Sergio Ruiz-Santana

A bedside scoring system ("Candida score") for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization.

Objective:To obtain a score for deciding early antifungal treatment when candidal infection is suspected in nonneutropenic critically ill patients. Design:Analysis of data collected from the database of the EPCAN project, an ongoing prospective, cohort, observational, multicenter surveillance study of fungal infection and colonization in intensive care unit (ICU) patients. Setting:Seventy-three medical-surgical ICUs of 70 teaching hospitals in Spain. Patients:A total of 1,699 ICU patients aged 18 yrs and older admitted for at least 7 days between May 1998 and January 1999 were studied. Interventions:Surveillance cultures of urine, tracheal, and gastric samples were obtained weekly. Patients were grouped as follows: neither colonized nor infected (n = 719), unifocal or multifocal Candida colonization (n = 883), and proven candidal infection (n = 97). The odds ratio (OR) for each risk factor associated with colonization vs. proven candidal infection was estimated. A logistic regression model was performed to adjust for possible confounders. The “Candida score” was obtained according to the logit method. The discriminatory power was evaluated by the area under the receiver operating characteristics curve. Measurements and main results:In the logit model, surgery (OR = 2.71, 95% confidence interval [CI], 1.45–5.06); multifocal colonization (OR = 3.04, 95% CI, 1.45–6.39); total parenteral nutrition (OR = 2.48, 95% CI, 1.16–5.31); and severe sepsis (OR = 7.68, 95% CI, 4.14–14.22) were predictors of proven candidal infection. The “Candida score” for a cut-off value of 2.5 (sensitivity 81%, specificity 74%) was as follows: parenteral nutrition, +0.908; surgery, +0.997; multifocal colonization, +1.112; and severe sepsis, +2.038. Central venous catheters were not a significant risk factor for proven candidal infection (p = .292). Conclusions:In a large cohort of nonneutropenic critically ill patients in whom Candida colonization was prospectively assessed, a “Candida score” >2.5 accurately selected patients who would benefit from early antifungal treatment.

Intensive care adult patients with severe respiratory failure caused by Influenza A (H1N1)v in Spain

IntroductionPatients with influenza A (H1N1)v infection have developed rapidly progressive lower respiratory tract disease resulting in respiratory failure. We describe the clinical and epidemiologic characteristics of the first 32 persons reported to be admitted to the intensive care unit (ICU) due to influenza A (H1N1)v infection in Spain.MethodsWe used medical chart reviews to collect data on ICU adult patients reported in a standardized form. Influenza A (H1N1)v infection was confirmed in specimens using real-time reverse transcriptase-polymerase-chain-reaction (RT PCR) assay.ResultsIllness onset of the 32 patients occurred between 23 June and 31 July, 2009. The median age was 36 years (IQR = 31 - 52). Ten (31.2%) were obese, 2 (6.3%) pregnant and 16 (50%) had pre-existing medical complications. Twenty-nine (90.6%) had primary viral pneumonitis, 2 (6.3%) exacerbation of structural respiratory disease and 1 (3.1%) secondary bacterial pneumonia. Twenty-four patients (75.0%) developed multiorgan dysfunction, 7 (21.9%) received renal replacement techniques and 24 (75.0%) required mechanical ventilation. Six patients died within 28 days, with two additional late deaths. Oseltamivir administration delay ranged from 2 to 8 days after illness onset, 31.2% received high-dose (300 mg/day), and treatment duration ranged from 5 to 10 days (mean 8.0 ± 3.3).ConclusionsOver a 5-week period, influenza A (H1N1)v infection led to ICU admission in 32 adult patients, with frequently observed severe hypoxemia and a relatively high case-fatality rate. Clinicians should be aware of pulmonary complications of influenza A (H1N1)v infection, particularly in pregnant and young obese but previously healthy persons.

Usefulness of the "Candida score" for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: a prospective multicenter study.

Objective:To assess the usefulness of the “Candida score” (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point. Design:Prospective, cohort, observational study. Setting:Thirty-six medical-surgical intensive care units of Spain, Argentina, and France. Patients:A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007. Measurements and Main Results:Clinical data, surveillance cultures for fungal growth, and serum levels of (1–3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition ×1, plus surgery ×1, plus multifocal Candida colonization ×1, plus severe sepsis ×2. A CS ≥3 accurately selected patients at high risk for IC. The colonization index was registered if ≥0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06–3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p ≤ 0.001). The area under the receiver operating characteristic curve for CS was 0.774 (95% CI 0.715–0.832) compared with 0.633 (95% CI 0.557–0.709) for CI. (1–3)-Beta-d-glucan was also an independent predictor of IC (odds ratio 1.004, 95% CI 1.0–1.007). The relative risk for developing IC in colonized patients without antifungal treatment was 6.83 (95% CI 3.81–12.45). Conclusions:In this cohort of colonized patients staying >7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.

Assessment of candidemia-attributable mortality in critically ill patients using propensity score matching analysis

IntroductionCandidemia in critically ill patients is usually a severe and life-threatening condition with a high crude mortality. Very few studies have focused on the impact of candidemia on ICU patient outcome and attributable mortality still remains controversial. This study was carried out to determine the attributable mortality of ICU-acquired candidemia in critically ill patients using propensity score matching analysis.MethodsA prospective observational study was conducted of all consecutive non-neutropenic adult patients admitted for at least seven days to 36 ICUs in Spain, France, and Argentina between April 2006 and June 2007. The probability of developing candidemia was estimated using a multivariate logistic regression model. Each patient with ICU-acquired candidemia was matched with two control patients with the nearest available Mahalanobis metric matching within the calipers defined by the propensity score. Standardized differences tests (SDT) for each variable before and after matching were calculated. Attributable mortality was determined by a modified Poisson regression model adjusted by those variables that still presented certain misalignments defined as a SDT > 10%.ResultsThirty-eight candidemias were diagnosed in 1,107 patients (34.3 episodes/1,000 ICU patients). Patients with and without candidemia had an ICU crude mortality of 52.6% versus 20.6% (P < 0.001) and a crude hospital mortality of 55.3% versus 29.6% (P = 0.01), respectively. In the propensity matched analysis, the corresponding figures were 51.4% versus 37.1% (P = 0.222) and 54.3% versus 50% (P = 0.680). After controlling residual confusion by the Poisson regression model, the relative risk (RR) of ICU- and hospital-attributable mortality from candidemia was RR 1.298 (95% confidence interval (CI) 0.88 to 1.98) and RR 1.096 (95% CI 0.68 to 1.69), respectively.ConclusionsICU-acquired candidemia in critically ill patients is not associated with an increase in either ICU or hospital mortality.

Epidemiology, Clinical Features, and Prognosis of Elderly Adults with Severe Forms of Influenza A (H1N1)

To examine epidemiological and clinical data of individuals aged 65 and older with influenza virus A (H1N1) admitted to the intensive care unit (ICU) and to identify independent predictors of ICU mortality.

Near zero catheter-related bloodstream infections: turning dreams into reality*.

Crit Care Med 2012 Vol. 40, No. 11 3083 Catheter-related bloodstream infection (CR-BSI) is a frequent complication in the intensive care unit (ICU) setting. Paradoxically, the presence of CR-BSI, which contributes substantially to increase patient’s morbidity, hospital costs, and ICU length of stay, is largely preventable (1). In fact, care bundles on line insertion have been effective to reduce CR-BSI rates. In the Keystone ICU Project, Berenholtz and colleagues (2) showed that implementation of an evidence-based bloodstream infection bundles that involves five well-known Centers of Disease Control and Prevention recommended measures (hand washing, full-barrier precautions during line insertion, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters) together with improving teamwork, communication, and patient safety culture was able to produce a large and sustained reduction of CR-BSI rates over an 18-month study period (3). Furthermore, most of the participating ICUs sustained reduced CR-BSI rates during a further postimplementation period of 18 months (4). Similar results were reported by others (5–7). This quality improvement program originally developed in Michigan has spread to many states in United States and abroad with consistent successful results (8). In Spain, an agreement of the Spanish Ministry of Health and the Patient Safety Programme of the World Health Organization in collaboration with the Spanish Society of Intensive and Critical Care Medicine and Coronary Units and the Johns Hopkins Quality and Safety Research Group was established to assess the applicability and effectiveness of the Keystone ICU Project (9). As a result, a nationwide multifactorial intervention program, named “Bacteremia Zero,” was designed and progressively implemented in 192 Spanish ICUs over an 18-month period between 2008 and 2010. Significant reductions of CRBSI rates as compared with baseline were observed (unpublished data), showing that this multifaceted quality improvement program can be effectively applied to a different health care system, despite varying levels of organizational structure and safety cultures. The study of the Johns Hopkins Quality and Safety Research Group had a cohort design, so that the next logical scientific step was to perform a randomized controlled trial to assess causality between the multifaceted intervention used in the Keystone ICU Project and the reduced CR-BSI rates as well as to evaluate the magnitude of the effectiveness of the intervention. In this issue of Critical Care Medicine, Marsteller and coworkers (10) report the results of a multicenter, phased, clusterrandomized controlled trial in 45 ICUs from 35 hospitals, in two faith-based affiliated health systems, which was designed to determine the causal effects of an intervention to reduce CR-BSIs in the ICU. The multifaceted intervention consisted of the above mentioned evidence-based practices to prevent CRBSI (2) and the Comprehensive Unit– based Safety Program to improve safety, teamwork, and communication (11). Interestingly, the study included a first phase (phase 1) in which the intervention was assessed according to the randomized controlled trial design and a second follow-up period of 1 yr (phase 2) in which the intervention was implemented to all participating ICUs (including those in the control arm), aimed to assess sustainability of the intervention. The intervention group started in March 2007 and the control group in October 2007, and the study period ended in September 2008. Baseline data for both groups were from 2006. The number of primary CR-BSI per 1000 central-line days was collected monthly and reported to the authors through the health systems corporate headquarters. The main primary outcome was the quarterly rate of CR-BSI during the postimplementation period (third quarter, from October to December 2007). By that time, the mean infection rate (CR-BSI per 1,000 central-line days) declined from 4.48 to 1.33 in the intervention group compared to a decline from 2.71 to 2.16 in the control group (adjusted incidence rate ratio 0.19; 95% confidence interval 0.06–0.57; p = .0003). The intervention and the control groups showed sustained CR-BSI rates <1/1,000 central-line days at 19 (81% reduction) and at 12 months (69% reduction), respectively. However, at the end of the study, reductions in CR-BSI rates near to 0.8 per 1,000 line days were observed in both study groups, which was even lower than the rates achieved in the Keystone ICU Project (3). The study shows a casual relationship between the multifaceted intervention and reduced rates of CR-BSI, decreased infection rates in both groups after implementation, and sustained results over time, providing further evidence that CR-BSI is a preventable condition. In addition to the design, other strengths of this study were that the authors decided to incorporate several modifications to optimize the intervention that contributed decisively to the Adventist collaborative success, such as the development of a dressing-change check-list, use of a preplanned educational curriculum, recognition as a nurse-led program, and measurement of the influential elements of the context at each site. However, from a methodological point of view, the authors use the zero-inflated Poisson models to analyze the effect of the intervention on CR-BSI and to identify other associated factors. The model is appropriate for “near zero” catheter-related bloodstream infections: turning dreams into reality*

Effects of reintubation on ventilator associated nosocomial pneumonias incidence in ICU patients with versus without selective digestive decontamination

Reintubation has been shown, among many others, to be an independent risk factor for development of ventilator-associated pneumonia1 (VAP) which is a major cause of morbidity and mortality in ICUs. Selective Digestive Decontamination (SDD) is a tool that prevent infections in critically ill patients particularly VAP, that has been used mainly in Holland and in Spain. Despite of the evidence its use remains controversial.