A Di Filippo

Continuous Infusion of Vancomycin in Methicillin- Resistant Staphylococcus Infection

Objective: The aim of the study was to verify the therapeutic response of vancomycin in methicillin-resistant staphylococcus infection (MRSA/MRCNS) administered according to two different methods (intermittent infusion vs. continuous infusion). Method: Experimental plan: retrospective study; study environment: university hospital, two intensive care units. Twenty-five critically ill patients submitted to antibiotic treatment with vancomycin for infection from MRSA/MRCNS were studied. The patients, who were classified according to SAPS II scores, were divided into two groups: group A (n = 14): dose of vancomycin of 0.5 g × 4/day and group B (n = 11): dose of 2 g/day of vancomycin administered in a continuous infusion. Before the antibiotic therapy was started (T1) and prior to its end (T2), the following parameters were evaluated: degree of impairment of the main organs and systems by means of sepsis-related organ failure assessment score (SOFA) and count of the white blood cells (WBC). The length of the hospital stay during intensive care was calculated for both groups (statistics: Student t test). Results: No significant differences were found in the SAPS II scores and in the length of the hospital stay. In a comparison of the T1 and T2 results, we noted that patients of group A had no variations in the SOFA scores (4.84 ± 2.48 vs. 4 ± 3.9) and in the WBC mean values (12,415 ± 5,099 vs. 12,841 ± 6,864 cells/mm3). In contrast, in the patients of group B, we noted significant variations (p < 0.05) in the mean values of the SOFA scores (6.62 ± 2.2 vs. 4.37 ± 3.5) and in the mean values relative to the WBC count (17,242 ± 12,842 vs. 10,757 ± 3,610 cells/mm3). Conclusions: In critically ill patients suffering from MRSA/MRCNS infection, vancomycin administration in continuous infusions improved organ function and leukocyte response, but did not seem to modify the overall evolution of the disease.

Glomerular permeability and trauma: A correlation between microalbuminuria and Injury Severity Score

OBJECTIVE To determine if there is a correlation between an increase in glomerular permeability, the magnitude of trauma, and the severity of illness. DESIGN Prospective study. SETTING Two university hospital intensive care units. PATIENTS Forty consecutive critically ill trauma patients admitted directly to the intensive care unit within 120 mins of their injuries. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For each patient, urine was collected from the time of admission until 7 am the next day. Within 48 hrs, only one sample of all urine collected (5 mL) was examined for microalbuminuria and urinary creatinine. Results were expressed as the microalbuminuria/urinary creatinine ratio (MACR). The mortality rate in the intensive care unit, Injury Severity Score at the moment of admission, Acute Physiology and Chronic Health Evaluation III score, and Simplified Acute Physiology Score in the first 24 hrs were calculated for each patient. The data were analyzed using the Pearson test for linear regression and Students t-test. During the first 24 hrs after trauma, there was an increase of MACR (6.9 +/- 0.6 mg/mmol) above normal (reference range, <3 mg/mmol) that was positively correlated with Injury Severity Score (31.4 +/- 1.9; r2 = .73, p < .05). However, there was no correlation between MACR, Acute Physiology and Chronic Health Evaluation III score, Simplified Acute Physiology Score, and mortality rate. CONCLUSIONS Patients with trauma show an increase in glomerular permeability during the first 24 hrs after injury. The magnitude of this increase is correlated with the extent of trauma but does not seem significant enough to be predictive of severity of illness and/or outcome.

Low-dose dopamine in kidney transplantation.

BACKGROUND The use of low-dose dopamine (LDD; 0.5-2.5 mug/kg/min) in kidney transplant recipients seeks to increase urine output, prevent arterial vasospasm, and reduce the incidence of acute tubular necrosis. The aim of this study was to evaluate the effect of LDD in the early postoperative period (12 hours) among kidney transplant recipients. METHODS We studied all kidney transplant recipients admitted to the Intensive Care Unit (ICU) in the early postoperative period from January 2004 to December 2008. A total of 105 patients were retrospectively assigned to two groups: group A (n = 57) was treated with LDD and group B (n = 48), not treated with LDD. All patients otherwise received the same therapy. Blood sample analysis and kidney function were recorded at 0, 6, and 12 hours after admission. For each patient, we collected the following data: donor and transplant kidney features, recipient demographics, intraoperative events, hemodynamic and kidney function parameters in the ICU, and outcomes. Patients were followed for 6 months after ICU discharge. RESULTS Hourly diuresis and kidney function parameters showed no significant difference between the groups. Significant differences between group A and group B were observed in heart rate (92.63 +/- 14.18 vs 82.87 +/- 13.5, respectively), hours of ICU length of stay (29.0 +/- 17.42 vs 20.43 +/- 7.35, respectively), and 6-month mortality rate (8.8% vs 0%, respectively; P < .05). CONCLUSION LDD prescription in kidney transplantation neither improved kidney function during the postoperative period nor short-term outcomes, but was associated with an increased heart rate, ICU length of stay and 6-month mortality.

Device-Related Infections in Critically Ill Patients. Part II: Prevention of Ventilator-Associated Pneumonia and Urinary Tract Infections

Abstract Device utilization in critically ill patients is responsible for a high risk of complications such as catheter-related bloodstream infections (CRBSI), ventilator-associated pneumonia (VAP) and urinary tract infections (UTI). In this article we will review the current status of data regarding the prevention of VAP and UTI. The results of the more recent (5 years) randomized controlled trials are reviewed and discussed. General recommendations include staffeducation and use of a surveillance program with a restrictive antibiotic policy. Adequate time must be allowed for hand washing and barrier precautions must always be used during device manipulation. Specific measures for VAP prevention are: 1) use of multi-use, closed-system suction catheters; 2) no routine change of the breathing circuit; 3) lubrication of the cuffof the endotracheal tube (ET) with a water-soluble gel; 4) maintenance of patient in semi-recumbent position to improve chest physiotherapy in intubated patients. Specific measures for UTI prevention include: 1) use of a catheter-valve instead of a standard drainage system; 2) use of a silver-alloy, hydro gel-coated latex urinary catheter instead of uncoated catheters. Biofilm represents a new variable: the capacity of bacteria to organize a biofilm on a device surface can explain the difficulty in preventing and eradicating an infection in a critically ill patient. More clinical trials are needed to verify the efficacy of prevention measures of ICU infections.

Sevoflurane low‐flow anaesthesia: best strategy to reduce Compound A concentration

Background: To define the best strategy to reduce Compound A production in Sevoflurane low‐flow anaesthesia by experiments in vitro and in vivo of different absorbers and different anaesthesia machines.

What is the role of streptogramins in intensive care

The combination of two injectable streptogramins, quinupristin/dalfopristin, provides a new pharmacological choice proven to be therapeutically efficacious against most Gram-positive, multi-resistant microorganisms. They have been shown to be efficacious above all in critically ill patients hospitalized in intensive care who have unique alterations in homeostasis that makes tissue penetration of various pharmacological antimicrobials difficult. In cases of infection localized in difficult-to-treat sites, the combination with other drugs, such as cefepime, a glycopeptide or linezolid, is able to potentiate the action of the streptogramin with positive results which allow resolution of the illness. In this article, we review data from the literature on the use of quinupristin/dalfopristin in the treatment of Gram-positive, multi-resistant infections in critically ill patients.Summary The combination of two injectable streptogramins, quinupristin/dalfopristin, provides a new pharmacological choice proven to be therapeutically efficacious against most Gram-positive, multi-resistant microorganisms. They have been shown to be efficacious above all in critically ill patients hospitalized in intensive care who have unique alterations in homeostasis that makes tissue penetration of various pharmacological antimicrobials difficult. In cases of infection localized in difficult-to-treat sites, the combination with other drugs, such as cefepime, a glycopeptide or linezolid, is able to potentiate the action of the streptogramin with positive results which allow resolution of the illness. In this article, we review data from the literature on the use of quinupristin/dalfopristin in the treatment of Gram-positive, multi-resistant infections in critically ill patients.

Intraoperative positive fluid balance improves tissue diffusion of ceftizoxime

Aim of Study: To demonstrate that administration of fluids and the consequent improvement of fluid balance during a surgical procedure can modify the tissue diffusion of ceftizoxime. Methods: Twenty-eight patients (30–79 years) undergoing major abdominal surgery of the colon were administered ceftizoxime 30 mg/kg i.v. at induction of anesthesia. A sample of arterial blood was taken before administration of the drug (t₀) and then again at the time of vascular occlusion of the colon segment to be removed (t1). A sample of the segment of removed colon was taken. The patients were divided into two groups on the basis of the fluid balance between t₀ and t1: group A (n = 17) with a fluid balance <1,000 ml and group B (n = 11) with a fluid balance >1,000 ml. The parameters evaluated in each group were: weight, height and age of the patients, serum and tissue antibiotic concentration, percent ratio of serum and tissue concentration, time elapsed between t₀ and t1, volume of administered fluids between t₀ and t1, diuresis and hourly diuresis between t₀ and t1 and body fluid distribution, obtained using a bioelectrical impedance analyzer. The mean results obtained in the two groups were then compared using Student’s t test. Results: The balance of fluids calculated up to t1 was 675 ± 308 ml for group A and 1,411 ± 405 ml for group B (p < 0.01). The means of the recorded values that showed statistically significant differences were: mean percent concentration ratio (43.6 ± 8.4 vs. 84 ± 16%; p < 0.05), concentration in the colonic segment (16.3 ± 7.9 vs. 37.2 ± 25.9 mg/ml; p < 0.05), urinary volume gathered up to t1 (538 ± 557 vs. 169 ± 104 ml; p < 0.05), hourly urinary volume up to t1 (311.1 ± 296 vs. 97.6 ± 77.9 ml/h; p < 0.05), percent variation of resistance (95.1 ± 5.1 vs. 89.7 ± 8.6; p < 0.05). The other means did not show any significant statistical differences. Conclusions: A higher tissue water level seems to facilitate the penetration of the antibiotic into the tissue according to the pharmacokinetic characteristics of ceftizoxime: high amount of free drug (not bound to plasma proteins) and high hydrosolubility.

Device-related infections in critically ill patients. Part I: Prevention of catheter-related bloodstream infections.

Abstract Device utilization in critically ill patients is responsible for a high risk of complications such as catheter-related bloodstream infections (CRBSI), ventilator-associated pneumonia (VAP) and urinary tract infections (UTI). In this article we will review the current status of data regarding CRBSI prevention. General recommendations include staffeducation and use of a surveillance program with a restrictive antibiotic policy. Adequate time must be allowed for hand washing and barrier precautions must always be used during device manipulation. The routine changing of central catheters is not necessary and increases costs; it is necessary to decrease the handling of administration sets, to use a more careful insertion technique and less frequent set replacement. Antiseptic-coated catheters appear to reduce catheter colonization but their ability to prevent catheter-related infections requires further demonstration. More clinical trials are needed to verify the efficacy of measures to prevent CRBSI.

Quale Ruolo per le Streptogramine in Terapia Intensiva

RiassuntoL’associazione di due streptogramine iniettabili, quinupristin/dalfopristin, rappresenta una nuova opzione farmacologica che ha dimostrato un’efficacia terapeutica contro la maggior parte dei microrganismi Gram-positivi multiresistenti. Questa azione si e dimostrata efficace soprattutto nel paziente critico ricoverato in terapia intensiva, che presenta alterazioni particolari dell’omeostasi che rendono difficile la penetrazione tissutale dei diversi farmaci antimicrobici.Nei casi di infezione localizzata in una sede che e di per se causa di difficile eradicazione, la combinazione con altri farmaci come cefepime, glicopeptidi e linezolid e in grado di potenziare l’azione delle streptogramine con esito positivo per la risoluzione della malattia.In questo articolo vengono revisionati i dati della letteratura che fanno riferimento all’uso di quinupristin/dalfopristin nel trattamento delle infezioni da Grampositivi multiresistenti nel paziente critico.Riassunto L’associazione di due streptogramine iniettabili, quinupristin/dalfopristin, rappresenta una nuova opzione farmacologica che ha dimostrato un’efficacia terapeutica contro la maggior parte dei microrganismi Gram-positivi multiresistenti. Questa azione si è dimostrata efficace soprattutto nel paziente critico ricoverato in terapia intensiva, che presenta alterazioni particolari dell’omeostasi che rendono difficile la penetrazione tissutale dei diversi farmaci antimicrobici. Nei casi di infezione localizzata in una sede che è di per sé causa di difficile eradicazione, la combinazione con altri farmaci come cefepime, glicopeptidi e linezolid è in grado di potenziare l’azione delle streptogramine con esito positivo per la risoluzione della malattia. In questo articolo vengono revisionati i dati della letteratura che fanno riferimento all’uso di quinupristin/dalfopristin nel trattamento delle infezioni da Grampositivi multiresistenti nel paziente critico.