Prior Carriage Predicts Intensive Care Unit Infections Caused by Extended-Spectrum Beta-Lactamase–Producing Enterobacteriaceae

Intensive care unit–acquired infection (ICU-AI) and extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-PE) carriage are a major concern worldwide. Our objective was to investigate the impact of ESBL-PE carriage on ICU-AI. Our study is prospective, observational, and noninterventional. It was conducted over a 5-year period (Jan 2013–Dec 2017) in the medical-surgical intensive care unit of the Cayenne General Hospital (French Amazonia). During the study period, 1,340 patients were included, 271 (20.2%) developed ICU-AI, and 16.2% of these were caused by ESBL-PE. The main sites of ICU-AI were ventilator-associated pneumonia (35.8%) and primary bloodstream infection (29.8%). The main responsible microorganisms were Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae (ESBL-P in 35.8% of isolates), and Enterobacter cloacae (ESBL-P in 29.8% of isolates). Prior ESBL-PE carriage was diagnosed in 27.6% of patients with ICU-AI. In multivariable analysis, the sole factor associated with ESBL-PE as the responsible organism of ICU-AI was ESBL-PE carriage before ICU-AI (P < 0.001; odds ratio: 7.9 95% CI: 3.4-18.9). ESBL-PE carriers (74 patients) developed ICU-AI which was caused by ESBL-PE in 32 cases (43.2%). This proportion of patients carrying ESBL-PE who developed ICU-AI to the same microorganism was 51.2% in ESBL-P K. pneumoniae, 5.6% in ESBL-P Escherichia coli, and 40% in ESBL-P Enterobacter spp. NPV of ESBL-PE carriage to predict ICU-AI caused by ESBL-PE was above 94% and PPV was above 43%. Carriage of ESBL-P K pneumoniae and Enterobacter spp. is a strong predictor of ICU-AI caused by these two microorganisms.

Nghiên cứu mức độ kháng kháng sinh của các vi khuẩn gram âm không lên men gây viêm phổi ở bệnh nhân thở máy

TÓM TẮT Đặt vấn đề: Viêm phổi liên quan thở máy là bệnh lý nhiễm khuẩn bệnh viện rất thường gặp trong đơn vị hồi sức tích cực. Có nhiều vi khuẩn gây viêm phổi liên quan thở máy, trong đó các vi khuẩn Gram âm không lên men như Acinetobacterbaumannii, Pseudomonasaeruginosa,.. là những vi khuẩn gây bệnh hàng đầu và có mức độ kháng kháng sinh cao. Phương pháp: Một nghiên cứu mô tả cắt ngang được thực hiện ở các chủng vi khuẩn Gram âm không lên men phân lập được từ các mẫu đờm của bệnh nhân thở máy trên 48 giờ điều trị tại các khoa Hồi sức tích cực - Ngoại khoa Bệnh viện Hữu nghị Đa khoa Nghệ An năm từ 1/2020 đến 6/2021. Kết quả: Phân lập được 120 chủng Vi khuẩn Gram âm không lên men, trong đó, Acinetobacter baumannii 85 chủng, Pseudomonas aeruginosa 31 chủng. Acinetobacter baumannii có mức độ đề kháng trên 70% với tất cả các kháng sinh thử nghiệm, trong đó kháng cao nhất với Ceftriaxone 96,9%. Pseudomonas aeriginosa kháng với tất cả các kháng sinh thử nghiệm, kháng cao nhất với Gentamycin 80,0%, kháng thấp nhất với Piperacillin/Tazobactam 32,3%. Kết luận: Vi khuẩn không lên men là những tác nhân chính gây viêm phổi liên quan thở máy, phổ biến nhất là Acinetobacter baumannii và Pseudomonas aeruginosa. Những vi khuẩn này kháng cao với các kháng sinh thử nghiệm, trong đó, A. baumannii kháng trên 70% các kháng sinh thử nghiệm, P. aeruginosa kháng tất cả kháng sinh thử nghiệm với mức độ khác nhau tử 32,3 - 80,0%. ABSTRACT ANTIBIOTIC RESISTANCE OF NON - FERMENTABLE GRAM - NEGATIVE BACTERIA CAUSING PNEUMONIA IN PATIENTS WITH MECHANICALLY VENTILATION Background: Ventilator - associated pneumonia is a very common nosocomial infection in the intensive care unit. Many bacteria cause ventilator - associated pneumonia, in which non - fermentative Gram - negative bacteria such as Acinetobacter baumannii, Pseudomonas aeruginosa, etc., are the leading pathogens and have high antibiotic resistance. Methods: A cross sectional descriptive study was conducted on non - fermentative bacteria strains causing ventilator - associated pneumonia which were isolated at the Surgical Intensive Care Unit Department of Nghe An General Friendship Hospital from January 2020 to June 2021. Results: A total of 120 strains of non - fermenting Gram - negative bacteria were isolated. Of these, 85 strains were Acinetobacter baumannii, 31 strains was Pseudomonas aeruginosa. Acinetobacter baumannii has a resistance rate of more than 70% with all tested antibiotics, of which the highest resistance is to Ceftriaxone 96.9%. Pseudomonas aeriginosa was resistant to all tested antibiotics, with the highest resistance to Gentamycin80.0%, the lowest resistance to Piperacillin/Tazobactam 32.3%. Conclusion: Non - fermentative bacteria are the main pathogens of ventilator - associated pneumonia. The most common pathogens were Acinetobacter baumannii and Pseudomonas aeruginosa. These bacteria were highly resistant to the tested antibiotics. In which, A. baumannii resisted over 70% of the tested antibiotics, and P. aeruginosa resisted all tested antibiotics with varying degrees from 32.3 to 80.0%. Keywords: Ventilation associated pneumonia, VAP, P. aeruginosa, A. baumannii.

Association of hyperchloremia with all-cause mortality in patients admitted to the surgical intensive care unit: a retrospective cohort study

Background Serum chloride (Cl−) is one of the most essential extracellular anions. Based on emerging evidence obtained from patients with kidney or heart disease, hypochloremia has been recognized as an independent predictor of mortality. Nevertheless, excessive Cl− can also cause death in severely ill patients. This study aimed to investigate the relationship between hyperchloremia and high mortality rate in patients admitted to the surgical intensive care unit (SICU). Methods We enrolled 2131 patients from the Multiparameter Intelligent Monitoring in Intensive Care III database version 1.4 (MIMIC-III v1.4) from 2001 to 2012. Selected SICU patients were more than 18 years old and survived more than 72 h. A serum Cl− level ≥ 108 mEq/L was defined as hyperchloremia. Clinical and laboratory variables were compared between hyperchloremia (n = 664) at 72 h post-ICU admission and no hyperchloremia (n = 1467). The Locally Weighted Scatterplot Smoothing (Lowess) approach was utilized to investigate the correlation between serum Cl- and the thirty-day mortality rate. The Cox proportional-hazards model was employed to investigate whether serum chlorine at 72 h post-ICU admission was independently related to in-hospital, thirty-day and ninety-day mortality from all causes. Kaplan-Meier curve of thirty-day and ninety-day mortality and serum Cl− at 72 h post-ICU admission was further constructed. Furthermore, we performed subgroup analyses to investigate the relationship between serum Cl− at 72 h post-ICU admission and the thirty-day mortality from all causes. Results A J-shaped correlation was observed, indicating that hyperchloremia was linked to an elevated risk of thirty-day mortality from all causes. In the multivariate analyses, it was established that hyperchloremia remained a valuable predictor of in-hospital, thirty-day and ninety-day mortality from all causes; with adjusted hazard ratios (95% CIs) for hyperchloremia of 1.35 (1.02 ~ 1.77), 1.67 (1.28 ~ 2.19), and 1.39 (1.12 ~ 1.73), respectively. In subgroup analysis, we observed hyperchloremia had a significant interaction with AKI (P for interaction: 0.017), but there were no interactions with coronary heart disease, hypertension, and diabetes mellitus (P for interaction: 0.418, 0.157, 0.103, respectively). Conclusion Hyperchloremia at 72 h post-ICU admission and increasing serum Cl− were associated with elevated mortality risk from all causes in severely ill SICU patients.

Charlson Comorbidity Index: A Critical Review of Clinimetric Properties

The present critical review was conducted to evaluate the clinimetric properties of the Charlson Comorbidity Index (CCI), an assessment tool designed specifically to predict long-term mortality, with regard to its reliability, concurrent validity, sensitivity, incremental and predictive validity. The original version of the CCI has been adapted for use with different sources of data, ICD-9 and ICD-10 codes. The inter-rater reliability of the CCI was found to be excellent, with extremely high agreement between self-report and medical charts. The CCI has also been shown either to have concurrent validity with a number of other prognostic scales or to result in concordant predictions. Importantly, the clinimetric sensitivity of the CCI has been demonstrated in a variety of medical conditions, with stepwise increases in the CCI associated with stepwise increases in mortality. The CCI is also characterized by the clinimetric property of incremental validity, whereby adding the CCI to other measures increases the overall predictive accuracy. It has been shown to predict long-term mortality in different clinical populations, including medical, surgical, intensive care unit (ICU), trauma, and cancer patients. It may also predict in-hospital mortality, although in some instances, such as ICU or trauma patients, the CCI did not perform as well as other instruments designed specifically for that purpose. The CCI thus appears to be clinically useful not only to provide a valid assessment of the patient’s unique clinical situation, but also to demarcate major diagnostic and prognostic differences among subgroups of patients sharing the same medical diagnosis.

Epidemiological profile of postoperative digestive fistulas

Background and objectives: Gastrointestinal fistulas are anomalous communications between the digestive system and other structures. This article presents the epidemiological profile of patients who developed postoperative abdominal fistulas and their outcomes. Methods: Cross-sectional study that evaluated surgical procedures done in a 25 week period that presented risks for fistulous formations. Were analyzed age, type of the surgery (elective or urgent), pre-existing risk factors, need for post-surgical intensive care unit, type of fistula, reoperations to the fistula treatment, and outcome (discharge or death). Results: There were 1785 abdominal surgical procedures, with a fistula incidence of 1.8%. Most of the patients who developed fistulas were over 60 years old (71.4%), and surgeries that resulted in fistulous complications were mainly urgent (75.0%), with the need for intensive care in 46.9%. The most frequent types of fistula were enteral (52.3%) and biliary (23.8%), and surgical treatment took place in 53.1% of cases. Late hospital discharge was predominant in these patients (40.6%), and the death rate was 3.1%. Discussion: These complications are common after abdominal surgery and require clinical attention. There is a correlation between the formation of the fistulas and urgent surgery procedures, directly impacting the length of hospital stay. Conclusion: The risk factors of fistula development are advanced age and the presence of malignant disease. They are more prevalent in urgent surgeries and patients were more likely to need reoperation and have a delay on discharge.

Prophylactic Enoxaparin in Critically Ill Trauma Patients: Evaluation of the Initial Dose

Background: Trauma patients are at increased risk of developing venous thromboembolism given alterations in the coagulation cascade. Chemoprophylaxis with standard dosing of enoxaparin 30 mg subcutaneously twice daily has evolved to incorporate the use of anti-factor Xa (AFXa) trough level monitoring given concerns for decreased enoxaparin bioavailability in this patient population. Current available evidence suggests low rates of goal AFXa trough level achievement with standard enoxaparin dosing. Our study aims to identify the incidence of critically ill trauma patients that did not achieve goal AFXa trough levels and attempts to identify predictors that may influence the lack of achievement of goal levels. Methods: This was a retrospective, cohort analysis performed at a single academic medical center. Adult patients 18 years or older admitted to the surgical intensive care unit secondary to trauma who were initiated on standard prophylactic enoxaparin and had at least 1 AFXa trough level representative of steady state were included. Patient demographics and clinical data were collected, and descriptive statistics were utilized. All statistical tests were 2-tailed and a P < .05 was considered significant. Variables with a P < .10 on univariable analysis were included in a multivariable logistic regression analysis. Results: A majority of our patient population did not achieve goal AFXa trough levels while receiving standard doses of prophylactic enoxaparin (82.4% [108/131]). Sub-target AFXa levels were associated with higher creatinine clearance values. Positive predictors of obtaining target AFXa levels included automobile versus pedestrian mechanism of injury and requiring an enoxaparin dose escalation to at least 40 mg twice daily. Conclusions: Our study found low rates of achievement of goal AFXa trough levels in critically ill trauma patients receiving standard prophylactic enoxaparin dosing. Certain variables were identified as negative and positive predictors for achievement of goal AFXa trough levels, although the biologic plausibility of these predictors is questionable and requires further investigation.