Alberto Sandiumenge

Variation in critical care services across North America and Western Europe

Objective:Critical care represents a large percentage of healthcare spending in developed countries. Yet, little is known regarding international variation in critical care services. We sought to understand differences in critical care delivery by comparing data on the distribution of services in eight countries. Design:Retrospective review of existing national administrative data. We identified sources of data in each country to provide information on acute care hospitals and beds, intensive care units and beds, intensive care admissions, and definitions of intensive care beds. Data were all referenced and from as close to 2005 as possible. Setting:United States, France, United Kingdom, Canada, Belgium, Germany, The Netherlands, and Spain. Patients:Not available. Interventions:None. Measurements and Main Results:No standard definition existed for acute care hospital or intensive care unit beds across countries. Hospital beds varied three-fold from 221/100,000 population in the United States to 593/100,000 in Germany. Adult intensive care unit beds also ranged seven-fold from 3.3/100,000 population in the United Kingdom to 24.0/100,000 in Germany. Volume of intensive care unit admissions per year varied ten-fold from 216/100,000 population in the United Kingdom to 2353/100,000 in Germany. The ratio of intensive care unit beds to hospital beds was highly correlated across all countries except the United States (r = .90). There was minimal correlation between the number of intensive care unit beds per capita and health care spending per capita (r = .45), but high inverse correlation between intensive care unit beds and hospital mortality for intensive care unit patients across countries (r = −.82). Conclusions:Absolute critical care services vary dramatically between countries with wide differences in both numbers of beds and volume of admissions. The number of intensive care unit beds per capita is not strongly correlated with overall health expenditure, but does correlate strongly with mortality. These findings demonstrate the need for critical care data from all countries, as they are essential for interpretation of studies, and policy decisions regarding critical care services.

De-escalation therapy in ventilator-associated pneumonia*

Objective:To evaluate de-escalation of antibiotic therapy in patients with ventilator-associated pneumonia. Design:Prospective observational study during a 43-month period. Setting:Medical-surgical intensive care unit. Patients:One hundred and fifteen patients admitted to the intensive care unit with clinical diagnosis of ventilator-associated pneumonia. All the episodes of ventilator-associated pneumonia received initial broad-spectrum coverage followed by reevaluation according to clinical response and microbiology. Quantitative cultures obtained by bronchoscopic examination or tracheal aspirates were used to modify therapy. Interventions:None. Measurements and Main Results:One hundred and twenty-one episodes of ventilator-associated pneumonia were diagnosed. Change of therapy was documented in 56.2%, including de-escalation (the most frequent cause) in 31.4% (increasing to 38% if isolates were sensitive). Overall intensive care unit mortality rate was 32.2%. Inappropriate antibiotic therapy was identified in 9% of cases and was associated with 14.4% excess intensive care unit mortality. Quantitative tracheal aspirates and bronchoscopic samples (58 protected specimen brush and three bronchoalveolar lavage) were associated with 32.7% and 29.5% intensive care unit mortality and 29.3% and 34.4% de-escalation rate. De-escalation was lower (p < .05) in the presence of nonfermenting Gram-negative bacillus (2.7% vs. 49.3%) and in the presence of late-onset pneumonia (12.5% vs. 40.7%). When the pathogen remained unknown, half of the patients died and de-escalation was not performed. Conclusion:De-escalation was the most important cause of antibiotic modification, being more feasible in early-onset pneumonia and less frequent in the presence of nonfermenting Gram-negative bacillus. The impact of quantitative tracheal aspirates or bronchoscopic techniques was comparable in terms of mortality.

Therapy of ventilator-associated pneumonia: A patient-based approach based on the ten rules of The Tarragona Strategy

Abstract.Therapy of ventilator-associated pneumonia should be a patient-based approach focusing on some key features are listed here: early initial therapy should be based on broad-spectrum antibiotics. Empirical treatment may be targeted after direct staining and should be modified according to good-quality quantitative microbiological findings, but should never be withdrawn in presence of negative direct staining or delayed until microbiological results are available. Courses of therapy should be given at high doses according to pharmacodynamic and tissue penetration properties. Prolonging antibiotic treatment does not prevent recurrences. Methicillin-sensitive Staphylococcus aureus should be expected in comatose patients. Methicillin-resistant Staphylococcus aureus should not be expected in patients without previous antibiotic coverage. Pseudomonas aeruginosa should be covered with combination therapy. Antifungal therapy, even when Candida spp is isolated in significant concentrations, is not recommended for intubated nonneutropenic patients. Vancomycin, given at the standard doses and route of administration for the treatment of VAP caused by Gram-positive pathogens, is associated with poor outcomes. The choice of initial antibiotic should be based on the patients previous antibiotic exposure and comorbidities, and local antibiotic susceptibility patterns, which should be updated regularly.

Effect of antibiotic diversity on ventilator-associated pneumonia caused by ESKAPE Organisms.

BACKGROUND The aim of this study was to test in the clinic whether antimicrobial diversity affects resistance of Enterococcus faecium, Staphylococcus aureus, Klebsiella species, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species (ESKAPE) pathogens in ventilator-associated pneumonia (VAP). METHODS Three different strategies of empirical antimicrobial prescription for VAP were consecutively implemented in an ICU: patient specific (10 months); scheduling, including sequential quarterly prioritization (12 months) and restriction (12 months) of antimicrobials; and mixing (10 months). Periods were compared, measuring the antimicrobial heterogeneity index (AHI). Incidence and resistance patterns of VAP caused by ESKAPE were compared. RESULTS Overall, 127 microbiologic VAP episodes were documented. ESKAPE VAP increased significantly during scheduling (AHI, 0.65) compared with patient-specific (AHI, 0.88) and mixing (AHI, 0.87) periods (relative risk, 2.67 and 3.84, respectively). This finding was associated with a significant (P < .05) increase of carbapenem-resistant A baumannii during the scheduling period (15.0%) compared with the patient-specific (2.4%) and mixing (0%) periods. ICU mortality of resistant patients with ESKAPE VAP was doubled that of patients without ESKAPE VAP (relative risk, 2.25; 95% CI, 1.67-9.48). Thirty-day mechanical ventilation-free days was significantly increased (5 days) in patients with resistant ESKAPE VAP. CONCLUSIONS Antibiotic strategies promoting diversity may prevent the emergence of resistance of ESKAPE organisms, improving use of health-care resources.

Obliterative Bronchiolitis Syndrome and Outcomes of Unplanned ICU Readmission Following Lung Transplantation

Clinical Research/epidemiology In Pneumonia & Sepsis (CRIPS). Introduction Hospital re-admissions after lung transplant (LT) negatively affect quality of life, and costs. Reports on ICU readmission (ICU-r) have been limited to short series. Table. No title available. Table. No title available. Methods Prospective, multicenter, observational study including 174 consecutive LT adults requiring ICU-r (august 2012-16). We evaluated epidemiological features of this population and studied the outcomes. Results Overall, 118 (68.2%) ICU-r were due to acute respiratory failure (ARF) and 78 (44.8%) had an infectious cause, with pneumonia the most prevalent (73%). Acute cellular and humoral rejection were identified in 12 (7%) and 2 (1%) respectively. Main lung diseases before transplant were pulmonary fibrosis (38.7%) and COPD (34.7%), 53.2% with bilateral transplant. (Table 1). When admitted by ARF, 90-day mortality was 44.2% (vs 26.4% when admitted by other causes, p<0.05). 90-day mortality for pneumonia was 49%. 36 patients (20.2%) ICU-r had obliterative bronchiolitis syndrome (BOS). Acute respiratory failure and pneumonia were more prevalent in BOS subgroup, BOS was significantly associated to higher requirement of mechanical ventilation, and ICU mortality. P. aeruginosa (most frequent MDR) was the pathogen isolated from both ICU-R with and without BOS. Hypoxemia was the main cause of death in patient with BOS, (Table 2). Conclusions Hypoxemia was the main cause of ICU readmission in LT, particularly within one year, whereas BOS showed association to prognosis. FISS PI1401296 and CIBERES.

Is the Lung Allocate Score Associated with the Decrease of the Primary Graft Dysfunction in Lung Transplantation

Background On 2014 the system for allocation of lung recipients for transplant in HUVH changed from allocation based on waiting time to allocation based on the Lung Allocate Score (LAS score). We have analyzed the impact in primary graft dysfunction (PGD). Methods We retrospectively reviewed the cohort of 418 adult recipients of lung transplantation performed between 01/01/2010 and 02/08/2016 in our hospital. Patients were grouped by type of allocation: before LAS era(BLE) and after LAS era(ALE). Descriptive and comparative analysis of donors, recipients and procedures was performed between both groups to ensure comparability. Univariate and multivariate analysis were carried out to study factors influencing on PGD. Results There are not statistically significant differences in receptor’s age, gender, type of lung disease or donor characteristics (Table 1,2). The number of recipient who needed oxygen requirements for arterial blood gas test and walking-6-minutes-test before lung transplant was increased in ALE(13.1% vs 40.4%, p=<0.001). During the procedure, cardiopulmonary bypass was needed more frequently in ALE (21% vs 35.8% p=<0.001) and recipients needed more packed red blood cells (3.38 vs 4.289, p=0.03) (Table 3). The incidence of PGD decreased in ALE(45.6% vs 32% p=0.007) (Table 4).After multivariante analysis, LAS was independently associated with a reduced risk for PGD(Table 5).. Conclusions Allocating lungs for transplant based on urgency and benefit instead of waiting time is associated with reduced risk of PGD after lung transplantation. Table. No title available. Table. No title available. Table. No title available. Table. No title available.