Role of critical care in urological sepsis

Infections arising from the urinary tract may either elicit a Systemic Inflammatory Response Syndrome or result in Sepsis. This may progress to severe sepsis with associated multi-organ dysfunction and perfusion abnormalities, including hypotension. The mortality associated with sepsis is high, reaching up to 46% in patients with septic shock. Infections arising from the urinary tract may arise either following a primary pathology in the urinary tract or may be acquired as a nosocomial infection. Most of these infections are caused by gram negative organisms, though occasionally gram positive organisms and fungi can infect the urinary tract under certain circumstances. Evaluation of a patient with sepsis should include establishing the diagnosis based on standard criteria, a search for the source and appropriate microbial cultures. Management of these patients requires aggressive fluid resuscitation to achieve well defined goals. This may need to be accompanied by the use of vasopressors and mechanical ventilation. Antimicrobial therapy based on the likely causative organism should be initiated, pending the culture results. Appropriate source control measures should also be taken. Prompt recognition, aggressive resuscitation and appropriate source control measures along with appropriate antimicrobial therapy will help to reduce the mortality in patients with urosepsis

Original Article - Factors influencing nursing care in a surgical intensive care unit

Context: The total time spent in nursing care depends on the type of patient and the patient′s condition. We analysed factors that influenced the time spent in nursing a patient. Aims : To analyse the factors in a patient′s condition that influenced time spent in nursing a patient. Materials and Methods: This study was performed in the Surgical Intensive Care Unit of a tertiary referral centre, over a period of one month. The total time spent on a patient in nursing care for the first 24 hours of admission, was recorded. This time was divided into time for routine nursing care, time for interventions, time for monitoring and time for administering medications. Statistical analysis used: A backward stepwise linear regression analysis using the age, sex, diagnosis, type of admission and ventilatory status as variables, was done. Results: Patients admitted after elective surgery required less time (852.4 ± 234.1 minutes), than those admitted after either emergency surgery (1069.5 ± 187.3 minutes), or directly from the ward or the emergency room (1253.7 ± 42.1 minutes). Patients who were ventilated required more time (1111.5 ± 132.5 minutes), than those brought on a T-piece (732.2 ± 134.8 minutes or extubated (639.5 ± 155.6 minutes). The regression analysis showed that only the type of admission and the ventilatory status significantly affected the time. Conclusions : This study showed that the type of admission and ventilatory status significantly influenced the time spent in nursing care. This will help optimal utilization of nursing resources

Role of quantitative endotracheal aspirate and cultures as a surveillance and diagnostic tool for ventilator associated pneumonia: A pilot study

Background: Accurate diagnosis and appropriate treatment of ventilator associated pneumonia (VAP) is crucial for good outcomes. Endotracheal suctioning is performed in ventilated patients as part of routine care and for tracheal toileting. Aim: We evaluated if quantitative endotracheal aspirate (ETA) was a suitable alternative to bronchoalveolar lavage (BAL) for suspected VAP. In addition we assessed if surveillance ETA guided antibiotic selection for subsequent VAP. Setting and Design: Prospective study in the surgical intensive care unit (ICU) of a tertiary hospital in India. Materials and Methods: Two hundred consecutive patients with mean (standard deviation) APACHE II score of 12.3±5 and requiring mechanical ventilation beyond 48 hours underwent surveillance ETA cultures. A second ETA and BAL were performed if the patient developed features of VAP. The threshold for microbiological diagnosis of VAP was taken as 10 5 colony forming units/ml (cfu/ml) for ETA and 10 4 cfu/ml for BAL. Statistical Analysis: The sensitivity and specificity of surveillance and concurrent ETA aspirate cultures were compared with BAL cultures. RESULTS: VAP was suspected clinically and corroborated radiologically in 27/177 patients (15.3%). Although microbiological support for VAP was obtained by ETA in 19 patients, bronchoscopy was possible only in 13 patients, 8 of whom had isolates at significant threshold. Of the 16 organisms isolated from BAL, 11 were of significant threshold with 9/11 (82%) BAL isolates having a similar antibiogram to a concurrent ETA. Only one BAL isolate (9%), at significant threshold, was not isolated on a concurrent ETA. On the other hand just 6/11 BAL isolates (55%) had an identical antibiogram to surveillance ETA. BAL had 3 additional isolates (27%) at significant threshold not isolated on surveillance ETA. Conclusions: Concurrent quantitative ETA could substitute BAL cultures for VAP. Surveillance ETA at 48 hours of ventilation does not appear to assist with antibiotic selection for a subsequent VAP

Dietary β-Tocopherol and Linoleic Acid, Serum Insulin, and Waist Circumference Predict Circulating Sex Hormone-Binding Globulin in Premenopausal Women1–4

Reduced levels of circulating sex hormone-binding globulin (SHBG) are implicated in the etiology of sex steroid-related pathologies and the metabolic syndrome. Dietary correlates of serum SHBG remain unclear and were studied in a convenient cross-sectional sample of healthy 30- to 40-y-old women (n = 255). By univariate analyses, serum SHBG correlated negatively with several indices of the metabolic syndrome, such as BMI, waist circumference, hip circumference (r = −0.36 to −0.44; P < 0.0001), fasting serum insulin (r = −0.41; P < 0.0001), serum triglycerides (r = −0.27; P < 0.0001), serum glucose (r = −0.23; P < 0.001), and plasma testosterone (r = −0.19; P = 0.002). Serum SHBG correlated positively with serum HDL-cholesterol (r = 0.33; P < 0.0001), plasma progesterone (r = 0.17; P = 0.007), and dietary intake of β-tocopherol (r = 0.17; P = 0.006), and negatively with that of fructose (r = −0.13; P = 0.04). Principal component analysis (PCA) extracted 12 nutrient factors with eigenvalues > 1.0 from 54 nutrients and vitamins in food records. Multivariate regression analyses showed that the PCA-extracted nutrient factor most heavily loaded with β-tocopherol and linoleic acid (P = 0.03) was an independent positive predictor of serum SHBG. When individual nutrients were the predictor variables, β-tocopherol (P = 0.002), but not other tocopherols or fatty acids (including linoleic acid), was an independent positive predictor of serum SHBG. Circulating insulin (P = 0.02) and waist circumference (P = 0.002), but not serum lipids, were negative independent predictors of SHBG in all regression models. Additional studies are needed in women of other age groups and men to determine whether consumption of foods rich in β-tocopherol and/or linoleic acid may increase serum SHBG concentrations and may thereby decrease the risk for metabolic syndrome and reproductive organ cancer

Device-Associated Infection Rates in 20 Cities of India, Data Summary for 2004–2013: Findings of the International Nosocomial Infection Control Consortium

To report the International Nosocomial Infection Control Consortium surveillance data from 40 hospitals (20 cities) in India 2004-2013. Surveillance using US National Healthcare Safety Network's criteria and definitions, and International Nosocomial Infection Control Consortium methodology. We collected data from 236,700 ICU patients for 970,713 bed-days Pooled device-associated healthcare-associated infection rates for adult and pediatric ICUs were 5.1 central line-associated bloodstream infections (CLABSIs)/1,000 central line-days, 9.4 cases of ventilator-associated pneumonia (VAPs)/1,000 mechanical ventilator-days, and 2.1 catheter-associated urinary tract infections/1,000 urinary catheter-days In neonatal ICUs (NICUs) pooled rates were 36.2 CLABSIs/1,000 central line-days and 1.9 VAPs/1,000 mechanical ventilator-days Extra length of stay in adult and pediatric ICUs was 9.5 for CLABSI, 9.1 for VAP, and 10.0 for catheter-associated urinary tract infections. Extra length of stay in NICUs was 14.7 for CLABSI and 38.7 for VAP Crude extra mortality was 16.3% for CLABSI, 22.7% for VAP, and 6.6% for catheter-associated urinary tract infections in adult and pediatric ICUs, and 1.2% for CLABSI and 8.3% for VAP in NICUs Pooled device use ratios were 0.21 for mechanical ventilator, 0.39 for central line, and 0.53 for urinary catheter in adult and pediatric ICUs; and 0.07 for mechanical ventilator and 0.06 for central line in NICUs. Despite a lower device use ratio in our ICUs, our device-associated healthcare-associated infection rates are higher than National Healthcare Safety Network, but lower than International Nosocomial Infection Control Consortium Report

Six-year multicenter study on short-term peripheral venous catheters-related bloodstream infection rates in 204 intensive care units of 57 hospitals in 19 cities of India: International Nosocomial Infection Control Consortium (INICC) findings

•We report peripheral venous catheters (PVC)-related BSI rates from 2013 to 2019.•We collected prospective data from 204 ICUs in 57 hospitals in 19 cities of India.•We followed 7,513 ICU patients for 296,893 bed-days and 295,795 PVC-days.•We identified 863 PVC-related BSIs, amounting to a rate of 2.91/1,000 PVC-days. Short-term peripheral venous catheters-related bloodstream infections (PVCR-BSIs) rates have not been systematically studied in developing countries, and data on their incidence by number of device-days are not available. Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013 to May 31, 2019 in 204 intensive care units (ICUs), members of the International Nosocomial Infection Control Consortium (INICC), from 57 hospitals in 19 cities of India. We applied US INICC definition criteria and reported methods using the INICC Surveillance Online System. We followed 7,513 ICU patients for 296,893 bed-days and 295,795 short term peripheral venous catheter (PVC)-days. We identified 863 PVCR-BSIs, amounting to a rate of 2.91/1,000 PVC-days. Mortality in patients with PVC but without PVCR-BSI was 4.14%, and 11.59% in patients with PVCR-BSI. The length of stay in patients with PVC but without PVCR-BSI was 4.13 days, and 5.9 days in patients with PVCR-BSI. The micro-organism profile showed 68% of gram negative bacteria: Escherichia coli (23%), Klebsiella spp (15%), Pseudomonas aeruginosa (5%), and others. The predominant gram-positive bacteria were Staphylococcus aureus (10%). PVCR-BSI rates found in our ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs