M.J.M. Bonten

Selective decontamination of the oral and digestive tract in surgical versus non-surgical patients in intensive care in a cluster-randomized trial.

Selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) are effective in improving survival in patients under intensive care. In this study possible differential effects in surgical and non‐surgical patients were investigated.

Predicting carriage with extended-spectrum beta-lactamase-producing bacteria at hospital admission: a cross-sectional study

The prevalence of patients colonized with extended-spectrum beta-lactamase (ESBL)-producing bacteria increases, especially in long-term-care facilities (LTCFs). Identification of ESBL carriers at hospital admission is relevant for infection control measures and antibiotic therapy for nosocomial infections. We aimed to develop a prediction rule for ESBL carriage at hospital admission for patients admitted from home and LTCFs, and to quantify incidences of nosocomial infections caused by ESBL-producing bacteria. The ESBL-carrier status was determined of patients admitted from LTCFs and from home settings in four hospitals in the Netherlands using perianal swabs obtained within 48 hours of admission. Risk factors for ESBL carriage were assessed. Infections caused by ESBL-producing bacteria were identified retrospectively. Among 1351 patients, 111 (8.2%) were ESBL carriers at admission: 50/579 (8.6%) admitted from LTCFs and 61/772 (7.9%) from home settings (p 0.63). Previous ESBL carriage and previous hospital admission were risk factors for ESBL carriage in multivariable analysis. The area under the curve of the receiver operating characteristic curve of the model was 0.64 (95% CI 0.58-0.71). Presence of ≥1 risk factor (n = 803; 59%) had sensitivity of 72%. Incidences of nosocomial infections caused by ESBL-producing bacteria were 45.5/10,000 and 2.1/10,000 admission days for ESBL carriers and non-carriers, respectively (p <0.05). In conclusion, prevalence of ESBL carriage at hospital admission was 8.2%, and was comparable among patients admitted from LTCF and home. A clinically useful prediction rule for ESBL carriage at admission could not be developed. The absolute incidence of nosocomial infections by ESBL-producing bacteria was low, but higher among patients carrying ESBL-producing bacteria at the time of hospital admission.

Multi-centre evaluation of a phenotypic extended spectrum β-lactamase detection guideline in the routine setting

This study aimed to evaluate the routine setting performance of a guideline for phenotypic detection of extended spectrum β-lactamases (ESBLs) in Enterobacteriaceae, recommending ESBL confirmation with Etest or combination disc for isolates with a positive ESBL screen test (i.e. cefotaxime and/or ceftazidime MIC >1 mg/L or an automated system ESBL warning). Twenty laboratories submitted 443 Enterobacteriaceae with a positive ESBL screen test and their confirmation test result (74%Escherichia coli, 12%Enterobacter cloacae, 8%Klebsiella pneumoniae, 3%Proteus mirabilis, 2%Klebsiella oxytoca). Presence of ESBL genes was used as reference test. Accuracy of local phenotypic ESBL detection was 88%. The positive predictive value (PPV) of local screen tests was 70%, and differed per method (Vitek-2: 69%, Phoenix: 68%, disc diffusion: 92%), and species (95%K. pneumoniae-27%K. oxytoca). A low PPV (3%) was observed for isolates with automated system alarm but third-generation cephalosporin MICs <2 mg/L. Local ESBL confirmation had a PPV and negative predictive value (NPV) of 93% and 90%, respectively. Compared with centrally performed confirmation tests, 7% of local tests were misinterpreted. Combination disc was more specific than Etest (91% versus 61%). Confirmation tests were not reliable for P. mirabilis and K. oxytoca (PPV 33% and 38%, respectively, although NPVs were 100%). In conclusion, performance of Etests could be enhanced by education of technicians to improve their interpretation, by genotypic ESBL confirmation of P. mirabilis and K. oxytoca isolates with positive phenotypic ESBL confirmation, and by interpreting isolates with a positive ESBL alarm but an MIC <2 mg/L for cefotaxime and ceftazidime as ESBL-negative.

Respiratory syncytial virus in critically ill adult patients with community-acquired respiratory failure: a prospective observational study.

The incidence of respiratory syncytial virus (RSV) and influenza virus infection was determined during three RSV seasons in 158 adult patients consecutively admitted to the intensive care unit with community-acquired respiratory failure. Nasopharyngeal swabs were tested for the presence of RSV and influenza virus by real-time polymerase chain reaction. Six patients (4%) were positive for RSV and all recovered. This finding was in sharp contrast to influenza (23 (15%) patients, 4 (17%) deaths). In conclusion, even in the midst of the RSV season, RSV is an infrequent cause of respiratory failure in adults admitted to the intensive care unit.

Is a randomized trial of a short course of aminoglycoside added to β-lactam antibiotics for empirical treatment in critically ill patients with sepsis justified?

Abstract Short-term adjunctive treatment with aminoglycosides in critically ill patients is advocated in guidelines for the empirical treatment of sepsis, despite lack of evidence from randomized trials. A large observational study recently reported more nephrotoxicity and a trend to worse patient outcome in critically ill patients receiving aminoglycosides added to beta-lactam antibiotics. Here, we discuss if a randomized controlled trial to obtain a more definite answer is justified and how it could be performed.

O064: Validation and assessment of the new surveillance paradigm for ventilator-associated events

Reliable, meaningful surveillance methods are essential for benchmarking of healthcare-associated infection rates. However case-definitions for ventilator-associated pneumonia (VAP) are complex and subjective. A novel surveillance paradigm for detection of ventilator-associated events (VAE) was recently proposed by the National Healthcare Safety Network (NHSN).

Ongoing Health Care Expenditure in Survivors of Sepsis in The Intensive Care Unit

Direct costs associated with an intensive care unit (ICU) admission for sepsis are approximately €30,000.[1] However, total cost for society is likely to be much higher, because survivors of sepsis may suffer from long-term sequelae that generate ongoing need for health care resources.[2]

A high anti-inflammatory response is associated with intermediate-term mortality in patients with sepsis

Sepsis is characterized by a complex systemic inflammatory response to infection. While an overwhelming pro-inflammatory response is held responsible for early deaths, subsequent anti-inflammatory cytokine production may lead to immunosuppression and secondary infections. This has been suggested as a cause of intermediate-term deaths[1].

P221: The value of administrative data for the surveillance of healthcare-associated infections: a systematic review

Administrative data are widely used in the surveillance of medical outcomes including healthcare-associated infections (HAI). The validity of administrative data-based surveillance, however, has been questioned.