Clinical impact of a commercially available multiplex PCR system for rapid detection of pathogens in patients with presumed sepsis

<p>Abstract</p> <p>Background</p> <p>Timely identification of pathogens is crucial to minimize mortality in patients with severe infections. Detection of bacterial and fungal pathogens in blood by nucleic acid amplification promises to yield results faster than blood cultures (BC). We analyzed the clinical impact of a commercially available multiplex PCR system in patients with suspected sepsis.</p> <p>Methods</p> <p>Blood samples from patients with presumed sepsis were cultured with the Bactec 9240™ system (Becton Dickinson, Heidelberg, Germany) and aliquots subjected to analysis with the LightCycler^®SeptiFast^®(SF) Test (Roche Diagnostics, Mannheim, Germany) at a tertiary care centre. For samples with PCR-detected pathogens, the actual impact on clinical management was determined by chart review. Furthermore a comparison between the time to a positive blood culture result and the SF result, based on a fictive assumption that it was done either on a once or twice daily basis, was made.</p> <p>Results</p> <p>Of 101 blood samples from 77 patients, 63 (62%) yielded concordant negative results, 14 (13%) concordant positive and 9 (9%) were BC positive only. In 14 (13%) samples pathogens were detected by SF only, resulting in adjustment of antibiotic therapy in 5 patients (7,7% of patients). In 3 samples a treatment adjustment would have been made earlier resulting in a total of 8 adjustments in all 101 samples (8%).</p> <p>Conclusion</p> <p>The addition of multiplex PCR to conventional blood cultures had a relevant impact on clinical management for a subset of patients with presumed sepsis.</p

El aceite de oliva en nutrición clínica

The different beneficial effects of olive oil have a rational and scientific basis due to advances in the knowledge of lipid metabolism. The evidence that for a similar plasma cholesterol concentration, the rate of cardiovascular deaths is lower in the Mediterranean countries than in other ones, suggests that the beneficial effects of olive oil may not be only related to the known quantitative changes in plasma lipoproteins, but also to other, as yet unknown or little known, anti-atherogenic factors. The peculiarities of olive oil in terms of certain biochemical, biological and nutritional characteristics, open up a field of application in normal clinical practice. The benefits of olive oil in clinical nutrition correlate with its action on lipid metabolism and the cardiovascular system. Even a moderate increase in the ingestion of monounsaturated fats and a reduction in the ingestion of carbohydrates could be more advantageous in those patients with diabetes and hypertriglyceridemia and/or in those where loss of weight is not a priority. Different studies have also demonstrated the benefits of olive oil in different inflammatory and autoimmune diseases, such as rheumatoid arthritis. The chemical composition of extra virgin olive oil contributes to daily requirements of essential fatty acids and active antioxidant nutrients in vitamin E deficiency. This particular and well-balanced situation [oleic acid (18:1 n -9) and minor components in an ideal ratio] undoubtedly has a significant relevance in human clinical nutrition.Los avances en el conocimiento del metabolismo lipídico están permitiendo establecer las bases científicas de los efectos saludables del aceite de oliva. En los países del área Mediterránea, la mortalidad cardiovascular es menor que en otros, aunque la concentración de colesterol en sangre es similar. Es muy probable que la capacidad cardio-protectora del aceite de oliva se relacione con otros factores de riesgo, algunos de los cuales son poco o completamente desconocidos. Las propiedades bioquímicas, biológicas y nutricionales del aceite de oliva son peculiares y permiten su aplicación en la nutrición clínica. Los beneficios del aceite de oliva se correlacionan con su acción sobre el metabolismo lipídico y el sistema cardiovascular. Un aumento moderado en la ingesta de grasa monoinsaturada (aceite de oliva), a expensas de los carbohidratos, es la recomendación en pacientes con diabetes e hipertrigliceridemia. En nutrición clínica, el aceite de oliva también tiene efectos beneficiosos en enfermedades relacionadas con respuestas inflamatorias y autoinmunes, como la artritis reumatoide. La composición química del aceite de oliva virgen extra contribuye a las necesidades diarias de ácidos grasos esenciales y de antioxidantes, especialmente en situaciones patológicas de deficiencia en vitamina E. Sin duda, el aceite de oliva (virgen extra) tiene máxima relevancia, por su contenido de ácido oleico (18:1 n -9) y compuestos minoritarios, en la nutrición clínica

Expert Statements on the Standard of Care in Critically Ill Adult Patients With Atypical Hemolytic Uremic Syndrome.

A typical hemolytic uremic syndrome (aHUS) presents similarly to thrombotic thrombocytopenic purpura (TTP) and other causes or conditions with thrombotic microangiopathy (TMA), such as disseminated intravascular coagulation or sepsis. Similarity in clinical presentation may hinder diagnosis and optimal treatment selection in the urgent setting in the ICU. However, there is currently no consensus on the diagnosis or treatment of aHUS for ICU specialists. This review aims to summarize available data on the diagnosis and treatment strategies of aHUS in the ICU to enhance the understanding of aHUS diagnosis and outcomes in patients managed in the ICU. To this end, a review of the recent literature (January 2009-March 2016) was performed to select the most relevant articles for ICU physicians. Based on the paucity of adult aHUS cases overall and within the ICU, no specific recommendations could be formally graded for the critical care setting. However, we recognize a core set of skills required by intensivists for diagnosing and managing patients with aHUS: recognizing thrombotic microangiopathies, differentiating aHUS from related conditions, recognizing involvement of other organ systems, understanding the pathophysiology of aHUS, knowing the diagnostic workup and relevant outcomes in critically ill patients with aHUS, and knowing the standard of care for patients with aHUS based on available data and guidelines. In conclusion, managing critically ill patients with aHUS requires basic skills that, in the absence of sufficient data from patients treated within the ICU, can be gleaned from an increasingly relevant literature outside the ICU. More data on critically ill patients with aHUS are needed to validate these conclusions within the ICU setting

Early Stepdown From Echinocandin to Fluconazole Treatment in Candidemia: A Post Hoc Analysis of Three Cohort Studies

[Background] There are no clear criteria for antifungal de-escalation after initial empirical treatments. We hypothesized that early de-escalation (ED) (within 5 days) to fluconazole is safe in fluconazole-susceptible candidemia with controlled source of infection.[Methods] This is a multicenter post hoc study that included consecutive patients from 3 prospective candidemia cohorts (2007–2016). The impact of ED and factors associated with mortality were assessed.[Results] Of 1023 candidemia episodes, 235 met inclusion criteria. Of these, 54 (23%) were classified as the ED group and 181 (77%) were classified as the non-ED group. ED was more common in catheter-related candidemia (51.9% vs 31.5%; P = .006) and episodes caused by Candida parapsilosis, yet it was less frequent in patients in the intensive care unit (24.1% vs 39.2%; P = .043), infections caused by Nakaseomyces glabrata (0% vs 9.9%; P = .016), and candidemia from an unknown source (24.1% vs 47%; P = .003). In the ED and non-ED groups, 30-day mortality was 11.1% and 29.8% (P = .006), respectively. Chronic obstructive pulmonary disease (odds ratio [OR], 3.97; 95% confidence interval [CI], 1.48–10.61), Pitt score > 2 (OR, 4.39; 95% CI, 1.94–9.20), unknown source of candidemia (OR, 2.59; 95% CI, 1.14–5.86), candidemia caused by Candida albicans (OR, 3.92; 95% CI, 1.48–10.61), and prior surgery (OR, 0.29; 95% CI, 0.08–0.97) were independent predictors of mortality. Similar results were found when a propensity score for receiving ED was incorporated into the model. ED had no significant impact on mortality (OR, 0.50; 95% CI, 0.16–1.53).[Conclusions] Early de-escalation is a safe strategy in patients with candidemia caused by fluconazole-susceptible strains with controlled source of bloodstream infection and hemodynamic stability. These results are important to apply antifungal stewardship strategies.This research forms part of an activity that has received funding from EIT Health. EIT Health is supported by the European Institute of Innovation and Technology (EIT), a body of the European Union that receives support from the European Union´s Horizon 2020 Research and Innovation Program. This study has been cofunded by the European Regional Development Fund. E. M.-G. (PI18/01061), P. P.-A. (“Rio Hortega” contract CM18/00132), M. F.-R. (“Miguel Servet” contract CP18/00073), and C. G.-V. (FIS PI18/01061) have received research grants from the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III.Peer reviewe

Multidrug resistant Acinetobacter baumannii: a descriptive study in a city hospital

<p>Abstract</p> <p>Background</p> <p>Multidrug resistant <it>Acinetobacter baumannii</it>, (MRAB) is an important cause of hospital acquired infection. The purpose of this study is to determine the risk factors for MRAB in a city hospital patient population.</p> <p>Methods</p> <p>This study is a retrospective review of a city hospital epidemiology data base and includes 247 isolates of Acinetobacter baumannii (AB) from 164 patients. Multidrug resistant <it>Acinetobacter baumannii </it>was defined as resistance to more than three classes of antibiotics. Using the non-MRAB isolates as the control group, the risk factors for the acquisition of MRAB were determined.</p> <p>Results</p> <p>Of the 247 AB isolates 72% (177) were multidrug resistant. Fifty-eight percent (143/247) of isolates were highly resistant (resistant to imipenem, amikacin, and ampicillin-sulbactam). Of the 37 patients who died with Acinetobacter colonization/infection, 32 (86%) patients had the organism recovered from the respiratory tract. The factors which were found to be significantly associated (p ≤ 0.05) with multidrug resistance include the recovery of AB from multiple sites, mechanical ventilation, previous antibiotic exposure, and the presence of neurologic impairment. Multidrug resistant Acinetobacter was associated with significant mortality when compared with sensitive strains (p ≤ 0.01). When surgical patients (N = 75) were considered separately, mechanical ventilation and multiple isolates remained the factors significantly associated with the development of multidrug resistant Acinetobacter. Among surgical patients 46/75 (61%) grew a multidrug resistant strain of AB and 37/75 (40%) were resistant to all commonly used antibiotics including aminoglycosides, cephalosporins, carbepenems, extended spectrum penicillins, and quinolones. Thirty-five percent of the surgical patients had AB cultured from multiple sites and 57% of the Acinetobacter isolates were associated with a co-infecting organism, usually a Staphylococcus or Pseudomonas. As in medical patients, the isolation of Acinetobacter from multiple sites and the need for mechanical ventilation were significantly associated with the development of MRAB.</p> <p>Conclusions</p> <p>The factors significantly associated with MRAB in both the general patient population and surgical patients were mechanical ventilation and the recovery of Acinetobacter from multiple anatomic sites. Previous antibiotic use and neurologic impairment were significant factors in medical patients. Colonization or infection with MRAB is associated with increased mortality.</p

Epidemiology of influenza-associated hospitalization in adults, Toronto, 2007/8

The purpose of this investigation was to identify when diagnostic testing and empirical antiviral therapy should be considered for adult patients requiring hospitalization during influenza seasons. During the 2007/8 influenza season, six acute care hospitals in the Greater Toronto Area participated in active surveillance for laboratory-confirmed influenza requiring hospitalization. Nasopharyngeal (NP) swabs were obtained from patients presenting with acute respiratory or cardiac illness, or with febrile illness without clear non-respiratory etiology. Predictors of influenza were analyzed by multivariable logistic regression analysis and likelihoods of influenza infection in various patient groups were calculated. Two hundred and eighty of 3,917 patients were found to have influenza. Thirty-five percent of patients with influenza presented with a triage temperature ≥38.0°C, 80% had respiratory symptoms in the emergency department, and 76% were ≥65 years old. Multivariable analysis revealed a triage temperature ≥38.0°C (odds ratio [OR] 3.1; 95% confidence interval [CI] 2.3–4.1), the presence of respiratory symptoms (OR 1.7; 95% CI 1.2–2.4), admission diagnosis of respiratory infection (OR 1.8; 95% CI 1.3–2.4), admission diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD)/asthma or respiratory failure (OR 2.3; 95% CI 1.6–3.4), and admission in peak influenza weeks (OR 4.2; 95% CI 3.1–5.7) as independent predictors of influenza. The likelihood of influenza exceeded 15% in patients with respiratory infection or exacerbation of COPD/asthma if the triage temperature was ≥38.0°C or if they were admitted in the peak weeks during the influenza season. During influenza season, diagnostic testing and empiric antiviral therapy should be considered in patients requiring hospitalization if respiratory infection or exacerbation of COPD/asthma are suspected and if either the triage temperature is ≥38.0°C or admission is during the weeks of peak influenza activity