A comparison between continuous indirect calorimetry and single weight-based formula in estimating resting energy expenditure in nutritional therapy: a prospective randomized controlled study in critically ill patients

Optimal nutritional therapy is important to improve outcome in critically ill population in an intensive care unit (ICU). Although indirect calorimetry (IC) is currently a gold standard for resting energy expenditure (REE) measurement, yet it is still not routinely used in the ICU. A total of 146 mechanically ventilated patients were randomised to receive enteral nutrition (EN) with energy targeted based on continuous indirect calorimetry (IC) measurements (IC group, n=73) or according to 25 kcal/kg/day (SWB group, n=73). Patient characteristics were equally distributed and the IC group showed lower mean measured REE (1668.1 + 231.7 vs 1512.0 + 177.1 kcal, p<0.001). Results also showed a significant deficiency in the daily (-148.8 + 105.1 vs. -4.99 + 44.0 kcal, p<0.001) and total cumulative energy balances (-1165.3 + 958.1 vs. 46.5 + 369.5 kcal, p<0.001) in the SWB group as compared to the IC group. From the Kaplan-Meier survival analysis, we found that ICU mortality was significantly lower in the IC group with better survival probability compared to the SWB group (log-rank test, p = 0.03). However, both groups showed comparable results in terms of ICU length of stay, duration of mechanical ventilation and incidence of feeding intolerance. In conclusion, this study showed that tightly supervised nutritional therapy based on continuous IC measurement provides significantly less mean daily and cumulative energy deficits as well as significantly reduced ICU mortality rate

Anaesthesiology & Critical Care Postgraduate Training in Malaysia : training curriculum

This document is the National Postgraduate Medical Curriculum (NPMC) for Anaesthesiology and Critical Care, and is part of the NPMC Project which is intended to cover the development of curricula for all clinical medical specialists in Malaysia. It is to ensure that the training is consistent and competency based, and meets the standards required by the respective national bodies and the National Specialist Register (NSR)

The decisive study: defining beta-lactam concentration in Intensive care unit patients.

Summary of Research Findings: 1. Patients age, estimated CLcr and recent surgery significantly predicted the Vd and CL of both beta-lactams. Piperacillin and meropenem concentrations were highly-variable with coefficient of variation (COV) of ≥67.7%. Forty-nine patients (58.3%) achieved the PK/PD target and they tend to be older, with slower CLcr and receiving continuous infusion. Based on the most parsimonious logistic regression model, higher CLcr and intermittent infusion were significant predictors of sub-optimal PK/PD target attainment. 2. Malaysian physicians are receptive to PK/PD approach in antibiotic optimization among ICU patients. Nonetheless, there is still a gap in the knowledge of antibiotic PK/PD as well as its application in the critically ill, especially for β-lactams. We also found variable compliance to guidelines for antibiotic choice, as well as antibiotic dosing, for commonly encountered infections in ICU. This warrants further study and interventions in order to improve guideline compliance among local physician. 3. Early and appropriate administration of antimicrobial therapy remains the most important intervention in managing sepsis. To achieve favourable outcomes, the goal is to achieve effective drug concentrations at the site of infection. In critically ill patients, development of organ failure may complicate antibiotic dosing. Two pharmacokinetic parameters that vary with greatest significance in patients with MODS are Vd and drug CL. In presence of AKI, antibiotic dose adjustments in patients with reduced clearance are commonly applied to avoid adverse effects. Augmented renal clearance is another important phenomenon which is a manifestation of enhanced renal function. Early recognition of patients at risk of ARC allows further intervention to prevent antibiotic failure. In patients with ARC, higher doses of renal eliminated antibiotics are recommended or administration of non-renally eliminated drugs should be considered

Antibiotic prescribing in an intensive care unit: findings from a public Malaysian setting

Introduction: Data on antibiotic prescribing together with its knowledge and perception in Malaysian ICU is lacking. Objectives: To explore knowledge, perception, and antibiotic prescribing among specialists and advanced trainees in Malaysian ICU. Materials and Methods: A cross-sectional survey was employed which consisted of three sections namely knowledge, perception, and practice. Three case vignettes consisted of hospital-acquired pneumonia (HAP), infected necrotising pancreatitis (INP), and catheter-related bloodstream infection (CRBSI) were presented in the practice section to gather information on prescribing practice. Results: About 868 respondents were approached but only 104 responded (12.0% response rate). Seven different classes of antibiotics giving a total of 390 were empirically prescribed for the three cases combined. Antibiotic prescribing compliance which indicates correct choice of antibiotics and dosing were 66.3%, 56.7%, and 19.2% for HAI, INP, and CRBSI respectively. In perception, 97.2% and 85.6% of respondents conceded that antibiotic concentration is inadequate, and that dosing be based on MIC respectively. Majority (94.2%) perceived that antibiotic dosing follows PK/PD profile but only half (50.9%) agreed that therapeutic drug monitoring be routinely performed. Comprehension on antibiotics showed that all respondents acknowledged PK/PD profile of antibiotics but only 64.4% able to correlate given antibiotic with their respective PK/PD. Only 13.5% of respondents able to identify the best PD approach for Î-lactam antibiotics in sepsis patients. Conclusion: Antibiotic prescribing was somewhat appropriate in Malaysian ICU. Prolong therapy and inadequate coverage are the hallmark need to be considered especially in CRBSI. Clinicians are conversant with available antibiotics but apprehension in its PK/PD is scan

Knowledge, perception, and antibiotic prescribing practice in the intensive care unit: findings from the Malaysian public setting

Introduction:\ua0Approach to managing infection in the intensive care unit (ICU) often varies between institutions and not many readily adapt to available local guidelines despite it was constructed to suite local clinical scenario. Malaysia already has two published guidelines on managing infection in the ICU but data on its compliance are largely unknown.\ua0Objectives:\ua0A cross-sectional survey was carried out and sent to a total of 868 specialists working primarily in the ICU. The aim of this study was to explore knowledge, perception, and the antibiotic prescribing practice among specialists and advanced trainees in Malaysian ICU.\ua0Materials and Methods:\ua0A cross-sectional survey was used, consisted of three sections: knowledge, perception, and antibiotic prescribing practice in ICU. Three case vignettes on hospital-acquired pneumonia (HAP), infected necrotizing pancreatitis (INP), and catheter-related bloodstream infection (CRBSI) were used to explore antibiotic prescribing practice.\ua0Results:\ua0A total of 868 eligible subjects were approached with 104 responded to the survey. Three hundred eighty-nine antibiotics were chosen from seven different classes in the case vignettes. All respondents acknowledged the importance of pharmacokinetic/pharmacodynamic (PK/PD) in antibiotic optimization and majority (97.2%) perceived that current dosing is inadequate to achieve optimal PK/PD target in ICU patients. Majority (85.6%) believed that antibiotic dose should be streamlined to the organisms’ minimum inhibitory concentration (MIC). In terms of knowledge, only 64.4% provided the correct correlations between antibiotics and their respective PK/PD targets. Compliance rates in terms of antibiotic choices were at 79.8%, 77.8%, and 27.9% for HAI, INP, and CRBSI, respectively.\ua0Conclusion:\ua0Malaysian physicians are receptive to use PK/PD approach to optimize antibiotic dosing in ICU patients. Nonetheless, there are still gaps in the knowledge of antibiotic PK/PD as well as its application in the critically ill, especially for β-lactams

The DECISIVE Study: defining beta-lactam concentration in intensive care unit patients-the pharmacokinetics of piperacillin and meropenem in critically ill patients with conserved renal function

This was a prospective, multi-centre pharmacokinetic (PK) study conducted in three Malaysian ICUs to describe the PK of piperacillin (co-administered with tazobactam) and meropenem, and the pharmacokinetic/pharmacodynamic (PK/PD) target attainment of critically ill patients. Serial blood samples were collected to determine concentrations across seven pre-determined time-points. PK/PD target attainment was defined as a composite of: (1) the achievement of concentration 4 x the epidemiologic cut-off (ECOFF) of Pseudomonas aeruginosa and; (2) concentration below the toxicity thresholds. For piperacillin, the target concentration range was 64 – 361 mg/L and for meropenem, 8 – 64 mg/L. PK parameters were estimated using non-compartmental method. Univariate and multivariate analyses were applied. Eighty-four patients were included, 51 received piperacillin and 33 received meropenem. The most common administration method was continuous infusion (48.8%), followed by extended infusion (36.9%) and intermittent infusion (14.3%). The median (IQR) of the cohort was 58 years (42 – 69), body mass index was 23 kg/m2 (21 – 26) and the estimated Cockroft-Gault creatinine clearance (CLcr) was 62 mL/min (40 – 100). The median APACHE II and SOFA scores on admission were 13 (11 – 17) and 6 (4 – 9), respectively. Twenty-four percent of patients underwent surgery 24 hours prior to study inclusion. The volume of distribution (Vd) and CL of piperacillin were 0.42 L/kg and 0.18 L/hr/kg. The Vd and CL of meropenem were 0.37 L/kg and 0.14 L/hr/kg, respectively. Patients age, estimated CLcr and recent surgery significantly predicted the Vd and CL of both beta-lactams. Piperacillin and meropenem concentrations were highly-variable with coefficient of variation (COV) of ≥67.7%. Forty-nine patients (58.3%) achieved the PK/PD target and they tend to be older, with slower CLcr and receiving continuous infusion. Based on the most parsimonious logistic regression model, higher CLcr and intermittent infusion were significant predictors of sub-optimal PK/PD target attainment

Plethora of Antibiotics Usage and Evaluation of Carbapenem Prescribing Pattern in Intensive Care Units: A Single-Center Experience of Malaysian Academic Hospital

Excessive antibiotic consumption is still common among critically ill patients admitted to intensive care units (ICU), especially during the coronavirus disease 2019 (COVID-19) period. Moreover, information regarding antimicrobial consumption among ICUs in South-East Asia remains scarce and limited. This study aims to determine antibiotics utilization in ICUs by measuring antibiotics consumption over the past six years (2016&ndash;2021) and specifically evaluating carbapenems prescribed in a COVID-19 ICU and a general intensive care unit (GICU) during the second year of the COVID-19 pandemic. (2) Methods: This is a retrospective cross-sectional observational analysis of antibiotics consumption and carbapenems prescriptions. Antibiotic utilization data were estimated using the WHO Defined Daily Doses (DDD). Carbapenems prescription information was extracted from the audits conducted by ward pharmacists. Patients who were prescribed carbapenems during their admission to COVID-19 ICU and GICU were included. Patients who passed away before being reviewed by the pharmacists were excluded. (3) Results: In general, antibiotics consumption increased markedly in the year 2021 when compared to previous years. Majority of carbapenems were prescribed empirically (86.8%). Comparing COVID-19 ICU and GICU, the reasons for empirical carbapenems therapy in COVID-19 ICU was predominantly for therapy escalation (64.7% COVID-19 ICU vs. 34% GICU, p &lt; 0.001), whereas empirical prescription in GICU was for coverage of extended-spectrum beta-lactamases (ESBL) gram-negative bacteria (GNB) (45.3% GICU vs. 22.4% COVID-19 ICU, p = 0.005). Despite microbiological evidence, the empirical carbapenems were continued for a median (interquartile range (IQR)) of seven (5&ndash;8) days. This implies the need for a rapid diagnostic assay on direct specimens, together with comprehensive antimicrobial stewardship (AMS) discourse with intensivists to address this issue

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2013-2018, Adult and Pediatric Units, Device-associated Module

•Data from 428,847 patients, 2,815,402 bed-days.•We collected 1,468,216 line days, 1,053,330 ventilator days, 1,740,776 urinary catheter days.•We found 7,785 CLAB, 12,085 VAE, and 5,509 CAUTI.•HAI rates were 5.91% and 9.01 HAIs/1,000 bed-days.•CLAB rate was 5.3/1000 CL-days; VAE rate was 11.4/1000 MV-days, CAUTI rate was 3.1/1000 UC-days. We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific. Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied. We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases. DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

•We report INICC device-associated module data of 50 countries from 2010-2015.•We collected prospective data from 861,284 patients in 703 ICUs for 3,506,562 days.•DA-HAI rates and bacterial resistance were higher in the INICC ICUs than in CDC-NHSN's.•Device utilization ratio in the INICC ICUs was similar to CDC-NHSN's. Background: We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific. Methods: During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days. Results: Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs. Conclusions: Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically