of antimicrobial resistance was observed according to setting of infection acquisition. Overall mortality was 29.1%. Independent risk factors for mortality included late-onset hospital-acquired infection, diffuse peritonitis, sepsis, septic shock, older age, malnutrition, liver failure, congestive heart failure, antimicrobial resistance (either methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase-producing Gram-negative bacteria, or carbapenem-resistant Gram-negative bacteria) and source control failure evidenced by either the need for surgical revision or persistent inflammation. Conclusion: This multinational, heterogeneous cohort of ICU patients with intra-abdominal infection revealed that setting of infection acquisition, anatomical disruption, and severity of disease expression are disease-specific phenotypic characteristics associated with outcome, irrespective of the type of infection. Antimicrobial resistance is equally common in community-acquired as in hospital-acquired infection

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

If you could change one thing in your school, what would this be? 469 suggestions of 429 medical graduates

OBJECTIVE The I CAN! questionnaire is an instrument for measuring the outcomes of medical curricula, based mainly on the Tuning project. The questionnaire is under construction and validation. It consists of 105 closed questions and the open question "if you could change one thing in your school, what would this be?". This paper presents the responses of medical graduates to this open question. METHOD The questionnaire was distributed to the graduates of six medical schools in Greece during the summer and autumn 2009 graduation periods, and to residents and specialist doctors during a primary health care conference in Greece (5.2.2010). The responses to the open question were grouped into categories and subcategories according to their conceptual content, and their frequency was calculated. RESULTS Questionnaires were collected from 408 new graduates of six medical schools (357 and 51 during the summer and autumn graduations, respectively): 45% male, 55% female; from Athens 148 (48% of its graduates), Thrace 38 (81%), Ioannina 12 (17%), Crete 32 (47%), and Thessaly 31 (100%). In addition, 21 questionnaires were collected from residents and specialist doctors. A total of 469 changes were proposed, related mainly to the curriculum (212) and teachers (215), and fewer to other elements of the educational environment (42). The suggestions included: increase in practical exercises (129) and clinical experience (8), introduction of practical subjects (21), exclusion of highly specialized subjects (12), changes in the timetable (6), the way of teaching (108), the method of student assessment (62), and the attitude (31) and selection (14) of the teachers. Only a few suggested changes were related to students' issues (10) and the administration of their school (30). CONCLUSIONS The majority of suggestions of the medical graduates recommended curriculum reform and a student-centered attitude from the teachers. The findings of this study, which are similar to those previously derived from students (80% preclinical) from the same medical schools, support the precept that changes in the medical curricula in Greece are essential, and may provide the impetus for immediate action by the medical faculties. © Athens Medical Society

I CAN! A graduate self-completion questionnaire for evaluating medical curriculum outcomes: How to use it, and preliminary findings on Greek medical education outcomes

Objective Although valid instruments are available for measuring the educational environment during the 6-year period of undergraduate medical study, there was no tool for measuring the end-product of the medical curriculum, i.e. the abilities of the "medical graduate". The I CAN! questionnaire, based on the tuning-medicine project, is an instrument designed to measure this. The construction and validation of the questionnaire Greek, and graduates' answers to the open question "if you could change one thing in your school, what would this be?" have been described elsewhere. The aim of this paper was to present how of the instrument works and the responses of medical graduates to its closed questions. METHOD The I CAN! questionnaire consists of 104 randomly arranged closed questions, based on the tuning-medicine level-two learning outcomes for undergraduate medical education in Europe, organized into 16 level-one outcomes, 12 for medical competencies and 4 for professionalism. The questionnaire was distributed to the graduates of Greek medical schools during the summer and autumn 2009 graduation. Their responses were coded (disagree absolutely=0, disagree=20, disagree moderately=40, agree moderately=60, agree=80, agree absolutely=100). The mean question, level-one outcomes and overall scores were calculated, and interpreted as: <50 very poor, 50-60.9 poor, 61-70.9 fairly poor, 71-78.9 fairly good, 79-88.9 good, 89-100 very good. Results Completed questionnaires were provided by 408 graduates of 6 medical schools, representing 55% of the total graduate population: 45% male, 55% female. They were graduates of the Universities of: Athens 148 (48% of graduates), Thessaloniki 147 (71%), Thrace 38 (81%), Ioannina 12 (17%), Crete 32 (47%), and Thessaly 31 (100%). On average they self-assessed their overall ability at 74% (i.e., in the "moderately good" interpretation zone), their ability to prescribe drugs 65% and to apply evidence-based medicine 68%, being a global doctor 80% and possessing professional atributes 83%. They considered themselves weaker in specific areas: Carrying out blood transfusion (37%), requesting autopsy (52%), administering intravenous therapy and using infusion devices (55%), completing correctly a death certificate (57%), matching appropriate drugs and other treatment to the clinical context (58%), and using diagnostic and therapeutic options available through other health professions (59%). They reported strength in: messuring blood pressure (96%), carrying out electrocardiography (92%), will to succeed (92%), maintaining confidentiality (91%), recognizing their own limits and asking for help (88%). Conclusions The I CAN! self-assessment questionnaire can identify the perceived strengths and weaknesses of medical graduates, offering the basis for implementation of a SWOT analysis (strengths, weaknesses, opportunities, threats) and evidence-based educational policy. Medical schools could use the instrument to monitor progress towards competence of tomorrow's doctors, and to assess effectiveness of policy changes. If all European medical schools were to use it on every graduate cohort, a time series database could be created to serve administrative, research and other purposes. © Athens Medical Society

Clinical factors affecting costs in patients receiving systemic antifungal therapy in intensive care units in Greece: Results from the ESTIMATOR study

Invasive fungal infections are common in intensive care units (ICUs) but there is a great variability in factors affecting costs of different antifungal treatment strategies in clinical practice. To determine factors affecting treatment cost in adult ICU patients with or without documented invasive fungal infection receiving systemic antifungal therapy (SAT) we have performed a prospective, multicentre, observational study enrolling patients receiving SAT in participating ICUs in Greece. During the study period, 155 patients received SAT at 14 participating ICUs: 37 (23.9%) for proven fungal infection before treatment began, 10 (6.5%) prophylactically, 77 (49.7%) empirically and 31 (20.0%) pre-emptively; 66 patients receiving early SAT (55.9%) were subsequently confirmed to have proven infection with Candida spp. (eight while on treatment). The most frequently used antifungal drugs were echinocandins (89/155; 57.4%), fluconazole (31/155; 20%) and itraconazole (20/155; 12.9%). Mean total cost per patient by SAT strategy was €20 458 (proven), €15 054 (prophylaxis), €23 594 (empiric) and €22 184 (pre-emptive). Factors associated with significantly increased cost were initial treatment failure, length of stay (LOS) in ICU before starting SAT (i.e. from admission until treatment start), fever and proven candidaemia (all P≤.05). Conclusion: Early administration of antifungal drugs was not a substantial component of total hospital costs. However, there was a significant adverse impact on costs with increasing LOS in febrile patients in ICU for whom diagnosis of fungaemia was delayed before starting SAT, and with initial treatment failure. Awareness of potential candidaemia and initiation of pre-emptive or empirical strategy as early appropriate treatment may improve ICU patient outcomes while reducing direct medical costs. © 2017 The Authors. Mycoses Published by Blackwell Verlag Gmb

Investigating the failure to aspirate subglottic secretions with the evac endotracheal tube

BACKGROUND: Aspiration of subglottic secretions is a widely used intervention for prevention of ventilator-associated pneumonia. However, using the Hi-Lo® Evac endotracheal tube (Hi-Lo Evac; Mallinckrodt; Athlone, Ireland) (Evac ETT), dysfunction of the suction lumen and subsequent failure to aspirate the subglottic secretions are common. Our objective in this study was to determine the causes of suction lumen dysfunction experienced with the Evac ETT. METHODS: We studied 40 adult patients intubated with the Evac ETT. In all cases for which dysfunction of the suction lumen was observed, the subglottic suction port was examined visually using a flexible bronchoscope. RESULTS: Dysfunction of the suction lumen occurred in 19 of 40 patients (48%). In 17 of these (43%), it was attributed to blockage of the subglottic suction port by suctioned tracheal mucosa. CONCLUSION: Evacuation of subglottic secretions using the Evac ETT is often ineffective due to prolapse of tracheal mucosa into the subglottic suction port. © 2007 by International Anesthesia Research Society

Improving outcomes of severe infections by multidrug-resistant pathogens with polyclonal IgM-enriched immunoglobulins

The emergence of infections by multidrug-resistant (MDR) Gram-negative bacteria, which is accompanied by considerable mortality due to inappropriate therapy, led to the investigation of whether adjunctive treatment with one polyclonal IgM-enriched immunoglobulin preparation (IgGAM) would improve outcomes. One hundred patients in Greece with microbiologically confirmed severe infections by MDR Gram-negative bacteria acquired after admission to the Intensive Care Unit and treated with IgGAM were retrospectively analysed from a large prospective multicentre cohort. A similar number of patient comparators well-matched for stage of sepsis, source of infection, appropriateness of antimicrobials and co-morbidities coming from the same cohort were selected. All-cause 28-day mortality was the primary end point; mortality by extensively drug-resistant (XDR) pathogens and time to breakthrough bacteraemia were the secondary end points. Fifty-eight of the comparators and 39 of the IgGAM-treated cases died by day 28 (p 0.011). The OR for death under IgGAM treatment was 0.46 (95% CI 0.26–0.85). Stepwise regression analysis revealed that IgGAM was associated with favourable outcome whereas acute coagulopathy, cardiovascular failure, chronic obstructive pulmonary disease and chronic renal disease were associated with unfavourable outcome. Thirty-nine of 62 comparators (62.9%) were infected by XDR Gram-negative bacteria and died by day 28 compared with 25 of 65 cases treated with IgGAM (38.5%) (p 0.008). Median times to breakthrough bacteraemia were 4 days and 10 days, respectively (p &lt;0.0001). Results favour the use of IgGAM as an adjunct to antimicrobial treatment for the management of septic shock caused by MDR Gram-negative bacteria. A prospective randomized trial is warranted. © 2016 The Author