Improvement of antibiotic therapy and ICU survival in severe non-pneumococcal community-acquired pneumonia: a matched case-control study

INTRODUCTION: We aimed to compare intensive care unit mortality due to non-pneumococcal severe community-acquired pneumonia between the periods 2000-2002 and 2008-2014, and the impact of the improvement in antibiotic strategies on outcomes. METHODS: This was a matched case-control study enrolling 144 patients with non-pneumococcal severe pneumonia: 72 patients from the 2000-2002 database (CAPUCI I group) were paired with 72 from the 2008-2014 period (CAPUCI II group), matched by the following variables: microorganism, shock at admission, invasive mechanical ventilation, immunocompromise, chronic obstructive pulmonary disease, and age over 65 years. RESULTS: The most frequent microorganism was methicillin-susceptible Staphylococcus aureus (22.1%) followed by Legionella pneumophila and Haemophilus influenzae (each 20.7%); prevalence of shock was 59.7%, while 73.6% of patients needed invasive mechanical ventilation. Intensive care unit mortality was significantly lower in the CAPUCI II group (34.7% versus 16.7%; odds ratio (OR) 0.78, 95% confidence interval (CI) 0.64-0.95; p = 0.02). Appropriate therapy according to microorganism was 91.5% in CAPUCI I and 92.7% in CAPUCI II, while combined therapy and early antibiotic treatment were significantly higher in CAPUCI II (76.4 versus 90.3% and 37.5 versus 63.9%; p < 0.05). In the multivariate analysis, combined antibiotic therapy (OR 0.23, 95% CI 0.07-0.74) and early antibiotic treatment (OR 0.07, 95% CI 0.02-0.22) were independently associated with decreased intensive care unit mortality. CONCLUSIONS: In non-pneumococcal severe community-acquired pneumonia , early antibiotic administration and use of combined antibiotic therapy were both associated with increased intensive care unit survival during the study period

A multicenter multinational study of abdominal candidiasis: epidemiology, outcomes and predictors of mortality

Abstract Purpose: Clinical data on patients with intra-abdominal candidiasis (IAC) is still scarce. Methods: We collected data from 13 hospitals in Italy, Spain, Brazil, and Greece over a 3-year period (2011\u20132013) including patients from ICU, medical, and surgical wards. Results: A total of 481 patients were included in the study. Of these, 27 % were hospitalized in ICU. Mean age was 63 years and 57 % of patients were male. IAC mainly consisted of secondary peritonitis (41 %) and abdominal abscesses (30 %); 68 (14 %) cases were also candidemic and 331 (69 %) hadconcomitant bacterial infections. The most commonly isolated Candida species were C. albicans (n = 308 isolates, 64 %) and C. glabrata (n = 76, 16 %). Antifungal treatment included echinocandins (64 %), azoles (32 %), and amphotericin B (4 %). Septic shock was documented in 40.5 % of patients. Overall 30-day hospital mortality was 27 % with 38.9 % mortality in ICU. Multivariate logistic regression showed that age (OR 1.05, 95 % CI 1.03\u20131.07, P\0.001), increments in 1-point APACHE II scores (OR 1.05, 95 % CI 1.01\u20131.08, P = 0.028), secondary peritonitis (OR 1.72, 95 % CI 1.02\u20132.89, P = 0.019), septic shock (OR 3.29, 95 % CI 1.88\u20135.86, P\0.001), and absence of adequate abdominal source control (OR 3.35, 95 % CI 2.01\u20135.63, P\0.001) wereassociated with mortality. In patients with septic shock, absence of source control correlated with mortality rates above 60 % irrespective of administration of an adequate antifungal therapy. Conclusions: Low percentages of concomitant candidemia and high mortality rates are documented in IAC. In patients presenting with septic shock, source control is fundamental

The Global Alliance for Infections in Surgery : defining a model for antimicrobial stewardship-results from an international cross-sectional survey

Background: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. Methods: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. Results: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p <0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). Conclusion: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.Peer reviewe

Intraabdominal Candidiasis: epidemiology, predictors of choice for treatment and factors associated with mortality.

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Intraabdominal candidiasis : epidemology, predictors of choice for treatment and factors associated with mortality

The clinical criteria for defining intraabdominal candidiasis (IAC) are not specific, although a recent European consensus of experts shortened the definition of an IAC episode [10]. Inter-national guidelines focus mostly on candidemia and make little reference to antifungal therapy for IAC [11,12]. Patients in the intensive care unit (ICU) are at the highest risk for invasive candidiasis, mostly due to the severity of their disease immune-suppressive states, pro-longed length of stay, septic shock and Candidacolonization. Colonization occurs in the ICU population during the first week in up to 80% of cases [7,13], but few develop an ensuing se-vere infection [14]. The pathophysiology route of infection will determine the clinical scenario [15]; indeed, during a large recent study [9] focusing on intra-abdominal candidiasis, only 14% patients also developed candidemiaDelay in the initiation of treatment for invasive candidiasis has been associated with increased mortality [16-18]. It remains unclear which patients should receive empirical treatment or which not. According to current guidelines, appropriate treatment is based on azoles, poly-enes or echinocandins; however, the differences between these groups according to thetreatment of IAC have not been assessed, neither the differences between those more severe than those in regular wards

Management of Pseudomonas aeruginosa pneumonia: one size does not fit all

In view of the mortality associated with Pseudomonas aeruginosa (PSA) ventilator-associated pneumonia (VAP) and the frequency of inadequate initial empiric therapy, recent findings underscore the need for a different management paradigm with effective anti-pseudomonal vaccines for prophylaxis of patients at risk. The association of virulence factors is a variable that splits PSA in two phenotypes, with the possibility of adjunctive immunomodulatory therapy for management of virulent strains. We comment on recent advances in and the state of the art of PSA-VAP management and discuss a new paradigm for tailored and optimal management

Causes of non-adherence to therapeutic guidelines in severe community-acquired pneumonia

Objetivo: Valorar tasa de adherencia y causas de no adherencia a las guías terapéuticas internacionales para la prescripción antibiótica empírica en la neumonía grave en Latinoamérica. Métodos: Encuesta clínica realizada a 36 médicos de Latinoamérica donde se pedía indicar el tratamiento empírico en 2 casos clínicos ficticios de pacientes con infección respiratoria grave: neumonía adquirida en la comunidad y neumonía nosocomial. Resultados: En el caso de la neumonía comunitaria el tratamiento fue adecuado en el 30,6% de las prescripciones. Las causas de no adherencia fueron monoterapia (16,0%), cobertura no indicada para multirresistentes (4,0%) y empleo de antibióticos con espectro inadecuado (44,0%). En el caso de la neumonía nosocomial el cumplimiento de las guías terapéuticas Infectious Disease Society of America/American Thoracic Society fue del 2,8%. Las causas de falta de adherencia fueron monoterapia (14,3%) y la falta de doble tratamiento antibiótico frente a Pseudomonas aeruginosa (85,7%). En caso de considerar correcta la monoterapia con actividad frente a P. aeruginosa, el tratamiento sería adecuado en el 100% de los casos. Conclusión: En la neumonía comunitaria la adherencia a las guías terapéuticas Infectious Disease Society of America/American Thoracic Society fue del 30,6%; la causa más frecuente de incumplimiento fue el uso de monoterapia. La adherencia en el caso de la neumonía nosocomial fue del 2,8% y la causa más importante de incumplimiento fue la falta de doble tratamiento frente a P. aeruginosa, considerando adecuada monoterapia con actividad frente a P. aeruginosa la adherencia sería del 100%

Perceived differences between intensivists and infectious diseases consultants facing antimicrobial resistance: a global cross-sectional survey.

To identify differences in perception on multi-drug-resistant (MDR) organisms and their management at intensive care units (ICU). A cross-sectional survey was conducted. A proposal addressing a pathogen priority list (PPL) for ICU, arising from the TOTEM study, was compared with a sample of global experts in infections in critically ill patients. The survey was responded by 129 experts. Globally, ESBL Enterobacteriaceae, followed by carbapenem-resistant Acinetobacter baumannii and carbapenem-resistant Klebsiella pneumoniae, were the main concerns. Some differences in opinion were identified between 63 (49%) ICU physicians (ICU/anesthesiology) and 43 (33%) infectious disease consultants (ID physicians/microbiologists). The pathogens most concerning in the ICU for intensivists were ESBL Enterobacteriaceae (38%) versus carbapenem-resistant A. baumannii (48.3%) for ID consultants, (p  70%) regarding emerging resistance. Differences in priorities regarding organisms, infection control practices, and educational priorities were visualized between ID/clinical microbiologists and ICU/anesthesiologists. Multi-disciplinary collaboration is required to achieve best care for ICU patients with severe infections.The study was funded in part by Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain and Observership Programme from ESCMID, Basel, Switzerlan

Assessing predictive accuracy for outcomes of ventilator-associated events in an international cohort: the EUVAE study

PURPOSE: To analyze the impact on patient outcome of ventilator-associated events (VAEs) as defined by the Centers for Disease Control and Prevention (CDC) in 2008, 2013, and the correlation with ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT). METHODS: This was a prospective, observational, multicenter, international study conducted at 13 intensive care units (ICUs); thirty consecutive adults mechanically ventilated for ≥ 48 h per site were eligible, with daily follow-up being recorded in a collaborative web database; VAEs were assessed using the 2013 CDC classification and its 2015 update. RESULTS: A total of 2856 ventilator days in 244 patients were analyzed, identifying 33 VAP and 51 VAT episodes; 30-day ICU mortality was significantly higher (42.8 vs. 19.6%, p