Microbial Environmental Pollution in ICUs: Results, Trends, and Suggestions from a Long-Lasting Surveillance

Intensive care units (ICUs) are special areas in hospitals for patients with severe and life-threatening diseases. ICUs are of several categories, such as neonatal ICUs, cardiac ICUs, neurological ICUs, surgical ICUs, etc. The ICUs’ patients may show a high susceptibility for hospital-acquired infections (HAIs) depending on underlying disease, duration of stay and treatment. ICUs are considered potential reservoirs for (opportunistic) pathogenic microbial strains and the risk of acquiring infection in these hospital environments is higher than in others. Several studies show the role of inanimate surface and equipment contamination in the transmission of pathogens to ICU patients. The aim of this study is to describe the results of 124 sampling campaigns performed during 12 years of microbiological surveillance of five ICUs of different categories, for an overall number of 714 samples (232 from air and 482 from surface), to analyze their trends and to elaborate suggestions to improve ICUs’ environmental quality and patients’ safety.

Phenotypic and Genotypic Evaluation of Antibiotic Resistance of Acinetobacter baumannii Bacteria Isolated from Surgical ICU Patients in Pakistan

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a significant nosocomial pathogen, causing serious threats concerning community-wide outbreaks globally, as well as in Pakistan. Antimicrobial resistance in A. baumannii is increasing day by day. Objectives: The study aimed to find out the antibiotic resistance (AMR) patterns and evaluate the AMR genes in clinical isolates from patients admitted to the surgical Intensive Care units (ICUs) at different hospitals in Lahore, Pakistan. Methods: A total of 593 clinical specimens were collected from patients admitted to the surgical ICUs of three different local hospitals in Lahore, Pakistan. From these samples, a total of 90 A. baumannii isolates were identified and further investigated to observe phenotypic resistance patterns and detect carbapenemases resistance genes. Results: The results showed that phenotypic resistance against amikacin was 27.2%, ceftriaxone 100%, ceftazidime 27.2%, cefepime 63.3%, ciprofloxacin and co-trimoxazole 100%, gentamicin 40%, imipenem 22.2%, meropenem 21.1%, piperacillin-tazobactam 27.2%, tigecycline 27.2%, and tetracycline 63.3%. All A. baumannii isolates were found to be sensitive to colistin (CT), polymixin-B (PB), and tobramycin (TOB). The PCR amplification of carbapenemases genes revealed the prevalence of blaOXA-23, blaOXA-51, and blaOXA-40 in 73, 90, and 64.4% of the isolates, respectively, along with blaNDM1 (92.2%), blaVIM (40%), blaIMP (90%), ISAba1 (85.5%), sul1 (16.6%), sul2 (20%), armA (32.2%), and PER-1 (12%) while the blaOXA-24 and blaOXA-58 genes were not detected in the isolates. The sequence analysis of the blaOXA-23 and blaOXA-51 genes showed 98% and 95% similarity with previously reported sequences in the GenBank database. Conclusions: The present study indicated that the emergence of high carbapenem resistance in CRAB isolates has increased, which may pose serious limitations in the choice of drugs for nosocomial infections.

Impact of Cardiovascular Failure in Intensive CareUnit-Acquired Pneumonia: A Single-Center, Prospective Study

Background: Cardiovascular failure (CVF) may complicate intensive care unit-acquired pneumonia (ICUAP) and radically alters the empirical treatment of this condition. The aim of this study was to determine the impact of CVF on outcome in patients with ICUAP. Methods: A prospective, single-center, observational study was conducted in six medical and surgical ICUs at a University Hospital. CVS was defined as a score of 3 or more on the cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score. At the onset of ICUAP, CVF was reported as absent, transient (if lasting ≤ 3 days) or persistent (>3 days). The primary outcome was 90-day mortality modelled through a Cox regression analysis. Secondary outcomes were 28-day mortality, hospital mortality, ICU length of stay (LOS) and hospital LOS. Results: 358 patients were enrolled: 203 (57%) without CVF, 82 (23%) with transient CVF, and 73 (20%) with persistent CVF. Patients with transient and persistent CVF were more severely ill and presented higher inflammatory response than those without CVF. Despite having similar severity and aetiology, the persistent CVF group more frequently received inadequate initial antibiotic treatment and presented more treatment failures than the transient CVF group. In the persistent CVF group, at day 3, a bacterial superinfection was more frequently detected. The 90-day mortality was significantly higher in the persistent CVF group (62%). The 28-day mortality rates for patients without CVF, with transient and with persistent CVF were 19, 35 and 41% respectively and ICU mortality was 60, 38 and 19% respectively. In the multivariate analysis chronic pulmonary conditions, lack of Pa02/FiO2 improvement at day 3, pulmonary superinfection at day 3 and persistent CVF were independently associated with 90-day mortality in ICUAP patients. Conclusions: Persistent CVF has a significant impact on the outcome of patients with ICUAP. Patients at risk from persistent CVF should be promptly recognized to optimize treatment and outcomes.

Association between phosphate disturbances and mortality among critically ill patients with sepsis or septic shock

Objective The aim of this study is to examine the association of hypophosphatemia and hyperphosphatemia on the first day of ICU admission with mortality in septic critically ill patients. Methods In this retrospective cohort study, all adult patients who were admitted to the medical-surgical ICUs between 2014 and 2017 with sepsis or septic shock were categorized as having hypophosphatemia, normophosphatemia and hyperphosphatemia based on day 1 serum phosphate values. We compared the clinical characteristics and outcomes between the three groups. We used multivariate analysis to examine the association of hypophosphatemia and hyperphosphatemia with these outcomes. Results Of the 1422 patients enrolled in the study, 188 (13%) had hypophosphatemia, 865 (61%) normophosphatemia and 369 (26%) had hyperphosphatemia. The patients in the hyperphosphatemia group had significantly lower GCS, higher APACHE II scores, higher serum creatinine, increased use of vasopressors, and required more mechanical ventilation with lower PaO2/FiO2 ratio compared with the other two groups. In addition, the hyperphosphatemia group showed significantly higher ICU and hospital mortality in comparison with the other two groups. Conclusion Hyperphosphatemia and not hypophosphatemia on the first ICU admission day was associated with an increase in the ICU and hospital mortality in septic critically ill patients.

EXTERNAL VALIDATION OF A NOVEL DIGITAL SIGNATURE IN CONTINUOUS CARDIORESPIRATORY MONITORING TO DETECT EARLY RESPIRATORY DETERIORATION OF ICU PATIENTS

The goal of predictive analytics monitoring is the early detection of patients at high risk of subacute potentially catastrophic illnesses. A good example of a target illness is respiratory failure leading to urgent unplanned intubation, where early detection might lead to interventions that improve patient outcome. Previously, we identified signatures of this illness in the continuous cardiorespiratory monitoring data of Intensive Care Unit patients and devised algorithms to identify patients at rising risk. Here, we externally validated 3 logistic regression models to estimate risk of emergency intubation that were developed in Medical and Surgical ICUs at the University of Virginia. We calculated the model outputs for more than 8000 patients in University of California San Francisco ICUs, 240 of whom underwent emergency intubation as determined by individual chart review. We found that the AUC of the models exceeded 0.75 in this external population, and that the risk rose appreciably over the 12 hours prior to the event. We conclude that abnormal signatures of respiratory failure in the continuous cardiorespiratory monitoring are a generalizable phenomenon.

Association Between Phosphate Disturbances and Mortality Among Critically Ill Patients With Sepsis or Septic Shock

Objective: The aim of this study is to examine the association of hypophosphatemia and hyperphosphatemia on the first day of ICU admission with mortality in septic critically ill patients. Methods: In this retrospective cohort study, all adult patients who were admitted to medical-surgical ICUs between 2014 and 2017 with sepsis or septic shock were categorized as having hypophosphatemia, hyperphosphatemia or based on day 1 serum phosphate values. We compared the clinical characteristics and outcomes between the three groups. We used multivariate analysis to examine the association of hypophosphatemia and hyperphosphatemia with these outcomes.Results: Of the 1422 patients enrolled in the study, 188 (13%) had hypophosphatemia, 865 (61%) normophosphatemia and 369 (26%) had hyperphosphatemia. Among the three groups, the patients in the hyperphosphatemia group had significantly lower GCS, higher APACHE II scores, higher serum creatinine, increased use of vasopressors, and required mechanical ventilation with lower PaO2/FiO2 ratio compared with the other two groups. In addition, hyperphosphatemia group also showed significantly higher ICU mortality and hospital mortality in comparison to the other two groups. Conclusion: Hyperphosphatemia and not hypophosphatemia on the first ICU admission day was associated with an increase in the ICU and hospital mortality in septic critically ill patients.

Frequency and characteristics of multi-resistant bacteria in the intensive care unit

Introduction: Patients in intensive care units (ICUs) are at higher risk of infections due to invasive procedures and antibiotic therapy. Infections caused by multidrug-resistant (MDR) bacteria represent a global problem, limiting the choice of antimicrobial therapy. Objective: To determine the rate of infections in ICUs, as well as the type of MDR bacteria associated with such infections. Material and methods: The study included strains of MDR bacteria isolated from laboratory samples of hospitalized patients in surgical ICUs in a one-year period. All strains of MDR bacteria were isolated and identified by standard microbiological methods for aerobic bacteria according to the recommendations and guidelines are given by the Clinical and Laboratory Standards Institute (CLSI). Results: Infections caused by MDR bacterial isolates were confirmed in 199 (19.17%) patients in ICUs. The frequency of Gram-negative isolates was significantly higher than Gram-positive (88.35% and 11.65%, p <0.001). The most common infections in ICUs caused by MDR bacteria were respiratory tract infections (49%), followed by soft tissue and skin infections. The CDI incidence density 1.13 cases/10,000 patient-days. Conclusion: A high frequency of infections caused by MDR bacteria was found with patients in ICUs, and respiratory tract infections dominated. Information on the types of infections and pathogens can help develop policies for prevention, diagnosis, treatment, and resource allocation.

Trends in the Epidemiology of Candidemia in Intensive Care Units From 2006 to 2017: Results From the Korean National Healthcare-Associated Infections Surveillance System

Candidemia is an important healthcare-associated infection (HAI) in intensive care units (ICUs). However, limited research has been conducted on candidemia in the Republic of Korea. We aimed to analyze the secular trends in the incidence and distribution of candidemia in ICUs over 12-years using data from the Korean National Healthcare-Associated Infections Surveillance System (KONIS). KONIS was established in 2006 and has performed prospective surveillance of HAIs including bloodstream infections (BSIs) in ICUs. We evaluated the trends in the distribution of causative pathogens and the incidence of candidemia. From 2006 to 2017, 2,248 candidemia cases occurred in 9,184,264 patient-days (PDs). The pooled mean incidence rates of candidemia significantly decreased from 3.05 cases/10,000 PDs in 2006 to 2.5 cases/10,000 PDs in 2017 (P = 0.001). Nevertheless, the proportion of candidemia gradually increased from 15.2% in 2006 to 16.6% in 2017 (P = 0.001). The most frequent causative pathogen of BSIs from 2006 to 2012 was Staphylococcus aureus; however, Candida spp. emerged as the most frequent causative pathogen since 2013. C. albicans (39.9%) was the most common among Candida spp. causing BSIs, followed by Candida tropicalis (20.2%) and Candida parapsilosis (18.2%). The proportion of candidemia caused by C. glabrata significantly increased from 8.9% in 2006 to 17.9% in 2017 (P &lt; 0.001). There was no significant change in the distribution of Candida spp. by year (P = 0.285). The most common source of BSIs was central lines associated BSI (92.5%). There was a significant increase in the proportion of candidemia by year in hospitals with organ transplant wards (from 18.9% in 2006 to 21.1% in 2017, P = 0.003), hospitals with &lt;500 beds (from 2.7% in 2006 to 13.6% in 2017, P &lt; 0.001), and surgical ICUs (from 16.2% in 2006 to 21.7% in 2017, P = 0.003). The proportion of candidemia has increased in Korea, especially in hospitals with &lt;500 beds and surgical ICUs. Thus, appropriate infection control programs are needed.

Inapropriate Use of Antibiotics Effective Against Gram Positive Microorganism in Under Restrictive Antibiotic Policies in ICU; A Prospective Observational Study

Background Gram-positive spectrum antibiotics such as vancomycin, teicoplanin, daptomycin ,and linezolid are frequently used in empirical treatment combinations in critically ill patients Although they are included in the national antibiotic restriction program, thought to be inappropriate, unnecessary and suboptimal use is high due to their widespread use. In our study, in addition to their widespread use, gram-positive spectrum antibiotics were evaluated due to their use in more limited and clear clinical indications. This study aims to determine the frequency of inappropriate uses of gram-positive spectrum antibiotics and risk factors for inappropriate use according to different quality parameters. Methods This clinical study was conducted prospectively between 01.10.2018 and 01.10.2019 in the medical and surgical ICUs of Gazi University Faculty of Medicine Hospital with a total bed capacity of 55. Patients older than 18 years of age onset of gram-positive spectrum antibiotics (vancomycin, teicoplanin, linezolid ,and daptomycin) were included. Patients under the age of eighteen or immunosuppressed (neutropenic, HIV-infected patients with hematologic or solid organ malignancies) were not included in the study. The demographic and clinical features of the patients were recorded. The treatment was also evaluated and recorded by 2 infectious diseases specialists and 2 clinical pharmacists except for the clinical staff at 24-hour intervals from the first day to the last day of treatment. SPSS software for Windows, version 17 (IBM, Armonk, NY) was used to analyze the data. Categorical variables are presented as number and percentage, and non-categorical variables are presented as mean ± standard deviation. Results In the use of antibiotics, the incidence of non-compliance with at least one of the determined quality parameters was 83%. Multivariate analysis was performed to evaluate risk factors for inappropriate antibiotic use, and creatine values ​​were found to increase the risk of inappropriate antibiotic use. Conclusions In spite of the restricted antibiotic program, inappropriate antibiotic use in ICUs is quite common. In particular, it is necessary to establish local guidelines in collaboration with different disciplines for the determination and follow-up of de-escalation and optimal treatment doses

Inapropriate Use of Antibiotics Effective Against Gram Positive Microorganism in Under Restrictive Antibiotic Policies in ICU; A Prospective Observational Study

Background Gram-positive spectrum antibiotics such as vancomycin, teicoplanin, daptomycin ,and linezolid are frequently used in empirical treatment combinations in critically ill patients Although they are included in the national antibiotic restriction program, thought to be inappropriate, unnecessary and suboptimal use is high due to their widespread use. In our study, in addition to their widespread use, gram-positive spectrum antibiotics were evaluated due to their use in more limited and clear clinical indications. This study aims to determine the frequency of inappropriate uses of gram-positive spectrum antibiotics and risk factors for inappropriate use according to different quality parameters. Methods This clinical study was conducted prospectively between 01.10.2018 and 01.10.2019 in the medical and surgical ICUs of Gazi University Faculty of Medicine Hospital with a total bed capacity of 55. Patients older than 18 years of age onset of gram-positive spectrum antibiotics (vancomycin, teicoplanin, linezolid ,and daptomycin) were included. Patients under the age of eighteen or immunosuppressed (neutropenic, HIV-infected patients with hematologic or solid organ malignancies) were not included in the study. The demographic and clinical features of the patients were recorded. The treatment was also evaluated and recorded by 2 infectious diseases specialists and 2 clinical pharmacists except for the clinical staff at 24-hour intervals from the first day to the last day of treatment. SPSS software for Windows, version 17 (IBM, Armonk, NY) was used to analyze the data. Categorical variables are presented as number and percentage, and non-categorical variables are presented as mean ± standard deviation. Results In the use of antibiotics, the incidence of non-compliance with at least one of the determined quality parameters was 83%. Multivariate analysis was performed to evaluate risk factors for inappropriate antibiotic use, and creatine values ​​were found to increase the risk of inappropriate antibiotic use. Conclusions In spite of the restricted antibiotic program, inappropriate antibiotic use in ICUs is quite common. In particular, it is necessary to establish local guidelines in collaboration with different disciplines for the determination and follow-up of de-escalation and optimal treatment doses Keywords:Antibiotic stewardship, rational antibiotic use, antibiotic resistance, gram positive microorganism, inapropriate use of antibiotics