Current treatment of nosocomial pneumonia and ventilator-associated pneumonia

Nosocomial pneumonia; Treatment; Ventilator-associated pneumoniaPneumònia nosocomial; Tractament; Pneumònia associada al ventiladorNeumonía nosocomial; Tratamiento; Neumonía asociada al ventiladorHospital-acquired pneumonia and ventilator-associated pneumonia are severe nosocomial infections leading to high morbidity and mortality. Broad-spectrum antibiotics with coverage against all likely pathogens are recommended by the international guidelines. Inappropriate empirical treatment is one of the most important prognostic factors. Knowledge of local epidemiology and continuous microbiological surveillance is crucial for improving clinical approaches to empirical antimicrobial treatment. The development of protocols and policies for training healthcare professionals on preventive strategies, such as the "Pneumonia Zero" project, and improved implementation of antimicrobial stewardship practices, will aid early de-escalation of antibiotics and prevent resistance

Risk factors and outcomes of ventilator-associated pneumonia in COVID-19 patients: a propensity score matched analysis

Mortalitat; Pneumònia associada a la ventilació mecànica; COVID-19Mortalidad; Neumonía asociada a la ventilación mecánica; COVID-19Mortality; Ventilator-associated pneumonia; COVID-1

Tiempo para la toma de decisiones en sepsis

Código de sepsis; Gestión de la sepsis; Indicadores de calidadCodi de sèpsia; Gestió de la sèpsia; Indicadors de qualitatSepsis Code; Sepsis management; Quality indicatorsIntroduction. This study aimed to identify the common barriers leading to delayed initial management, microbiological diagnosis, and appropriate empirical antimicrobial treatment in sepsis. Patients and methods. A cross-sectional study was performed by the application of a population-based survey. Four different surveys were designed, targeting the healthcare personnel located in main hospital areas [emergency department (SEMES); infectious diseases and clinical microbiology-microbiological diagnosis (SEIMC-M); intensive care and infectious diseases, (SEMICYUC-GTEIS); and infectious diseases and clinical microbiology-clinical diagnosis, (SEIMC-C)]. Results. A total of 700 valid surveys were collected from June to November 2019: 380 (54.3%) of SEMES, 127 (18.1%) of SEIMC-M, 97 (13.9%) de SEMICYUC-GTEIS and 96 (13.7%) of SEIMC-C, in 270 hospitals of all levels of care. The qSOFA score was used as a screening tool. The most used biomarker was procalcitonin (n=92, 39.8%). The sepsis code was implemented in 157 of 235 participating centers (66.2%), particularly in tertiary level hospitals. The mean frequency of contaminated blood cultures was 8.9% (8.7). In 85 (78.7%) centers, positive results of blood cultures were available within the first 72 hours and were communicated to the treating physician effectively by phone or e-mail in 76 (81.7%) cases. The main reason for escalating treatment was clinical deterioration, and the reason for de-escalating antimicrobials was significantly different between the specialties. Quality indicators were not frequently monitored among the different participating centers. Conclusion. There are significant barriers that hinder adequate management processes in sepsis in Spanish hospitals.Introducción. Este estudio tuvo como objetivo identificar las barreras comunes que conducen al retraso en el manejo inicial, el diagnóstico microbiológico y el tratamiento antimicrobiano empírico adecuado en la sepsis. Pacientes y métodos. Se realizó un estudio transversal mediante la aplicación de una encuesta de base poblacional. Se diseñaron cuatro encuestas diferentes, dirigidas al personal de salud ubicado en las principales áreas hospitalarias [urgencias (SEMES); enfermedades infecciosas y microbiología clínica-diagnóstico microbiológico (SEIMC-M); cuidados intensivos y enfermedades infecciosas (SEMICYUC-GTEIS); y enfermedades infecciosas y microbiología clínica-diagnóstico clínico, (SEIMC-C)]. Resultados. Se recogieron un total de 700 encuestas válidas de junio a noviembre de 2019: 380 (54,3%) de SEMES, 127 (18,1%) de SEIMC-M, 97 (13,9%) de SEMICYUC-GTEIS y 96 (13,7%) de la SEIMC-C, en 270 hospitales de todos los niveles de atención. El qSOFA se utilizó principalmente como herramienta de detección. El biomarcador más utilizado fue la procalcitonina (n=92, 39,8%). El código sepsis estaba implementado en 157 de 235 centros participantes (66,2%), particularmente en hospitales de tercer nivel. La frecuencia media de hemocultivos contaminados fue del 8,9% (8,7). En 85 (78,7%) de los centros, los resultados de los hemocultivos positivos estuvieron disponibles en las primeras 72 horas y se comunicaron al médico responsable del paciente por teléfono o correo electrónico en 76 casos (81,7%). El motivo principal de la escalada del tratamiento fue el deterioro clínico y el motivo de la desescalada de los antimicrobianos fue significativamente diferente entre las especialidades. Los indicadores de calidad no se monitorizaban con frecuencia en los diferentes centros. Conclusión. Existen importantes barreras que dificultan los procesos de manejo adecuado de la sepsis en los hospitales españoles.This research has received an unrestricted grant Beckton, Dickinson and Company (BD), S.A

Case report: Cytokine hemoadsorption in a case of hemophagocytic lymphohistiocytosis secondary to extranodal NK/T-cell lymphoma

Cytokine hemoadsorption; Hemophagocytic lymphohistiocytosis; Multiorgan dysfunctionHemoadsorció de citocines; Limfohistiocitosi hemofagocítica; Disfunció multiorgànicaHemoadsorción de citoquinas; Linfohistiocitosis hemofagocítica; Disfunción multiorgánicaWe discuss a single case of Hemophagocytic lymphohistiocytosis (HLH) due to NK-type non-Hodgkin lymphoma and Epstein-Barr virus reactivation with multiorgan dysfunction and distributive shock in which we performed cytokine hemoadsorption with Cytosorb ®. A full microbiological panel was carried out, including screening for imported disease, standard serologies and cultures for bacterial and fungal infection. A liver biopsy and bone marrow aspirate were performed, confirming the diagnosis. The patients fulfilled the HLH-2004 diagnostic criteria, and according to the 2018 Consensus Statements by the HLH Steering Committee of the Histiocyte Society, dexamethasone and etoposide were started. There was an associated hypercytokinemia and, due to refractory distributive shock, rescue therapy with cytokine hemoadsorption was performed during 24 h (within day 2 and 3 from ICU admission). After starting this procedure, rapid hemodynamic control was achieved with a significant reduction in vasopressor support requirements. This case report highlights that cytokine hemoadsorption can be an effective since rapid decrease in IL-10 levels and a significant hemodynamic improvement was achieved

Cytokine Hemoadsorption as Rescue Therapy for Critically Ill Patients With SARS-CoV-2 Pneumonia With Severe Respiratory Failure and Hypercytokinemia

Introduction: A dysregulated inflammatory response, known as "cytokine storm", plays an important role in the pathophysiology of coronavirus 2019 disease (COVID-19). Identifying patients with a dysregulated inflammatory response and at high risk for severe respiratory failure, organ dysfunction, and death is clinically relevant, as they could benefit from the specific therapies, such as cytokine removal by hemoadsorption. This study aimed to evaluate cytokine hemoadsorption as rescue therapy in critically ill patients with SARS-CoV-2 pneumonia, severe respiratory failure refractory to prone positioning, and hypercytokinemia. Methods: In this single center, observational and retrospective study, critically ill patients with SARS-CoV-2 pneumonia, severe acute respiratory failure, and hypercytokinemia were analyzed. All the patients underwent cytokine hemoadsorption using CytoSorb ® (Cytosorbents Europe, Berlin, Germany). The indication for treatment was acute respiratory failure, inadequate clinical response to the prone position, and hypercytokinemia. Results: Among a total of 343 patients who were admitted to the intensive care unit (ICU) due to SARS-CoV-2 infection between March 3, 2020 and June 22, 2020, six patients received rescue therapy with cytokine hemoadsorption. All the patients needed invasive mechanical ventilation and prone positioning. A significant difference was found in the pre- and post-treatment D-dimer (17,868 mcg/ml [4,196-45,287] vs. 4,488 mcg/ml [3,166-17,076], p = 0.046), C-reactive protein (12.9 mg/dl [10.6] vs. 3.5 mg/dl [2.8], p = 0.028), ferritin (1,539 mcg/L [764-27,414] vs. 1,197 ng/ml [524-3,857], p = 0.04) and interleukin-6 (17,367 pg/ml [4,539-22,532] vs. 2,403 pg/ml [917-3,724], p = 0.043) levels. No significant differences in the pre- and post-treatment interleukin-10 levels (22.3 pg/ml [19.2-191] vs. 5.6 pg/ml [5.2-36.6], p = 0.068) were observed. Improvements in oxygenation (prehemoadsorption PaO/FIO ratio 103 [18.4] vs. posthemoadsorption PaO/FIO ratio 222 [20.9], p = 0.029) and in the organ dysfunction (prehemoadsorption SOFA score 9 [4.75] vs. posthemoadsorption SOFA score 7.7 [5.4], p = 0.046) were observed. ICU and in-hospital mortality was 33.7%. Conclusions: In this case series, critically ill patients with COVID-19 with severe acute respiratory failure refractory to prone positioning and hypercytokinemia who received adjuvant treatment with cytokine hemoadsorption showed a significant reduction in IL-6 plasma levels and other inflammatory biomarkers. Improvements in oxygenation and SOFA score were also observe

Case report : Cytokine hemoadsorption in a case of hemophagocytic lymphohistiocytosis secondary to extranodal NK/T-cell lymphoma

We discuss a single case of Hemophagocytic lymphohistiocytosis (HLH) due to NK-type non-Hodgkin lymphoma and Epstein-Barr virus reactivation with multiorgan dysfunction and distributive shock in which we performed cytokine hemoadsorption with Cytosorb ®. A full microbiological panel was carried out, including screening for imported disease, standard serologies and cultures for bacterial and fungal infection. A liver biopsy and bone marrow aspirate were performed, confirming the diagnosis. The patients fulfilled the HLH-2004 diagnostic criteria, and according to the 2018 Consensus Statements by the HLH Steering Committee of the Histiocyte Society, dexamethasone and etoposide were started. There was an associated hypercytokinemia and, due to refractory distributive shock, rescue therapy with cytokine hemoadsorption was performed during 24 h (within day 2 and 3 from ICU admission). After starting this procedure, rapid hemodynamic control was achieved with a significant reduction in vasopressor support requirements. This case report highlights that cytokine hemoadsorption can be an effective since rapid decrease in IL-10 levels and a significant hemodynamic improvement was achieved

Coagulation management in patients requiring extracorporeal membrane oxygenation support: a comprehensive narrative review

Anticoagulation; Extracorporeal life support; ThrombosisAnticoagulación; Soporte vital extracorpóreo; TrombosisAnticoagulació; Suport vital extracorpòri; TrombosiBackground and Objective: Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy to support respiratory or cardiorespiratory function in critically ill patients when conventional treatments fail. The exposure of the patient’s blood components to the foreign surface of the ECMO extracorporeal circuit activates the inflammatory and coagulation cascades. Systemic anticoagulation is generally required to prevent thrombotic complications, assuming an increased risk of patient bleeding. Despite the increased biocompatibility of novel ECMO devices, the variety of anticoagulation drugs, and the different anticoagulation monitoring tools, there is no gold-standard hemostasis management in patients with extracorporeal life support (ECLS). We aimed to describe the underlying physiology as a rationale for the need for anticoagulation in ECMO. To describe the different alternatives for anticoagulation management, bleeding prevention, and the specific management of anticoagulation in different subgroups of patients, including coronavirus disease 2019 (COVID-19) patients. Methods: We conducted a comprehensive literature search in the main databases, including Cochrane Database, PubMed, Google Scholar, CINAHL, and Scopus databases, with no start date until December 1st, 2023. We reviewed articles written in English and Spanish. Key Content and Findings: Evolving evidence has been changing the current practices on anticoagulation in ECMO, and novel alternatives are available to decrease the bleeding risk in high-risk patients and for the management of bleeding complications. Conclusions: Anticoagulation practices in ECMO are ubiquitous though variable among different geographic areas. However, as clinical experience in ECMO patients increases, best practices can be reproduced among different settings to improve patient management and patient outcomes. Some challenges remain regarding the best anticoagulation strategy in specific groups of patients