Microorganismos más frecuentes en pacientes con diagnóstico de sinusitis nosocomial hospitalizados en la Unidad de Cuidados Intensivos del Hospital de San José en el período de febrero de 2013 a marzo de 2015

12 p.Entre febrero de 2013 a marzo de 2015, se incluyeron 19 pacientes con diagnóstico de sinusitis nosocomial. La mediana de edad fue de 55 años (RIQ 48-63), el 84.2% son hombres. Los motivos de ingreso a la UCI fueron múltiples siendo los trastornos neurológicos los de mayor porcentaje. Las frecuencias de los signos clínicos se describen en la tabla 1. Todos los pacientes presentaron rinorrea y en menor porcentaje escurrimiento posterior, fiebre y leucocitosis. Un 58% de los pacientes no recibió manejo antibiótico previo, para aquellos que lo recibieron el antibiótico más prescrito fue piperacilina Tazobactam y Vancomicina. Los principales factores de riesgo encontrados fueron: presencia de sonda orogástrica, ventilación mecánica invasiva, intubación orotraqueal (Tabla 1). Los aerobios más reportados en la punción de seno maxilar fueron: klebsiella pneumoniae, proteus mirabilis, staphylococcus aureus y staphylococcus epidermidis. Los anaerobios que se identificaron; bacteroides, peptostreptococcus sp., porphyromonas sp, prevotella sp., veillonella sp y se aislo en hongos la presencia de candida albicans. (Tabla 2) Se encontró mayor perfil de resistencia para los microorganismos gram positivos, llama la atención que todos los staphylococcus fueron resistentes a betalactamasas para ampicilina y penicilina. No se estudiaron para estos microorganismos los antibióticos nitrofurantoina, gentamicina Sinerg, estreptomicina Sinerg, cefepima, ceftazidima/aclavulanico., cefotaxime, cloranfenicol, cefuroxime, cefotaxima/aclav, ceftazidima, aztreonam, ceftriaxona. (Tabla 3) De los 8 pacientes que recibieron tratamiento previo a la punción de seno maxilar mostraron resistencia a ampicilina sulbactam, ampicilina, trimetoprim sulfametoxazol, amoxicilina clavulonato, cefazolina, oxacilina, cefoxitina, tetraciclina, clindamicina, cefazolina, ciprofloxacina, eritromicina, gentamicina y levofloxacina. Se halló una sensibilidad para gram positivos con el uso de vancomicina. Los gram negativos fueron sensibles a piperacilina tazobactam

Use of early corticosteroid therapy on ICU admission in patients affected by severe pandemic (H1N1)v influenza A infection

Introduction: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection, although relatively common, remains controversial. Methods: Prospective, observational, multicenter study from 23 June 2009 through 11 February 2010, reported in the European Society of Intensive Care Medicine (ESICM) H1N1 registry. Results: Two hundred twenty patients admitted to an intensive care unit (ICU) with completed outcome data were analyzed. Invasive mechanical ventilation was used in 155 (70.5%). Sixty-seven (30.5%) of the patients died in ICU and 75 (34.1%) whilst in hospital. One hundred twenty-six (57.3%) patients received corticosteroid therapy on admission to ICU. Patients who received corticosteroids were significantly older and were more likely to have coexisting asthma, chronic obstructive pulmonary disease (COPD), and chronic steroid use. These patients receiving corticosteroids had increased likelihood of developing hospital-acquired pneumonia (HAP) [26.2% versus 13.8%, p < 0.05; odds ratio (OR) 2.2, confidence interval (CI) 1.1-4.5]. Patients who received corticosteroids had significantly higher ICU mortality than patients who did not (46.0% versus 18.1%, p < 0.01; OR 3.8, CI 2.1-7.2). Cox regression analysis adjusted for severity and potential confounding factors identified that early use of corticosteroids was not significantly associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. Conclusions: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections. associated with mortality [hazard ratio (HR) 1.3, 95% CI 0.7-2.4, p = 0.4] but was still associated with an increased rate of HAP (OR 2.2, 95% CI 1.0-4.8, p < 0.05). When only patients developing acute respiratory distress syndrome (ARDS) were analyzed, similar results were observed. Conclusions: Early use of corticosteroids in patients affected by pandemic (H1N1)v influenza A infection did not result in better outcomes and was associated with increased risk of superinfections

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p &lt; 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p &lt; 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p &lt; 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease