Aurelio Cayuela

Acinetobacter baumannii ventilator-associated pneumonia : epidemiological and clinical findings

ObjectiveTo investigate prognostic factors and predictors of Acinetobacter baumannii isolation in ventilator-associated pneumonia (VAP). We specifically analyzed these issues for imipenem-resistant episodes.Design and settingAll episodes of VAP are prospectively included in a database. Information about risk factors was retrieved retrospectively.PatientsEighty-one patients exhibiting microbiologically documented VAP: 41 by A. baumannii (26 by imipenem-resistant) and 40 by other pathogens.Measurements and resultsThe following variables were noted: underlying diseases, severity of illness, duration of mechanical ventilation and of hospitalization before VAP, prior episode of sepsis, previous antibiotic, corticosteroid use, type of nutrition, renal replacement therapy, reintubation, transportation out of the ICU, micro-organisms involved in VAP, concomitant bacteremia, clinical presentation, Sequential Organ Failure Assessment (SOFA) scale on the day of diagnosis, and adequacy of empirical antibiotic therapy. Prior antibiotic use was found to be associated with development of VAP by A. baumannii (OR 14). Prior imipenem exposure was associated with the isolation of imipenem-resistant strains (OR 4). SOFA score on the day of diagnosis was the only predictor of in-hospital mortality (OR 1.22); adequacy of empirical antibiotic therapy was a protective factor (OR 0.067).ConclusionsOur results confirm that prior exposure to antimicrobials is an independent predictor for the development of A. baumannii VAP, the prognosis of which is similar to that of infections caused by other pathogens. This study highlights the importance of initial antibiotic choice in VAP or whatever cause.

Optimal management therapy for Pseudomonas aeruginosa ventilator-associated pneumonia: an observational, multicenter study comparing monotherapy with combination antibiotic therapy.

Objective:To evaluate whether one antibiotic achieves equal outcomes compared with combination antibiotic therapy in patients with Pseudomonas aeruginosa ventilator-associated pneumonia. Design:A retrospective, multicenter, observational, cohort study. Setting:Five intensive care units in Spanish university hospitals. Patients:Adult patients identified to have monomicrobial episodes of ventilator-associated pneumonia with significant quantitative respiratory cultures for P. aeruginosa. Interventions:None. Measurement and Main Results:A total of 183 episodes of monomicrobial P. aeruginosa ventilator-associated pneumonia were analyzed. Monotherapy alone was used empirically in 67 episodes, being significantly associated with inappropriate therapy (56.7% vs. 90.5%, p < .001). Hospital mortality was significantly higher in the 40 patients with inappropriate therapy compared with those at least on antibiotic with activity in vitro (72.5% vs. 23.1%, p < .05). Excess mortality associated with monotherapy was estimated to be 13.6% (95% confidence interval −2.6 to 29.9). The use of monotherapy or combination therapy in the definitive regimen did not influence mortality, length of stay, development of resistance to the definitive treatment, or appearance of recurrences. Inappropriate empirical therapy was associated with increased mortality (adjusted hazard ratio 1.85; 95% confidence interval 1.07–3.10; p = .02) in a Cox proportional hazard regression analysis, after adjustment for disease severity, but not effective monotherapy (adjusted hazard ratio 0.90; 95% confidence interval 0.50–1.63; p = .73) compared with effective combination therapy (adjusted hazard ratio 1). The other two variables also independently associated with mortality were age (adjusted hazard ratio 1.02; 95% confidence interval 1.01–1.04; p = .005) and chronic cardiac insufficiency (adjusted hazard ratio 1.90; 95% confidence interval 1.04–3.47; p = .035). Conclusions:Initial use of combination therapy significantly reduces the likelihood of inappropriate therapy, which is associated with higher risk of death. However, administration of only one effective antimicrobial or combination therapy provides similar outcomes, suggesting that switching to monotherapy once the susceptibility is documented is feasible and safe.

Timing of adequate antibiotic therapy is a greater determinant of outcome than are TNF and IL-10 polymorphisms in patients with sepsis.

IntroductionGenetic variations may influence clinical outcomes in patients with sepsis. The present study was conducted to evaluate the impact on mortality of three polymorphisms after adjusting for confounding variables, and to assess the factors involved in progression of the inflammatory response in septic patients.MethodThe inception cohort study included all Caucasian adults admitted to the hospital with sepsis. Sepsis severity, microbiological information and clinical variables were recorded. Three polymorphisms were identified in all patients by PCR: the tumour necrosis factor (TNF)-α 308 promoter polymorphism; the polymorphism in the first intron of the TNF-β gene; and the IL-10-1082 promoter polymorphism. Patients included in the study were followed up for 90 days after hospital admission.ResultsA group of 224 patients was enrolled in the present study. We did not find a significant association among any of the three polymorphisms and mortality or worsening inflammatory response. By multivariate logistic regression analysis, only two factors were independently associated with mortality, namely Acute Physiology and Chronic Health Evaluation (APACHE) II score and delayed initiation of adequate antibiotic therapy. In septic shock patients (n = 114), the delay in initiation of adequate antibiotic therapy was the only independent predictor of mortality. Risk factors for impairment in inflammatory response were APACHE II score, positive blood culture and delayed initiation of adequate antibiotic therapy.ConclusionThis study emphasizes that prompt and adequate antibiotic therapy is the cornerstone of therapy in sepsis. The three polymorphisms evaluated in the present study appear not to influence the outcome of patients admitted to the hospital with sepsis.

Transfusion of erythrocyte concentrates produces a variable increment on cerebral oxygenation in patients with severe traumatic brain injury : A preliminary study

ObjectiveTo investigate the long-term influence of erythrocyte transfusion on cerebral oxygenation in patients with severe traumatic brain injury.DesignProspective and observational study.SettingNeurotrauma intensive care unit of trauma center level I.PatientsSixty consecutive, hemodynamically stable patients with severe traumatic brain injury, pretransfusion hemoglobinu202f<u202f100u202fg/l, non-bleeding and monitored through intracranial pressure and brain tissue partial pressure of oxygen (PtiO2) catheters were included.InterventionsTransfusion of 1–2 units of red blood cells.Measurements and resultsTen sets of variables (pretransfusion, end of transfusion, and 1, 2, 3, 4, 5, 6, 12 and 24u202fh after transfusion) were recorded, including: PtiO2, cerebral perfusion pressure (CPP), end-tidal CO2, peripheral saturation of oxygen, temperature, hemoglobin, lactate and PaO2/FiO2 ratio. Transfusion was associated with an increase in PtiO2 during axa06-h period, with axa0peak at 3u202fh (26.2%; pu202f=u202f0.0001) in 78.3% of the patients. No relationship was observed between PtiO2, CPP and hemoglobin increments. The relative increment in PtiO2 at hour 3 was only correlated with baseline PtiO2 (r2 0.166; pu202f=u202f0.001). All of the patients with basal PtiO2u202f<u202f15u202fmmHg showed an increment in PtiO2 versus 74.5% of patients with basal PtiO2u202f≥u202f15u202fmmHg (pu202f<u202f0.01, hour 3).ConclusionsErythrocyte transfusion is associated with axa0variable and prolonged increment of cerebral tissue oxygenation in anemic patients with severe traumatic brain injury. Low baseline PtiO2 levels (<u202f15u202fmmHg) could define those patients who benefit the most from erythrocyte transfusion.

Red blood cell transfusion in non-bleeding critically ill patients with moderate anemia: is there a benefit?

PurposeThis study was undertaken to investigate the efficacy of red blood cell transfusion (RBCT) at reversing the deleterious effects of moderate anemia in critically ill, non-bleeding patients.MethodsThis was a retrospective, pair-matched (ratio 1:1) cohort study. Non-bleeding critically ill patients with moderate anemia (nadir hemoglobin level between 70 and 95xa0g/l), admitted to the ICU over a 27-month period, were included. Anemic patients were included upon meeting five matching criteria of having the same nadir hemoglobin (±5xa0g/l), APACHE II score (±5), SOFA score (±2), admission diagnostic group, and age (±5xa0years). Outcome events occurring over the whole ICU stay and after RBCT were collected. After hospital discharge, all patients had a 2-year follow-up period.ResultsTwo hundred fourteen non-transfused anemic patients (NTAPs) were successfully matched with 214 transfused anemic patients (TAPs). In addition to the matching criteria, at baseline, both groups were homogenous with respect to multiple comorbidities. Compared with TAPs, NTAPs showed significantly lower rates of hospital mortality (21 vs.13xa0%, respectively; pxa0<xa00.05) and ICU re-admission (7.4 vs. 1.9xa0%, respectively; pxa0<xa00.05). Additionally, NTAPs had significantly lower rates of nosocomial infection (12.9 vs. 6.7xa0%, respectively; pxa0<xa00.05) and acute kidney injury (24.8 vs. 16.7xa0%, respectively; pxa0<xa00.05). Similar results were obtained in subgroup analysis where only more anemic patients (68 matched pairs) or patients with cardiovascular comorbidities (63 matched pairs) were considered.ConclusionsRBCT does not improve the clinical outcome in non-bleeding critically ill patients with moderate anemia.

Uso prudente de antibióticos y propuestas de mejora desde la medicina hospitalaria

The largest consumption of antimicrobials is concentrated in hospitals and within them, the intensive care units. The quality of antimicrobial use is not optimal, with up to 50% of prescriptions being unnecessary or inappropriate. Inappropriate antibiotic use leads to severe consequences, such as increased patient mortality and morbidity and bacterial resistance. The primary reason for inappropriate use is the insufficient knowledge of the increasingly vast and complex information about the diagnosis and treatment of infectious diseases. There is general agreement on the need to improve the use of antimicrobials in hospitals but not on how to improve it. University Hospital Virgen del Rocío (Seville) has launched the Institutional Programme for the Optimisation of Antimicrobial Treatment (PRIOAM), inspired by the recommendations of the Infectious Diseases Society of America and adapted to the structural, functional and cultural characteristics of the hospital. PRIOAM is coordinated by a multidisciplinary team chosen by the Committee on Infections and Antimicrobials and has three basic characteristics: it is an institutional programme that has incentives linked to achieving goals; it is an educational programme in which training and knowledge are the basis for the proper use of antimicrobials; and it is a programme subject to results, in which the main objectives are clinical, not economic, to reduce mortality and morbidity in patients with infections and to delay the development of resistance.The largest consumption of antimicrobials is concentrated in hospitals and within them, the intensive care units. The quality of antimicrobial use is not optimal, with up to 50% of prescriptions being unnecessary or inappropriate. Inappropiate antibiotic use leads to severe consequences, such as increased patient mortality and morbidity and bacterial resistance. The primary reason for inappropriate use is the insufficient knowledge of the increasingly vast and complex information about the diagnosis and treatment of infectious diseases. There is general agreement on the need to improve the use of antimicrobials in hospitals but not on how to improve it. University Hospital Virgen del Rocio (Seville) has launched the Institutional Programme for the Optimisation of Antimicrobial Treatment (PRIOAM), inspired by the recommendations of the Infectious Diseases Society of America and adapted to the structural, functional and cultural characteristics of the hospital. PRIOAM is coordinated by a multidisciplinary team chosen by the Committee on Infections and Antimicrobials and has three basic characteristics: it is an institutional programme that has incentives linked to achieving goals; it is an educational programme in which training and knowledge are the basis for the proper use of antimicrobials; and it is a programme subject to results, in which the main objectives are clinical, not economic, to reduce mortality and morbidity in patients with infections and to delay the development of resistance.

Red Blood Cell Transfusion Guided by Near Infrared Spectroscopy in Neurocritically Ill Patients with Moderate or Severe Anemia: A Randomized, Controlled Trial

In neurocritically ill patients (NCPs), the use of hemoglobin level as the sole indicator for red blood cell transfusion (RBCT) can result in under- or over-transfusion. This randomized controlled trial was conducted to ascertain whether a transcranial oxygen saturation (rSO2) threshold, as measured by near-infrared spectroscopy, reduces RBCT requirements in anemic NCPs (closed traumatic brain injury, subarachnoid, or intracerebral hemorrhage), compared with a hemoglobin threshold alone. Patients with hemoglobin 70-100u2009g/L received RBCTs to attain an rSO2 > 60% (rSO2 arm) or to maintain hemoglobin between 85 and 100u2009g/L (hemoglobin arm). A total of 102u2009NCPs (51 in each group) were included in the intention-to-treat analysis, and 97 were included in the per-protocol analysis (51 and 46, respectively). Compared with those from the hemoglobin arm, patients in rSO2 arm received fewer RBC units (1.0u2009±u20090.1 vs. 1.5u2009±u20091.4 units/patient; pu2009<u20090.05) and showed lower hemoglobin levels while in protocol. There were no differences between the study arms regarding the percentage of transfused patents (59% vs. 71%; relative risk 0.83 [95% CI 0.62-1.11]), stay on neurocritical care unit (21 vs. 20 days), unfavorable Glasgow Outcome Scale scores on hospital discharge (57% vs. 71%), in-hospital mortality (6% vs. 10%), or 1 year mortality (24% vs. 24%). Among NCPs with hemoglobin concentrations of 70-85u2009g/L, withholding transfusion until rSO2 is <60% may result in reduced RBCs requirements compared with routinely transfusing to attain a hemoglobin level >85u2009g/L. Further studies are required to confirm this finding and its possible impact on clinically significant outcomes.

Effects of Red Blood Cell Transfusion on Long-Term Disability of Patients with Traumatic Brain Injury

AbstractBackgroundnThis 3-year prospective study examined the association between red blood cell transfusion (RBCT) and 1-year neurocognitive and disability levels in 309 patients with traumatic brain injury (TBI) admitted to the neurological intensive care unit (NICU).MethodsUsing a telephone interview-based survey, functional outcomes were assessed by the Glasgow Outcome Scale (GOS), Rancho Los Amigos Levels of Cognitive Functioning Scale (RLCFS), and Disability Rating Scale (DRS) and dichotomized as favorable and unfavorable (dependent variable). The adjusted influence of RBCT on unfavorable results was assessed by conventional logistic regression, controlling for illness severity and propensity score (introduced as a continuous variable and by propensity score-matched patients).ResultsOverall, 164 (53xa0%) patients received ≥1 unit of RBCT during their NICU stay. One year postinjury, transfused patients exhibited significantly higher unfavorable GOS (46.0 vs. 22.0xa0%), RLCFS (37.4 vs. 15.4xa0%), and DRS (39.6 vs. 18.7xa0%) scores than nontransfused patients. Although transfused patients were more severely ill upon admission, their adjusted odds ratios (95xa0% confidence intervals) for unfavorable GOS, RLCFS, and DRS scores were 2.5 (1.2–5.1), 3.0 (1.4–6.3), and 2.3 (1.1–4.8), respectively. These odds ratios remained largely unmodified when the calculated propensity score was incorporated as an independent continuous variable into the multivariate analysis. Furthermore, in 76 pairs of propensity score-matched patients, the rate of an unfavorable RLCFS score at the 1-year (but not 6-month) follow-up was significantly higher in transfused than nontransfused patients [3.0 (1.1–8.2)].ConclusionOur results strongly suggest an independent association between RBCT and unfavorable long-term functional outcomes of patients with TBI.

Administration of fibrinogen concentrate for refractory bleeding in massively transfused, non-trauma patients with coagulopathy: a retrospective study with comparator group

BackgroundThis retrospective, single centre study was conducted to investigate the efficacy of fibrinogen concentrate (FBNc) in decreasing blood requirements and reaching optimal fibrinogen level, in non-trauma, massively transfused, bleeding patients with coagulopathy.MethodsOver a 3-years period, all patients for whom a massive transfusion protocol was activated and had received ≥4 units of allogeneic blood components within a ≤4xa0h period, were included. Patients were classified according to whether they received FBNc or achieved an optimal fibrinogen level of ≥2xa0g/L within 24xa0h after FBNc administration.ResultsSeventy-one patients received 2 [2,4] g of FBNc (FBNc group) and 72 did not (comparator group). FBNc was administered after transfusing 5 [5,9] blood component units, 3 [2,6] hours after massive transfusion protocol activation. Linear regression analysis showed that SOFA (AOR 0.75 [95% CI:0.08-1.43]) and admission fibrinogen level (AOR -2.7 [95% CI:-4.68 – -0.78]), but not FBNc administration, were independently associated with total transfused units. There was a significant inverse relation between both admission and target fibrinogen levels, and total transfused components. Logistic regression showed a direct relationship between admission fibrinogen level and achieving a target level ≥2xa0g/L (AOR 3.29 [95% CI;1.95-5.56]). No thromboembolic events associated with FBNc were observed.ConclusionsIn massively transfused, non-trauma patients with coagulopathy and refractory bleeding, late administration of low FBNc dosage was not associated with decreased blood transfusion or increased post-infusion fibrinogen level. Given that both fibrinogen upon admission and target fibrinogen levels were associated with decreased blood transfusion, earlier administration and higher doses of FBNc could be needed.

Red blood cell transfusion guided by near infrared spectroscopy in neurocritically ill patients with moderate or severe anaemia

In neurocritically ill patients (NCPs), the use of hemoglobin level as the sole indicator for red blood cell transfusion (RBCT) can result in under- or over-transfusion. This randomized controlled trial was conducted to ascertain whether a transcranial oxygen saturation (rSO2) threshold, as measured by near-infrared spectroscopy, reduces RBCT requirements in anemic NCPs (closed traumatic brain injury, subarachnoid, or intracerebral hemorrhage), compared with a hemoglobin threshold alone. Patients with hemoglobin 70-100u2009g/L received RBCTs to attain an rSO2 > 60% (rSO2 arm) or to maintain hemoglobin between 85 and 100u2009g/L (hemoglobin arm). A total of 102u2009NCPs (51 in each group) were included in the intention-to-treat analysis, and 97 were included in the per-protocol analysis (51 and 46, respectively). Compared with those from the hemoglobin arm, patients in rSO2 arm received fewer RBC units (1.0u2009±u20090.1 vs. 1.5u2009±u20091.4 units/patient; pu2009<u20090.05) and showed lower hemoglobin levels while in protocol. There were no differences between the study arms regarding the percentage of transfused patents (59% vs. 71%; relative risk 0.83 [95% CI 0.62-1.11]), stay on neurocritical care unit (21 vs. 20 days), unfavorable Glasgow Outcome Scale scores on hospital discharge (57% vs. 71%), in-hospital mortality (6% vs. 10%), or 1 year mortality (24% vs. 24%). Among NCPs with hemoglobin concentrations of 70-85u2009g/L, withholding transfusion until rSO2 is <60% may result in reduced RBCs requirements compared with routinely transfusing to attain a hemoglobin level >85u2009g/L. Further studies are required to confirm this finding and its possible impact on clinically significant outcomes.