Infections in intensive care; epidemiology and outcome

Abstract Systematic analyses of infections in critical illness are sparse and mostly restricted to specific infection categories. Thus, a prospective study was carried out in a medical-surgical ICU during 14 months on patients whose ICU stay was longer than 48 h. The prospectively gathered data included detailed patient history, infection survey, severity of illness scores (APACHE II, SOFA), resource use, short-term and long-term outcome and quality of life following hospital discharge. Altogether 335 patients were included, of whom 251 (74.9%) had an infection on admission; 59.3% had a community-acquired infection (CAI) and 40.7% a hospital-acquired infection (HAI), while 84 (25.1%) did not have any infection (NI). APACHE II scores and ICU or hospital mortality rates did not differ between the groups. The median hospital stay was longer in the HAI than in the CAI or NI groups. Eighty (23.9%) of the 335 patients developed an ICU-acquired infection (48 per 1000 patient days): ventilator-associated pneumonia (VAP) in 33.8% of the cases, central catheter-related (CRI) or primary bloodstream infections in 6.3% and urinary tract infections in 1.3%, while the corresponding device-related incidences per 1000 days were 18.8, 2.2 and 0.5, respectively. ICU-acquired infection was an independent risk factor for hospital mortality. It doubled the risk for hospital mortality in patients with an infection on admission and caused a threefold the risk in patients without an infection on admission and an almost fourfold increase in the use of nursing resources. Of the 272 hospital survivors, 83 (30.5%) died after discharge during the median follow-up of 17 weeks. Infection status on admission or during the ICU stay did not affect long-term mortality. ICU-acquired infection did not have an impact on patients' quality of life. The current general level of health compared to the status before ICU admission did not differ between the groups, either. Only 36% of those employed resumed their previous jobs. Three-fourths of patients had an infection on admission, while nearly one fourth acquired an ICU infection. The high VAP rate suggests a need for re-evaluation of preventive measures, whereas the low CRI indicates more successful prevention. ICU-acquired infection was a significant risk factor for hospital mortality, but did not affect patients' long-term survival or quality of life

Clostridium difficile infections in teaching hospital in northern Finland

Abstract Background: The aim of this study to compare the incidence of Clostridium difficile (CD) infections in the five university hospital districts in Finland based on national register. The clinical findings of CD cases in the Oulu University Hospital (OUH) in one-year cohort were also analyzed. Methods: The numbers of the CD cases from the national register were used for the hospital district comparison. A retrospective cohort study was conducted among all adult (> 16 years) patients treated in the OUH in 2013, who had positive CD toxin B gene test in stools. The selection of the cohort was based on the data from the OUH microbiology laboratory and the clinical characteristics were collected from hospital records. Results: The incidence of CD findings in 2013 was higher in the OUH district than in the other four university hospital districts: 159 vs. 70 to 84 per 100,000 inhabitants. In 2013, 261 patients had CD infection treated in the OUH. The yearly number of CD cases treated in the OUH in 2009–2016 varied between 221 and 287, and the corresponding proportion of positive CD findings out of all samples taken varied from 10.0 to 17.8%. A recurrent infection was seen in 58 patients (22%) while the all-cause 30 day mortality was 7.3%. Conclusions: Diagnostic strategies differed nationally, which may explain the differences in CD incidence between the university hospital districts. In the OUH, no increase in the number of CD infections was seen in 2009–2016. Main characteristics of the patient cohort in the OUH were in harmony with earlier literature

A retrospective nationwide case study on the use of a new antifungal agent: patients treated with caspofungin during 2001–2004 in Finland

ABSTRACTThe aim of this study was to evaluate the efficacy and safety of caspofungin in patients treated in Finland during the period 2001–2004. The medical records of 78 adult patients treated with caspofungin in five major hospitals were reviewed retrospectively. Fifty-nine (76%) patients had proven invasive fungal infection, of whom 22 (28%) had aspergillosis and 37 (47%) had candidiasis. Nineteen (24%) patients were treated empirically; only 13 (17%) patients received caspofungin as primary therapy. A favourable response was achieved in 52 (67%) patients. The response rate was 78% in patients with candidiasis, and 50% in patients with aspergillosis. At the end of the study period, 40 (51%) patients remained alive; of the 38 deaths, nine (24%) were caused by fungal infection. The response rates were lower, although not significantly, for patients with high (>20) vs. low (≤20) Acute Physiology and Chronic Health Evaluation (APACHE II) scores (response rate 50% vs. 68%, p 0.48, respectively), and were also lower in patients with long-term (>20 days) vs. shorter duration (≤20 days) neutropenia (55% vs. 73%, p 0.32, respectively), and in those with an underlying haematological malignancy vs. patients with other diseases (59% vs. 73%, p 0.2, respectively). In five (6%) patients, caspofungin therapy was discontinued prematurely because of adverse drug reactions (ADRs) (elevated liver enzyme values in three patients, neuropathic pain in one, and skin rash in one). Serious ADRs occurred in two (3%) patients (severe hepatic insufficiency with consequent death, and eosinophilia with elevated alkaline phosphatase levels), and laboratory abnormalities, mostly mild and reversible, in 24 (31%) patients. In this unselected patient population, caspofungin was safe, well-tolerated, and had an efficacy comparable to that in previous reports from prospective trials

Evaluation of endotracheal-suctioning practices of critical care nurses:an observational correlation study

Abstract Background: Endotracheal-suctioning (ETS) is a procedure that may constitute a risk factor for ventilator-associated pneumonia (VAP) by increasing microbial colonization of the lower airway. Unsafe ETS practices have been observed worldwide during recent years. Because of adverse reactions, practioners need to take all necessary precautions to ensure patient safety and a high quality of nursing care. The aim of the present study was to evaluate critical-care nurses’ performance in relation to current recommendations in their daily practice prior to, during and post ETS events. Methods: A structured, non-participatory, observational study (n=40) was conducted using a 25-item best-practice information sheet to assess critical-care nurses’ ETS practices in a mixed medical-surgical intensive-care unit. One-sample- and independent-samples t-tests were used to compare critical-care nurses’ ETS performance against current recommendations within different ICU experience groups. Results: The quality of observed ETS practices was significantly lower than the required quality of care (p<0.001). The most significant discrepancies were observed in ETS practices related to infection-control practices. Conclusion: Critical-care nurses are currently not following current ETS recommendations. Significant discrepancies, which may constitute a risk factor for VAP by increasing microbial colonization of the lower airway, were identified. Unsafe ETS practices may jeopardize patient safety, and thus the quality of nursing care. Educational interventions, clinical guidelines and adequate support need to be provided to critical-care nurses to assess and improve their professional capabilities and current practice. Regular auditing and prompt feedback would be beneficial

Critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for the prevention of ventilator-associated pneumonia:a survey study

Abstract Objectives: To explore critical care nurses’ knowledge of, adherence to and barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. Design: A quantitative cross-sectional survey. Methods: Two multiple-choice questionnaires were distributed to critical care nurses (n = 101) in a single academic centre in Finland in the autumn of 2010. An independent-samples t-test was used to compare critical care nurses’ knowledge and adherence within different groups. The principles of inductive content analysis were used to analyse the barriers towards evidence-based guidelines for prevention of ventilator-associated pneumonia. Results: The mean score in the knowledge test was 59.9%. More experienced nurses performed significantly better than their less-experienced colleagues (p = 0.029). The overall, self-reported adherence was 84.0%. The main self-reported barriers towards evidence-based guidelines were inadequate resources and disagreement with the results as well as lack of time, skills, knowledge and guidance. Conclusion: There is an ongoing need for improvements in education and effective implementation strategies. Clinical implications: The results could be used to inform local practice and stimulate debate on measures to prevent ventilator-associated pneumonia. Education, guidelines as well as ventilator bundles and instruments should be developed and updated to improve infection control

ICU-treated influenza A(H1N1) pdm09 infections more severe post pandemic than during 2009 pandemic:a retrospective analysis

Abstract Background: We compared in a single mixed intensive care unit (ICU) patients with influenza A(H1N1) pdm09 between pandemic and postpandemic periods. Methods: Retrospective analysis of prospectively collected data in 2009–2016. Data are expressed as median (25th–75th percentile) or number (percentile). Results: Seventy-six influenza A(H1N1) pdm09 patients were admitted to the ICU: 16 during the pandemic period and 60 during the postpandemic period. Postpandemic patients were significantly older (60 years vs. 43 years, p < 0.001) and less likely to have epilepsy or other neurological diseases compared with pandemic patients (5 [8.3%] vs. 6 [38%], respectively; p = 0.009). Postpandemic patients were more likely than pandemic patients to have cardiovascular disease (24 [40%] vs. 1 [6%], respectively; p = 0.015), and they had higher scores on APACHE II (17 [13–22] vs. 14 [10–17], p = 0.002) and SAPS II (40 [31–51] vs. 31 [25–35], p = 0.002) upon admission to the ICU. Postpandemic patients had higher maximal SOFA score (9 [5–12] vs. 5 [4–9], respectively; p = 0.03) during their ICU stay. Postpandemic patients had more often septic shock (40 [66.7%] vs. 8 [50.0%], p = 0.042), and longer median hospital stays (15.0 vs. 8.0 days, respectively; p = 0.006). During 2015–2016, only 18% of the ICU- treated patients had received seasonal influenza vaccination. Conclusions: Postpandemic ICU-treated A(H1N1) pdm09 influenza patients were older and developed more often septic shock and had longer hospital stays than influenza patients during the 2009 pandemic

Intracellular co-localization of trypsin-2 and matrix metalloprotease-9: Possible proteolytic cascade of trypsin-2, MMP-9 and enterokinase in carcinoma

Tumor-associated trypsin-2 and matrix metalloprotease-9 (MMP-9) are associated with cancer, particularly with invasive squamous cell carcinomas. They require activation for catalytical competence via proteolytic cascades. One cascade is formed by enterokinase, trypsin-2 and MMP-9; enterokinase activates trypsinogen-2 to trypsin-2, which is an efficient proMMP-9 activator. We describe here that oral squamous cell carcinomas express all members of this cascade: MMP-9, trypsin-2 and enterokinase. The expression of enterokinase in a carcinoma cell line not derived from the duodenum was shown here for the first time. Enterokinase directly cleaved proMMP-9 at the Lys(65)-Ser(66) site, but failed to activate it in vitro. We demonstrated by confocal microscopy that MMP-9 and trypsin-2 co-localized in intracellular vesicles of the carcinoma cells. This co-localization of trypsin-2 and MMP-9 resulted in intracellular proMMP-9 processing that represented fully or partially activated MMP-9. However, although both proteases were present also in various bone tumor tissues, MMP-9 and trypsin-2 never co-localized at the cellular level in these tissues. This suggests that the intracellular vesicular co-localization, storage and possible activation of these proteases may be a unique feature for aggressive epithelial tumors, such as squamous cell carcinomas, but not for tumors of mesenchymal origin