Initial antimicrobial management of sepsis.

Sepsis is a common consequence of infection, associated with a mortality rate > 25%. Although community-acquired sepsis is more common, hospital-acquired infection is more lethal. The most common site of infection is the lung, followed by abdominal infection, catheter-associated blood steam infection and urinary tract infection. Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens. To reduce mortality, it is necessary to give immediate, empiric, broad-spectrum therapy to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship. Biomarkers such a procalcitonin can provide decision support for antibiotic use, and may identify patients with a low likelihood of infection, and in some settings, can guide duration of antibiotic therapy. Sepsis can involve drug-resistant pathogens, and this often necessitates consideration of newer antimicrobial agents

Future research directions in pneumonia

Pneumonia is a complex pulmonary disease in need of new clinical approaches. Although triggered by a pathogen, pneumonia often results from dysregulations of host defense that likely precede infection. The coordinated activities of immune resistance and tissue resilience then dictate whether and how pneumonia progresses or resolves. Inadequate or inappropriate host responses lead to more severe outcomes such as acute respiratory distress syndrome and to organ dysfunction beyond the lungs and over extended time frames after pathogen clearance, some of which increase the risk for subsequent pneumonia. Improved understanding of such host responses will guide the development of novel approaches for preventing and curing pneumonia and for mitigating the subsequent pulmonary and extrapulmonary complications of pneumonia. The NHLBI assembled a working group of extramural investigators to prioritize avenues of host-directed pneumonia research that should yield novel approaches for interrupting the cycle of unhealthy decline caused by pneumonia. This report summarizes the working group’s specific recommendations in the areas of pneumonia susceptibility, host response, and consequences. Overarching goals include the development of more host-focused clinical approaches for preventing and treating pneumonia, the generation of predictive tools (for pneumonia occurrence, severity, and outcome), and the elucidation of mechanisms mediating immune resistance and tissue resilience in the lung. Specific areas of research are highlighted as especially promising for making advances against pneumonia

Multi-drug resistant organism infections in a medical ICU: Association to clinical features and impact upon outcome [Infecciones por organismos multirresistentes en una UCI médica: asociación con las características clínicas e impacto en los resultados]

Objective: To define clinical features associated with Intensive Care Unit (ICU) infections caused by multi-drug resistant organisms (MDRO) and their impact on patient outcome. Design: A single-center, retrospective case–control study was carried out between January 2010 and May 2010. Setting: A medical ICU (MICU) in the United States. Patients: The study included a total of 127 MDRO-positive patients and 186 MDRO-negative patients. Interventions: No interventions were carried out. Results: Out of a total of 313 patients, MDROs were present in 127 (41.7%). Based on the multivariate analysis, only infection as a cause of admission [OR 3.3 (1.9–5.8)]), total days of ventilation [OR 1.07 (1.01–1.12)], total days in hospital [OR 1.04 (1.01–1.07)], immunosuppression [OR 2.04 (1.2–3.5)], a history of hyperlipidemia [OR 2.2 (1.2–3.8)], surgical history [OR 1.82 (1.05–3.14)] and age [OR 1.02 (1.00–1.04)] were identified as clinical factors independently associated to MDROs, while the Caucasian race was negatively associated to MDROs. The distribution of days on ventilation, days in hospital and days of antibiotic treatment prior to infection differed between the MDRO-positive and MDRO-negative groups. The MDRO-positive patients showed a greater median number of days in hospital and days of antibiotic treatment before infection, with a greater median number of days in hospital, days of antibiotic treatment and days of ventilation after infection, compared to the MDRO-negative patients. The mortality rate was not significantly different between the two groups. Appropriate empirical antibiotic therapy was prescribed in 82% of the MDRO-positive cases – such treatment being started within 24 h after onset of the infection in 68.5% of the cases. Conclusion: Defining clinical factors associated with MDRO infections and administering timely and appropriate empirical antibiotic therapy may help reduce the mortality associated with these infections. In our hospital we did not withhold broad spectrum drugs as empirical therapy in patients with clinical features associated to MDRO infection. Our rate of appropriate empirical therapy was therefore high, which could explain the absence of excessive mortality in patients infected with MDROs. © 2017 Elsevier España, S.L.U. y SEMICYU

Potentially resistant microorganisms in intubated patients with hospital-acquired pneumonia: The interaction of ecology, shock and risk factors

Purpose: As per 2005 American Thoracic Society and Infectious Disease Society of America (ATS/IDSA) guidelines for managing hospital-acquired pneumonia, patients with early-onset pneumonia and without risk factors do not need to be treated for potentially resistant microorganisms (PRM). Methods: This was a secondary analysis of a prospective, observational, cohort, multicentre study conducted in 27 ICUs from nine European countries. Results: From a total of 689 patients with nosocomial pneumonia who required mechanical ventilation, 485 patients with confirmed etiology and antibiotic susceptibility were further analysed. Of these patients, 152 (31.3 %) were allocated to group 1 with early-onset pneumonia and no risk factors for PRM acquisition, and 333 (68.7 %) were classified into group 2 with early-onset pneumonia with risk factors for PRM or late-onset pneumonia. Group 2 patients were older and had more chronic renal failure and more severe illness (SAPS II score, 44.6 ± 16.5 vs. 47.4 ± 17.8, p = 0.04) than group 1 patients. Trauma patients were more frequent and surgical patients less frequent in group 1 than in group 2 (p < 0.01). In group 1, 77 patients (50.7 %) had PRM in spite of the absence of classic risk factors recognised by the current guidelines. A logistic regression analysis identified that presence of severe sepsis/septic shock (OR = 3.7, 95 % CI 1.5-8.9) and pneumonia developed in centres with greater than 25 % prevalence of PRM (OR = 11.3, 95 % CI 2.1-59.3) were independently associated with PRM in group 1 patients. Conclusions: In patients admitted to ICUs with a prevalence of PRM greater than 25 % or with severe sepsis/septic shock, empiric therapy for group 1 nosocomial pneumonia requiring mechanical ventilation should also include agents likely to be effective for PRM pathogens. © 2013 Springer-Verlag Berlin Heidelberg and ESICM

Prognostic role of clinical and laboratory criteria to identify early ventilator-associated pneumonia in brain injury

BACKGROUND: We investigated the role of the clinical pulmonary infection score (CPIS), serum levels of procalcitonin (PCT), C-reactive protein (CRP), and serum amyloid A (SAA) in the detection of patients with early ventilator-associated pneumonia (VAP). METHODS: Observational study in a university hospital. In 58 patients with severe brain injury receiving mechanical ventilation, CPIS, PCT, CRP and SAA were evaluated at ICU entry and at days 3 to 4 of hospital stay for VAP diagnosis (confirmed by endotracheal aspirate or BAL cultures). RESULTS: We found the following: (1) PCT at entry was increased in patients who later had early VAP develop (25 patients) compared to no VAP (median, 1.4 ng/mL; 25-75 percentiles, 0.14-0.78; vs median, 0.2 ng/mL; 25-75 percentiles, 0.76-2.4, p<0.001; sensitivity, 76%; and specificity, 75%); (2) CPIS increased at the day of VAP diagnosis, compared to entry (median, 6.6+/-1.1 vs 1.5+/-1.1, p<0.001; sensitivity, 97%; specificity, 100%), while other serum inflammatory markers did not change; and (3) deterioration in oxygenation and changes in tracheal secretions were the main determinants of CPIS changes. CONCLUSIONS: PCT may be a useful marker to predict which patients subsequently have early VAP. The CPIS could help as an early way to detect the patients with early VAP and who need further diagnostic testing

Prognostic role of clinical and laboratory criteria to identify earlyventilator-associated pneumonia in brain injury.

BACKGROUND: We investigated the role of the clinical pulmonary infection score (CPIS), serum levels of procalcitonin (PCT), C-reactive protein (CRP), and serum amyloid A (SAA) in the detection of patients with early ventilator-associated pneumonia (VAP). METHODS: Observational study in a university hospital. In 58 patients with severe brain injury receiving mechanical ventilation, CPIS, PCT, CRP and SAA were evaluated at ICU entry and at days 3 to 4 of hospital stay for VAP diagnosis (confirmed by endotracheal aspirate or BAL cultures). RESULTS: We found the following: (1) PCT at entry was increased in patients who later had early VAP develop (25 patients) compared to no VAP (median, 1.4 ng/mL; 25-75 percentiles, 0.14-0.78; vs median, 0.2 ng/mL; 25-75 percentiles, 0.76-2.4, p<0.001; sensitivity, 76%; and specificity, 75%); (2) CPIS increased at the day of VAP diagnosis, compared to entry (median, 6.6+/-1.1 vs 1.5+/-1.1, p<0.001; sensitivity, 97%; specificity, 100%), while other serum inflammatory markers did not change; and (3) deterioration in oxygenation and changes in tracheal secretions were the main determinants of CPIS changes. CONCLUSIONS: PCT may be a useful marker to predict which patients subsequently have early VAP. The CPIS could help as an early way to detect the patients with early VAP and who need further diagnostic testing