High risk of short-term mortality and postoperative complications in patients with generalized peritonitis undergoing major emergency abdominal surgery-a cohort study

BACKGROUND

Secondary generalized peritonitis is a potentially life-threatening condition. The aim of this study was to investigate the association between secondary generalized peritonitis and short-term mortality and postoperative complications in patients undergoing major abdominal emergency surgery.

METHODS

The study included patients with the age ≥ 18 years undergoing major emergency abdominal surgery in a University Hospital from 2017 to 2019 after the introduction of a perioperative bundle care program. The primary outcome measures were short-term mortality, defined as death within 30 and 90 days after surgery and postoperative complications within 30 days after surgery. Uni- and multivariable logistic regression analyses were performed to evaluate risk factors for 30- and 90-days mortality and 30-days postoperative complications.

RESULTS

A total of 591 patients were included, of whom 21% (124/591) had generalized peritonitis. The overall 30 day-mortality rate was 12.5% (74/591). Patients with generalized peritonitis had a significantly higher 30-day mortality rate than patients with non-generalized peritonitis 18.5% (23/124) vs. 10.9% (51/467), P = 0.033. Generalized peritonitis was an independent risk factor for 30- and 90- days mortality. There was a significantly higher rate of admission to ICU for patients with generalized peritonitis 39.5% (49/124) vs. 12.6% (59/467), P < 0.001. Patients with generalized peritonitis had significantly higher rates of surgical and non-surgical complication compared to patients with non-generalized peritonitis 87.1% (108/124) vs. 65.7% (307/467), P < 0.001. Generalized peritonitis was an independent risk factor of 30 days postoperative complications.

CONCLUSION

In a population undergoing major emergency abdominal surgery treated in a perioperative optimization protocol, generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and postoperative complications.

Difficult-to-Treat Pseudomonas aeruginosa Infections in Critically Ill Patients: A Comprehensive Review and Treatment Proposal

The management of infections caused by difficult-to-treat Pseudomonas aeruginosa in critically ill patients poses a significant challenge. Optimal antibiotic therapy is crucial for patient prognosis, yet the numerous resistance mechanisms of P. aeruginosa, which may even combine, complicate the selection of an appropriate antibiotic. In this review, we examine the epidemiology, resistance mechanisms, risk factors, and available and future therapeutic options, as well as strategies for treatment optimization. Finally, we propose a treatment algorithm to facilitate decision making based on the resistance patterns specific to each Intensive Care Unit.

Suggested Dosing of Select Beta-lactam Agents for the Treatment of Antimicrobial-Resistant Gram-Negative Infections in Children

The Infectious Diseases Society of America (IDSA) publishes annual guidance on the treatment of antimicrobial-resistant (AMR) gram-negative infections. Within the AMR guidance, suggested dosages of antibiotics for adults infected with AMR pathogens are provided. This document serves as a companion document to the IDSA guidance to assist pediatric specialists with dosing β-lactam agents for the treatment of AMR infections in children. A panel of 13 pediatric infectious diseases specialists, including 11 pharmacists and 2 physicians, reviewed existing pharmacokinetic/pharmacodynamic, animal, and clinical data for newer β-lactam agents that are available in the United States and suggested for the treatment of AMR infections (ie, cefiderocol, ceftazidime-avibactam, ceftazidime-avibactam and aztreonam, ceftolozane-tazobactam, imipenem-cilastatin-relebactam, meropenem-vaborbactam, sulbactam-durlobactam). Suggested dosing for ampicillin-sulbactam is also provided, given complexities in dosing for carbapenem-resistant Acinetobacter baumannii infections. Consensus-based suggested dosing for β-lactam agents used to treat AMR infections in neonates, infants, children, and adolescents and relevant supporting evidence are provided. Content is up to date as of December 1, 2024. Gaps and limitations to existing data are discussed. Optimizing antibiotic dosing is critical to improving the outcomes of children with AMR infections.

Transfer of POCUS Skills of Anesthesia Trainees from the Simulation Laboratory to Clinical Practice: A Follow-Up Pilot Evaluation After ABC US Protocol Training

Background/objectives: Point-of-care ultrasound (POCUS) in the intensive care unit (ICU) has gained much attention in the last few years as an alternative to the classic ways of assessing and diagnosing life-threatening conditions in critical patients. During the COVID-19 pandemic, we proposed a POCUS protocol based on the airway, breathing, and circulation (ABC) approach to quickly evaluate and diagnose life-threatening diseases in critical patients with acute respiratory failure and shock, and later, we used it as a curriculum to teach POCUS to anesthesia and intensive care trainees. Methods: We developed an evaluation protocol where evaluators with experience in POCUS in critically ill patients had to assess the trainee's ultrasound scan; this was based on the ABC protocol taught in the simulation laboratory and applied in a clinical setting at the bedside. Results: Statistically significant differences were observed in some categories evaluated regarding independence and diagnosis. Conclusion: Initial POCUS simulation-based training using an ABC POCUS protocol (that demonstrated good results in the simulation laboratory) is useful when transferring US skills to the bedside and is applicable in daily clinical practice with good results in terms of operator independence.

Insights from serial cardiovascular magnetic resonance imaging show early progress in diastolic dysfunction relates to impaired right ventricular deformation

Latent pulmonary vascular disease is a distinct feature already in the early pathophysiology of masked heart failure with preserved ejection fraction (HFpEF) and associated with reduced right ventricular (RV) functional reserve. We hypothesized that serial real-time cardiovascular magnetic resonance (CMR) imaging at rest and during exercise-stress may detect early progress in pathophysiological alterations in HFpEF. Patients presenting with exertional dyspnoea and signs of diastolic dysfunction (E/e'>8, left ventricular (LV) ejection fraction > 50%) were prospectively enrolled in the HFpEF Stress Trial (NCT03260621). Rest and exercise-stress echocardiography, CMR and right heart catheterisation were performed at baseline. Pulmonary capillary wedge pressure (PCWP) was used for classification of HFpEF (≥ 15/25mmHg at rest/during exercise-stress) and non-cardiac dyspnoea (NCD). Repeat rest and exercise-stress CMR was performed in median 2.94 years after recruitment during which timeframe some HFpEF patients had undergone interatrial shunt device (IASD) implantation. Cardiovascular events were assessed after 4 years.Serial CMR scans were available for NCD n = 10, HFpEF n = 10 and HFpEF with IASD implantation following baseline diagnosis n = 6. RV long axis strain at rest and during exercise-stress decreased in HFpEF (p = 0.007 for both) but neither in NCD nor HFpEF with IASD. In contrast, in NCD, an improvement in LA LAS during exercise-stress (p = 0.028) was noted. There were no functional alterations in HFpEF patients who had undergone IASD implantation. RV functional deterioration may be a pathophysiological feature during early-stage disease progress in HFpEF. In this observational study RV functional deterioration was detected in HFpEF patients only but not patients with NCD and patients with HFpEF that were treated with IASD placement. These findings should next be explored in adequately powered future research trials. Clinicaltrials.gov: NCT03260621 (First posted date 24/08/2017).

A Retrospective Study Evaluating the Safety and Clinical Impact of High Dose (6.75 grams) Piperacillin-Tazobactam Dosing in Critically Ill Obese Patients for Pneumonia

Background: Piperacillin-tazobactam (PTZ) demonstrates time-dependent bactericidal activity, potentially increasing the need for higher dosing in obese and critically ill patients. However, limited information is available on the safety of higher dosing strategies. Objective: To evaluate the safety and clinical impact of high dose 6.75 g IV PTZ for the treatment of pneumonia in critically ill, obese (≥120 kg) patients vs standard dose 4.5 g IV PTZ. Methods: Retrospective, cohort study, multicenter in health-system consisting of four acute-care teaching hospitals. Adult patients weighing at least 120 kg on PTZ for pneumonia in the intensive care unit (ICU) from January 2013 to September 2018 were included. The primary outcome of the study was acute nephrotoxicity defined as initiation of renal replacement therapy and/or serum creatinine increase within 48 hours of last PTZ dose. Secondary outcomes included thrombocytopenia, 14-day all-cause mortality, and ICU length of stay (LOS). Results: One hundred thirty-six patients were included with 52 and 84 in 4.5 g PTZ and 6.75 g PTZ respectively. The rate of acute nephrotoxicity was comparable between cohorts (50% 4.5 g vs 40.5% 6.75 g, P = 0.277). High dose PTZ was not independently associated with acute nephrotoxicity after control for selected confounders. All secondary outcomes were similar. Concomitant vancomycin and calculated supratherapeutic vancomycin area under curve were not independently associated with increased nephrotoxicity. Conclusions: High dose PTZ was not associated with increased acute nephrotoxicity, thrombocytopenia, 14-day all-cause mortality, or ICU LOS. Additionally, more robust trials are needed to fully assess the clinical impact of 6.75 g PTZ dosing for critically ill, obese patients, for pneumonia.

Individualized drug therapy and survival prediction in ICU patients with acute kidney injury: construction and validation of a nomogram

BACKGROUND

Acute kidney injury (AKI) is defined by a sharp decrease in the estimated glomerular filtration rate (eGFR). However, the impact of medication history on the survival of AKI patients has received little attention. Hence, it is necessary to investigate the potential of medication history as a predictor of survival outcomes among AKI patients in the intensive care unit (ICU).

METHODS

Critically ill AKI patients were sourced from the MIMIC-IV database. To ascertain significant, drug-related, independent predictors of survival, univariate Cox analysis and stepwise Cox regression were performed. Based on the identified predictor, a nomogram was developed to estimate the individualized survival probability for AKI patients. Additionally, to address potential confounders among patients with medications referenced in the nomogram, a propensity score matching procedure was applied. Ultimately, a comparative analysis was performed to elucidate the prognostic disparities among these patient subgroups.

RESULTS

This study enrolled 1,208 patients and developed a nomogram incorporating oxygen flow rate, respiratory frequency, continuous venovenous hemodiafiltration status, age, and medication use (including ibuprofen, epinephrine, cefazolin, warfarin, and vasopressin). The predictive model demonstrated diagnostic accuracy, with AUC values for 1-year, 3-year, and 5-year survival among AKI patients of 0.827, 0.799, and 0.777 in the training dataset, and 0.760, 0.743, and 0.740 in the internal validation dataset, respectively. Kaplan-Meier survival analyses revealed significant differences in survival outcomes among AKI patients based on their exposure to different medications.

CONCLUSIONS

In summary, the developed prediction model demonstrated accuracy for AKI patients in the ICU and helped clinical decision-making. However, future studies will require external validation to confirm these findings.

Detecting occult hemorrhage bleeding using a new protocol called the UFOH protocol: Ultrasound Focused Occult Hemorrhage

Point-of-care abdominal ultrasound (US) has emerged as a powerful tool for clinicians and is becoming a routine bedside tool to rapidly diagnose, manage hemodynamics, monitor fluid status, and guide procedures in emergency and critical care. Extended focused assessment with sonography for trauma (eFAST), is commonly used to detect free intraperitoneal blood in the trauma setting and may also be an option in non-trauma patients. However, it has significant limitations for detecting gastrointestinal or retroperitoneal bleeding. To date, there is no US protocol described for the diagnosis of occult bleeding in the retroperitoneal space. We describe a new US protocol called "Ultrasound For Occult Hemorrhage" (UFOH) for a fast diagnosis of occult hemorrhage. The UFOH protocol is a novel ultrasound-guided approach designed to detect occult bleeding in various clinical settings, including emergency department, intensive care and perioperative environment.

Tracheostomy: update on why, when and how

PURPOSE OF REVIEW

The aim of this review is to summarize available data, including the most recent ones, to help develop the best possible strategy regarding the use of tracheostomy in ICU patients requiring prolonged mechanical ventilation or who experience loss of airway-protecting mechanisms.

RECENT FINDINGS

Tracheostomy facilitates the weaning process by reducing the patient's work of breathing and increasing comfort. It thus allows for a reduction in sedation levels. It also helps with secretions clearance, facilitates disconnection from the ventilator, and enables earlier phonation, oral intake, and mobilization. Despite these advantages, tracheostomy does not reduce mortality and is associated with both early and late complications, particularly tracheal stenosis. The timing of tracheostomy remains a subject of debate, and only a personalized approach that considers each patient's specific characteristics can help find the best possible compromise between avoiding unnecessary delays and minimizing the risks of performing a needless invasive procedure. In the absence of contraindications, the percutaneous single dilator technique under fibroscopic guidance should be the first choice, but only if the team is properly trained.

SUMMARY

A step-by-step individualized approach based on the available evidence allows identifying the best strategy regarding the use of tracheostomy in ICU patients.

Sepsis-induced cardiomyopathy: understanding pathophysiology and clinical implications

Sepsis is a life-threatening form of organ dysfunction resulting from a dysregulated response to infection. The complex pathogenesis of sepsis poses challenges because of the lack of reliable biomarkers for early identification and effective treatments. As sepsis progresses to severe forms, cardiac dysfunction becomes a major concern, often manifesting as ventricular dilation, a reduced ejection fraction, and a diminished contractile capacity, known as sepsis-induced cardiomyopathy (SIC). The absence of standardized diagnostic and treatment protocols for SIC leads to varied criteria being used across medical institutions and studies, resulting in significant outcome disparities. Despite the high prevalence of SIC, accurate statistical data are lacking. To understand how SIC affects sepsis prognosis, a thorough exploration of its pathophysiological mechanisms, including systemic factors and complex signalling within myocardial and immune cells, is required. Identifying the factors influencing SIC occurrence and progression is crucial and must be conducted within specific clinical contexts. In this review, the clinical manifestations, pathophysiological mechanisms, and treatment strategies for SIC are discussed, along with the clinical background. We aim to connect current practices with future research challenges, providing clear guidance for clinicians and researchers.

'Real-life' approach to applying PK/PD principles in infectious diseases clinical practice without access to prompt TDM

INTRODUCTION

Infectious disease treatments are transitioning from a one-size-fits-all approach to a more tailored approach. The increasing adoption of therapeutic drug monitoring (TDM) of antimicrobials is a clear example of this trend. Routine antimicrobial TDM in critically ill patients should be mandatory. Unfortunately, nowadays, only expert centers can provide it. Given the crucial nature of the first hours/days for achieving a favorable clinical outcome, empirical antibiotic therapy with an adequate choice of drug, dose and administration modalities is fundamental.

AREAS COVERED

We outline common scenarios encountered in clinical practice, such as in edematous patients, hypoalbuminemia, patients with liver and renal diseases, patients under renal replacement therapy or extracorporeal membrane oxygenation (ECMO), over or under-weight patients, in old adults and cases of infections caused by relatively high minimum inhibitory concentration (MIC) pathogens. Various clinical situations were analyzed with the help of the available literature (PubMed/MEDLINE/Google Scholar and books written by experts in pharmacology and infectious diseases).

EXPERT OPINION

In these different scenarios, we reported common examples of optimizing drug utilization to maximize therapeutic outcomes, reduce incorrect prescriptions and limit the emergence of antimicrobial resistance.

Association of norepinephrine with pressure ulcer development in critically ill patients with COVID-19-related acute respiratory distress syndrome: A dose-response analysis

OBJECTIVES

To investigate the correlation between varying doses of norepinephrine (NE) and the incidence of pressure injuries (PIs) in COVID-19 patients in intensive care units (ICUs).

DESIGN

A retrospective multicenter study was conducted on 1,078 COVID-19 patients admitted to ICUs with acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. The research spanned from March 2020 to April 2021 across five university-affiliated hospitals in Iran. Univariate and multivariate binary logistic regression analyses, along with linear and non-linear dose-response assessments, were utilized to evaluate the relationship between NE dosages and the probability of PI development.

FINDINGS

The multivariate analysis revealed a significant association between higher doses of NE administered over 24 h (OR: 1.832, 95 % CI: 1.218-2.754, P=0.004) and cumulative doses (OR: 1.408, 95 % CI: 1.204-1.975, P=0.048) with the occurrence of PIs. Moreover, patients receiving high NE doses had a nearly fourfold increased risk of developing PIs, regardless of PIs stage, compared to those on low or moderate doses (>15 µg/min vs. ≤ 15 µg/min; OR: 4.401, 95 % CI: 3.339-5.801, P=0.001). Although the linear dose-response analysis did not show a significant correlation between NE doses and PI development (P>0.05), the non-linear analysis indicated that NE doses ≤ 9 µg/min were associated with a reduced risk of PI development.

CONCLUSION

Maintaining NE infusion within the range of 1-9 µg/min appears to be most effective in reducing the likelihood of PIs in ICU patients with COVID-19. Lower NE doses (≤9 µg/min) were associated with a lower risk of PI development, suggesting that factors beyond NE dosage or the use of other vasopressors may play a crucial role in PI formation in this patient cohort.

IMPLICATIONS FOR CLINICAL PRACTICE

Rather than suggesting a specific threshold, clinicians should consider further studies to determine the optimal dose that balances microvascular perfusion and patient outcomes. It is crucial to comprehensively evaluate additional factors and selectively use vasopressors. Individualized care, including regular monitoring and personalized treatment plans, is essential for achieving the best outcomes in this patient population.

Beyond the Beat: A Multifaceted Review of Atrial Fibrillation in Sepsis: Risk Factors, Management Strategies, and Economic Impact

Atrial fibrillation (AF) is a common arrhythmia in critically ill patients. The objective of this narrative review is to evaluate the characteristics of patients who develop new-onset atrial fibrillation (NOAF) because of sepsis, current management of NOAF in sepsis patients, special consideration in different populations that developed NOAF, health economic and quality of life of patients. We conducted a literature search on PubMed to find research related to NOAF, sepsis and critical illness. Nineteen studies were analyzed for risk factors and outcomes. The incidence rate ranges from 0.53% to 43.9% among these studies. There were numerous risk factors that had been reported from these articles. The most reported risk factors included advanced age, male sex, White race, and cardiovascular comorbidities. The management of septic patients is significantly challenging because of the unfavorable cardiovascular consequences and thromboembolic hazards associated with NOAF. There are comprehensive guidelines available for managing AF, but the effectiveness and safety of therapies in patients with sepsis are still uncertain. Various approaches for managing newly diagnosed AF have been explored. Sinus rhythm can be restored through either pharmacological or non-pharmacological intervention or combination of both. In addition, thromboembolism is a complication that can occur in patients with AF and can have a negative impact on the prognosis of sepsis patients. The use of anticoagulation to prevent stroke after NOAF in sepsis patients is still controversial. Extensive prospective investigations are required to have a deeper understanding of the necessity for anticoagulation following NOAF in sepsis. Beside the treatment of NOAF, early detection of NOAF in sepsis plays a critical role. The prompt initiation of rhythm control medication following a clinical diagnosis of AF can enhance cardiovascular outcomes and reduce mortality in patients with AF and cardiovascular risk factors. Additionally, NOAF in the intensive care unit can prolong hospital stays, increasing hospitalization costs and burdening the hospital. Therefore, preventing and managing NOAF effectively not only benefit the patients but also the hospital in financial aspect. Lastly, to address the existing gaps in knowledge, future research should focus on developing machine learning models that can accurately anticipate risks, establish long-term follow-up protocols, and create complete monitoring systems. The focus is on early intervention and personalized approaches to improve outcomes and quality of life.

Intraoperative Low-Dose Glucocorticoids in Surgical Patients With Abdominal Sepsis: A Multicenter Retrospective Cohort Study

Background and Aims

Abdominal sepsis refers to a severe and potentially life-threatening condition characterized by the presence of infection, inflammation, and tissue damage within the abdominal cavity. Glucocorticoids (GCs) play an important role in regulation of the host immune and inflammation responses involved in sepsis and surgery. This study aimed to investigate the potential impact of intraoperative GCs administration on the clinical outcome of surgical patients with abdominal sepsis.

Methods

This retrospective cohort study included a 1:1 propensity score-matched cohort of surgical patients afflicted with abdominal sepsis at two medical centers from January 2008 to December 2022. Patients were classified into low-GCs, high-GCs, and non-GCs groups according to the dosage of steroids used intraoperatively, and in-hospital mortality was designated as the primary outcome.

Results

This study included a total of 476 patients, with 217 in the non-GCs group, 213 in the low-GCs group, and 46 in the high-GCs group. The overall in-hospital mortality rate was 7.56%. After propensity score matching (PSM), there were 168 cases in both the low-GCs group and the non-GCs group, with no significant differences observed between the groups regarding mortality rate, length of hospital-stay, and duration of intensive care unit (ICU) stay. In patients with septic shock, the use of low-dose GCs increased the urine output and decreased the requirements for vasopressors on the first postoperative day, however, it had no impact on the in-hospital mortality or ICU stay. Moreover, prophylactic use of GCs during anesthesia induction did not decrease the incidence of intraoperative hypotension or necessity of vasopressors use.

Conclusion

Intraoperative administration of low-dose GCs demonstrates a transient improvement in hemodynamics of patients with septic shock, however, it did not lead to improved clinical outcomes. Further research remains necessary to elucidate the optimal perioperative dosing strategy.

High-Riding Innominate Artery: Booby Trap for ICU Tracheotomy

Despite tracheotomy being a routine procedure, it is not rare to encounter anatomic irregularities that can compromise its success. In this report, we describe a case in which a high riding innominate artery was identified within the surgical trajectory moments before incision, which ultimately necessitated airway securement using an alternative laryngological procedure. Laryngoscope, 135:626-628, 2025.

Efficacy of extended infusion of β-lactam antibiotics for the treatment of febrile neutropenia in haematologic patients (BEATLE): a randomized, multicentre, open-label, superiority clinical trial

OBJECTIVES

The efficacy of extended infusions (EI) of β-lactam antibiotics for optimising outcomes in febrile neutropenia is unclear. We assessed whether the administration of β-lactams was more effective in EI than in intermittent infusion (II) for the treatment of febrile neutropenia.

METHODS

We performed a randomized, open-label, superiority clinical trial of patients with febrile neutropenia at four Spanish university hospitals. Patients undergoing haematopoietic stem cell transplantation or with acute leukaemia receiving chemotherapy who required empirical antibiotic treatment for febrile neutropenia were randomly assigned (1:1) to receive EI of β-lactam or II after a first dose in bolus. The choice of antipseudomonal β-lactam was left to the discretion of the attending physician. The primary endpoint was treatment success at day 5, defined as defervescence without modifying the antibiotic treatment. Secondary endpoints included adverse events, attainment of the pharmacokinetic/pharmacodynamic target of 50%, 75%, and 100%ƒuT > MIC, and 30-day mortality.

RESULTS

From November 19, 2019 to June 22, 2022, 295 patients were screened for eligibility, of whom 150 were randomly assigned to receive EI (n = 77) or II (n = 73) of the antipseudomonal β-lactam of choice. In the intention-to-treat analysis, treatment success at day 5 was achieved in 39/77 patients (50.6%) receiving EI versus 46/73 patients (63.0%) receiving II (risk difference, -12.4%; 95% CI, -29.4 to 4.7; p 0.17). The pharmacokinetic/pharmacodynamic targets of 75% and 100% ƒuT > MIC for empirical treatment were achieved more frequently in the EI group. No statistically significant differences were found between groups in terms of adverse events or 30-day mortality.

DISCUSSION

Our findings do not support the routine use of empirical EI of β-lactams in febrile neutropenia. Further studies should consider the clinical heterogeneity of febrile neutropenia and focus on patients with sepsis or septic shock and microbiologically documented infections, particularly those with infections caused by microorganisms less susceptible to β-lactams.

Beneficial Effects of Angiotensin II Receptor Blockers on Mortality in Patients with COVID-19: A Retrospective Study from 2019 to 2020 in China

BACKGROUND

The COVID-19 pandemic has become a serious global public health problem. Although the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor type 1 blockers (ARBs) has been recommended in patients with COVID-19 and cardiovascular diseases (CVDs), according to the results of some small-sample retrospective analyses, there remains a lack of sufficient evidence to validate their efficacy. This multicenter retrospective study investigated whether ACEI/ARB administration was beneficial in patients with COVID-19 and CVDs.

METHODS

A total of 11,231 patients with confirmed COVID-19 and CVDs, from 138 hospitals in Hubei Province, were included in this multicenter retrospective study. We compared the clinical characteristics and outcomes between the ARB and non-ARB groups and analyzed the risk factors for in-hospital death using univariate and multivariate Cox regression analyses and Kaplan-Meier curves.

RESULTS

In the multivariate Cox regression model, after adjusting for age, gender, comorbidities, and in-hospital medications, ARB use was associated with lower all-cause mortality (adjusted HR, 0.53; 95% CI, 0.38-0.73; P < 0.001). After propensity score-matched analysis, the adjusted HR for the use of ARB associated with all-cause mortality was 0.62 (95% CI, 0.40-0.88; P = 0.02). Further subgroup analyses found that the adjusted HRs for the use of ARB associated with all-cause mortality were 0.52 (95% CI, 0.30-0.89; P = 0.016), 0.37 (95% CI, 0.21-0.64; P < 0.001), 0.42 (95% CI, 0.28-0.64; P < 0.001), and 0.55 (95% CI, 0.37-0.84; P = 0.005) in patients with heart failure, diabetes, and hypercholesterolemia, and severe COVID-19, respectively.

CONCLUSIONS

ARB administration was significantly associated with a lower risk of all-cause mortality in patients with COVID-19 and CVDs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05615792. https://www.

CLINICALTRIALS

gov/ct2/show/NCT05615792.

Antimicrobial Resistance Trends and Epidemiological Characteristics of Isolates from Intra-Abdominal Infections in China: A 6-Year Retrospective Study (2017-2022)

Background: Antimicrobial resistance represents a continuing threat to the health of patients with intra-abdominal infections (IAIs). This study aimed to provide clinicians with guidance to optimize antibiotic therapy. Methods: The clinical data and antibiotic susceptibility results of pathogens from patients with IAIs from 2017 to 2022 were retrospectively collected. The 6-year period was segmented into two stages, namely, the early (2017-2020) and recent stages (2021-2022). The distribution and antibiotic resistance of pathogens were compared between the stages. Results: In total, 5,795 pathogens were isolated from 2,283 patients diagnosed with IAIs. Gram-negative bacteria, Gram-positive bacteria, and fungi accounted for 71.0%, 21.4%, and 7.5% of the isolates, respectively. Klebsiella pneumoniae (1,037, 17.9%) was the primary isolate. The proportion of extended-spectrum β-lactamase-producing Enterobacteriaceae was 89.8% (2,028/2,259), with extended-spectrum β-lactamase-producing Escherichia coli and K. pneumoniae accounting for 27.4% and 43.2%, respectively, of all such isolates. The carbapenem resistance rates of E. coli and K. pneumoniae were 17.1% and 75.9%, respectively. Compared with that in the early stage, the imipenem resistance rate of E. coli was significantly higher in the recent stage (13.8% vs. 25.1%, p < 0.001). Among Gram-positive bacteria, 88 strains of vancomycin-resistant Enterococcus were detected, giving a resistance rate of 10.3%, and the detection rate of methicillin-resistant Staphylococcus aureus was 65.7%. Conclusions: Enterobacteriales and non-fermentative bacteria from IAIs remain highly resistant to carbapenems. The epidemiological characteristics and antibiotic resistance profiles of pathogens in various regions should be closely monitored to mitigate the appearance of drug-resistant bacteria in clinical settings.

Machine Learning Model for Predicting Risk Factors of Prolonged Length of Hospital Stay in Patients with Aortic Dissection: a Retrospective Clinical Study

The length of hospital stay (LOS) is crucial for assessing medical service quality. This study aimed to develop machine learning models for predicting risk factors of prolonged LOS in patients with aortic dissection (AD). The data of 516 AD patients were obtained from the hospital's medical system, with 111 patients in the prolonged LOS (> 30 days) group based on three quarters of the LOS in the entire cohort. Given the screened variables and prediction models, the XGBoost model demonstrated superior predictive performance in identifying prolonged LOS, due to the highest area under the receiver operating characteristic curve, sensitivity, and F1-score in both subsets. The SHapley Additive exPlanation analysis indicated that high density lipoprotein cholesterol, alanine transaminase, systolic blood pressure, percentage of lymphocyte, and operation time were the top five risk factors associated with prolonged LOS. These findings have a guiding value for the clinical management of patients with AD.

Are contemporary antifungal doses sufficient for critically ill patients? Outcomes from an international, multicenter pharmacokinetics study for Screening Antifungal Exposure in Intensive Care Units-the SAFE-ICU study

PURPOSE

Appropriate antifungal therapy is a major determinant of survival in critically ill patients with invasive fungal disease. We sought to describe whether contemporary dosing of antifungals achieves therapeutic exposures in critically ill patients.

METHODS

In a prospective, open-label, multicenter pharmacokinetic study, intensive care unit (ICU) patients prescribed azoles, echinocandins, or polyene antifungals for treatment or prophylaxis of invasive fungal disease were enrolled. Blood samples were collected on two occasions, with three samples taken during a single dosing interval on each occasion. Total concentrations were centrally measured using validated chromatographic methods. Pharmacokinetic parameters were estimated using noncompartmental methods. Antifungal dosing adequacy was assessed using predefined PK/PD targets.

RESULTS

We included 339 patients from 30 ICUs across 12 countries. Median age 62 (interquartile range [IQR], 51-70) years, median APACHE II score 22 (IQR, 17-28), and 61% males. Antifungal therapy was primarily prescribed for treatment (80.8%). Fluconazole was the most frequently prescribed antifungal (40.7%). The most common indication for treatment was intra-abdominal infection (30.7%). Fungi were identified in 45% of patients, of which only 26% had a minimum inhibitory concentration available. Target attainment was higher for patients receiving prophylaxis (> 80% for most drugs). For patients receiving treatment, low target attainment was noted for voriconazole (57.1%), posaconazole (63.2%), micafungin (64.1%) and amphotericin B (41.7%).

CONCLUSION

This study highlights the varying degrees of target attainment across antifungal agents in critically ill patients. While a significant proportion of patients achieved the predefined PK/PD targets, wide variability and subtherapeutic exposures persist.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03136926, 2017-04-21.

Target attainment of beta-lactam antibiotics and ciprofloxacin in critically ill patients and its association with 28-day mortality

OBJECTIVES

This study aims to assess pharmacodynamic target attainment in critically ill patients and identify factors influencing target attainment and mortality outcomes.

METHODS

We analysed data from the DOLPHIN trial. Beta-lactam and ciprofloxacin peak and trough concentration were measured within the first 36 h (T1) after initiation of treatment. The study outcome included the rate of pharmacodynamic target attainment of 100 % ƒT>1xEpidemiological cut-off value (ECOFF) for beta-lactams, and of fAUC0-24h/ECOFF>125 for ciprofloxacin at T1.

RESULTS

The target attainment rates were 78.1 % (n = 228/292) for beta-lactams, and 41.5 % (n = 39/94) for ciprofloxacin, respectively. Lower estimated glomerular filtration rate and higher SOFA score were associated with target attainment. In patients receiving beta-lactams, 28-day mortality was significantly higher in patients who attained 100 % ƒT>1xECOFF (28.9 % vs. 12.5 %; p = 0.01). In the multivariate analysis, attainment of 100 % ƒT>4xECOFF, but not 100 % ƒT>1xECOFF, was associated with a higher 28-day mortality (OR 2.70, 95 % CI 1.36-5.48 vs. OR 1.28, 95 % CI 0.53-3.34).

CONCLUSIONS

A high rate of target attainment (100 % ƒT>1xECOFF) for beta-lactams and a lower rate for ciprofloxacin was observed. Achieving exposures of 100 % ƒT>4xECOFF was associated with 28-day mortality. The impact of antibiotic target attainment on clinical outcome needs to be a focus of future research.

High VExUS grades are linked to cardiac function in general intensive care unit patients

AIMS

Even though initially considered as a new standard in systemic venous congestion assessment, the semi-quantitative Doppler ultrasound-based venous excess ultrasound grading system (VExUS) showed inconsistent associations with outcomes in general intensive care unit (ICU) patients. It is unclear why VExUS is so effective in predicting outcomes in some cohorts and not in others. The determinants of higher VExUS have not been studied in a general ICU cohort. The aim of this study was to determine the factors associated with higher VExUS (≥ 2) in a general ICU cohort.

METHODS AND RESULTS

We performed a post-hoc analysis of a prospective, observational cohort, including adult patients within 24 h of ICU admission and expected ICU length of stay longer than 2 days. Collected data included patients' haemodynamic status (including ultrasound evaluation) at several points in time: ICU admission, Day 1, Day 2, Day 5, and the last day of ICU stay. We analysed 514 haemodynamic evaluations in 145 patients. In total, 96/514 (18.7%) had a VExUS grade ≥ 2. The univariable followed by multivariable mixed-effects logistic regression analyses only found a statistically significant association between VExUS ≥ 2 and right ventricle S wave [OR 0.85 (0.74;0.97), P = 0.02] and left ventricle E/A ratio [OR 2.34, 95% CI (1.27;4.33), P = 0.006].

CONCLUSION

The current study has elucidated that higher VExUS is primarily associated with cardiac comorbidities and ultrasound parameters of left- and right-sided cardiac systolic and/or diastolic function in general ICU patients.

Antibacterial and antifungal drug concentrations in intra-abdominal abscesses: a prospective clinical study

Secondary peritonitis with intra-abdominal abscesses (IAA) is difficult to treat because of the supposed low rate of penetration of antimicrobial drugs at the site of infection. However, clinical data about the actual bioavailability of antimicrobial drugs in IAA are scarce. This prospective observational study aimed at assessing the drug penetration in IAA of the antibiotics (piperacillin-tazobactam, carbapenems) and antifungals (fluconazole, echinocandins) that are usually recommended for the treatment of intra-abdominal infections. Patients with IAA who underwent a radiological or surgical drainage procedure were included. Antimicrobial drug concentrations were measured in IAA (CIAA) and in a simultaneous plasma sample (Cplasma) to assess the CIAA/Cplasma ratio. The pharmacodynamic target was defined as a CIAA equal or superior to the clinical breakpoints of susceptibility of the most relevant intra-abdominal pathogens. Clinical outcomes were assessed at hospital discharge. A total of 54 antimicrobial drug measurements were performed in 39 IAA samples originating from 36 patients. Despite important inter-individual variability, piperacillin-tazobactam exhibited the highest CIAA/Cplasma ratios (median 2). The rates of target achievement were 75%-80% for piperacillin-tazobactam and meropenem but 0% for imipenem and ertapenem. These results tended to correlate with clinical outcomes (96% success rate versus 73%, respectively, P = 0.07). Among antifungals, fluconazole exhibited higher CIAA/Cplasma ratios and rates of target achievement compared to echinocandins. However, no differences in clinical outcomes were observed. These results provide unique information about antimicrobial drug penetration in IAA in real clinical conditions and suggest that piperacillin-tazobactam and meropenem may have better efficacy compared to imipenem or ertapenem.

Cost-effectiveness of data driven personalised antibiotic dosing in critically ill patients with sepsis or septic shock

PURPOSE

This study provides an economic evaluation of bedside, data-driven, and model-informed precision dosing of antibiotics in comparison with usual care among critically ill patients with sepsis or septic shock.

METHODS

This economic evaluation was conducted alongside an AutoKinetics randomized controlled trial. Effect measures included quality-adjusted life years (QALYs), mortality and pharmacokinetic target attainment. Costs were measured from a societal perspective. Missing data was multiply imputed, and bootstrapping was used to estimate statistical uncertainty. Differences in effects and costs were estimated using bivariate regression and used to calculate incremental cost-effectiveness ratios.

RESULTS

Patients in the intervention group had higher costs (€42,684 vs. 39,475), lower mortality (42% vs. 49%), more QALYs (0.184 vs. 0.153), and higher pharmacokinetic target attainment (69% vs. 48%). Only the difference for target attainment was found statistically significant. An additional €18,129, €55,576, and €123,493 needs to be invested to attain the targeted plasma levels for one more patient, to save one life and gain one QALY, respectively. The probability of cost-effectiveness for all effect outcomes is below 60% for most acceptable willingness-to-pay thresholds.

CONCLUSIONS

Data-driven personalised antibiotic dosing in critically ill patients as implemented in the AutoKinetics trial cannot be recommended for implementation as a cost-effective intervention.

TRIAL REGISTRATION

The trial was prospectively registered at Netherlands Trial Register (NTR), NL6501/NTR6689 on 25 August 2017 and at the European Clinical Trials Database (EudraCT), 2017-002478-37 on 6 November 2017.

Correlation Between the Inferior Vena Cava/Aorta (Ivc/Ao) Ratio and Serum Lactate Levels in Children With Renal Disorder

Background

Acute kidney injury (AKI) is common in critically ill children in the PICU, with incidence rates from 2.5% to 58%, impacting mortality and hospital duration. Early AKI detection is vital, but conventional hemodynamic monitoring often lacks specificity. This study investigates the relationship between the inferior vena cava/aortic (IVC/Ao) ratio and serum lactate levels as non-invasive indicators of renal hemodynamics and tissue perfusion in children. Understanding these parameters could improve early diagnosis, aid clinical decisions, and enhance outcomes for pediatric AKI patients, offering an accessible monitoring method for clinicians.

Methods

This cross-sectional study involved 48 pediatric patients aged 5-18 years showing Pediatric Early Warning Score (PEWS) ≥3 and diagnosed with renal disorders. Patients were admitted to the emergency department, high care unit, PICU, and pediatric ward at Dr. Hasan Sadikin Hospital, Bandung, between May and August 2023. AKI was diagnosed using pRIFLE or KDIGO criteria. The IVC/Ao ratio was assessed via transabdominal USG, and serum lactate levels were measured. Spearman correlation analysis was conducted to assess their relationship.

Results

The median (IQR) IVC/Ao ratio was 0.91 (0.70-1.10), and serum lactate levels were 1.5 (1.1-2.4) mmol/L. Spearman correlation analysis revealed a negative correlation between the IVC/Ao ratio and serum lactate (rho = -0.65, p < 0.001).

Conclusion

A decrease in the IVC/Ao ratio correlates with an increase in serum lactate levels in children with AKI.

Venoarterial Membrane Oxygenation in Cardiogenic Shock Complicated from an Acute Myocardial Infarction: An Overview and Comprehensive Meta-Analysis

Background: Cardiogenic shock remains a significant cause of mortality in patients with acute coronary syndrome, despite early interventions, such as coronary revascularization. Mechanical circulatory support devices, particularly venoarterial extracorporeal membrane oxygenation (VA-ECMO), are increasingly being utilized to address this issue. Limited randomized controlled trials (RCTs) exist to evaluate the efficacy of VA-ECMO in cardiogenic shock related to acute coronary syndrome. Methods: A meta-analysis was conducted to assess the effectiveness of VA-ECMO in adult patients with infarct-related cardiogenic shock. Trials were identified through database searches and selected based on specific inclusion criteria. The primary outcome was 30-day all-cause mortality, with secondary outcomes including bleeding and vascular complications. Results: A total of 24 studies met the inclusion criteria and were included in the meta-analysis, involving 4706 patients. The median age of the patients was 61.8 ± 4.1 years, with 76% of them being males. The analysis revealed that 30-day mortality rates for patients with cardiogenic shock receiving ECMO were still high, with a mortality of 63%. Vascular complications were identified as factors associated with a worse prognosis. Conclusions: The meta-analysis highlights the ongoing challenge of high mortality rates in cardiogenic shock patients despite the use of VA-ECMO. While VA-ECMO shows promise in providing circulatory support, further research is needed to explore ways to improve outcomes and reduce complications associated with the use of these devices. The complexity of patient management in cardiogenic shock cases underscores the need for a multidisciplinary approach to optimize treatment strategies and enhance patient outcomes.

Assessing fluid responsiveness by using functional hemodynamic tests in critically ill patients: a narrative review and a profile-based clinical guide

Fluids are given with the purpose of increasing cardiac output (CO), but approximately only 50% of critically ill patients are fluid responders. Since the effect of a fluid bolus is time-sensitive, it diminuish within few hours, following the initial fluid resuscitation. Several functional hemodynamic tests (FHTs), consisting of maneuvers affecting heart-lung interactions, have been conceived to discriminate fluid responders from non-responders. Three main variables affect the reliability of FHTs in predicting fluid responsiveness: (1) tidal volume; (2) spontaneous breathing activity; (3) cardiac arrythmias. Most FTHs have been validated in sedated or even paralyzed ICU patients, since, historically, controlled mechanical ventilation with high tidal volumes was the preferred mode of ventilatory support. The transition to contemporary methods of invasive mechanical ventilation with spontaneous breathing activity impacts heart-lung interactions by modifying intrathoracic pressure, tidal volumes and transvascular pressure in lung capillaries. These alterations and the heterogeneity in respiratory mechanics (that is present both in healthy and injured lungs) subsequently influence venous return and cardiac output. Cardiac arrythmias are frequently present in critically ill patients, especially atrial fibrillation, and intuitively impact on FHTs. This is due to the random CO fluctuations. Finally, the presence of continuous CO monitoring in ICU patients is not standard and the assessment of fluid responsiveness with surrogate methods is clinically useful, but also challenging. In this review we provide an algorithm for the use of FHTs in different subgroups of ICU patients, according to ventilatory setting, cardiac rhythm and the availability of continuous hemodynamic monitoring.

Safety Analysis of Visual Percutaneous Tracheostomy in Neurocritical Care Patients with Anticoagulation and Antithrombosis

BACKGROUND

This study aims to evaluate the safety of visual percutaneous tracheostomy (vPDT) in neurologic intensive care unit (NICU) patients who are under anticoagulant and antithrombotic therapy.

METHODS

A retrospective cohort study was conducted on 54 NICU patients who underwent vPDT at Tai'an Central Hospital from September 2022 to September 2023. The cohort included 36 men and 18 women aged 36-90 years (mean age 62.24 ± 12.24 years). Patients were divided into two groups based on their treatment: an anticoagulant and antithrombotic group (22 patients) and a non-anticoagulant and non-antithrombotic group (32 patients). Clinical data, including demographic information, comorbidities, Glasgow Coma Scale (GCS) score before vPDT, time from NICU admission to vPDT, laboratory indicators, and vPDT complications, were analyzed.

RESULTS

The incidence of vPDT complications in the anticoagulant and antithrombotic group was 18.2%, involving three cases of minor intraoperative bleeding and one case of posterior airway wall injury. The non-anticoagulant and non-antithrombotic group had an 18.8% complication rate, including four cases of minor intraoperative bleeding, one case of subcutaneous emphysema with local infection, and one unrelated death. No significant difference in vPDT complications was observed between the two groups (P > 0.05). However, the anticoagulant and antithrombotic group had a higher average age, higher GCS scores, and longer time intervals from NICU admission to vPDT and from intubation to vPDT (all P < 0.05).

CONCLUSION

vPDT appears to be a safe and feasible procedure for NICU patients receiving anticoagulant and antithrombotic therapy, with no significant increase in complications compared to those not on such therapies.

Navigating the Waves of Critical Care Echocardiography: Unveiling its Role, Advantages, and Pitfalls in the Cardiac Intensive Care Unit

PURPOSE OF REVIEW

Critical Care Echocardiography (CCE) is now established as an important tool in the intensive care unit (ICU). This paper aims to examine the expanding role of cardiovascular ultrasound in the ICU, focusing on its applications, benefits, and challenges, while highlighting recent advancements shaping the future of critical care echocardiography.

RECENT FINDINGS

Non-invasive echocardiographic measurement of hemodynamic parameters including stroke volume, cardiac output, left ventricular filling pressures, and pulmonary pressures have been well-validated against invasive measurements. Myocardial perfusion can also be evaluated using ultrasound enhancing agent techniques to further risk-stratify patients with chest pain. Echocardiography enables clinicians to visualize cardiac anatomy and physiology directly at the bedside, providing immediate feedback in rapidly changing clinical situations. Assessment of stroke volume, cardiac output, and left ventricular filling pressures can be readily measured at the bedside and correspond with clinical outcomes including mortality. Measurement of central venous pressure and pulmonary pressures may guide clinical decisions in fluid management and mechanical ventilation strategies. Lastly, myocardial perfusion imaging can supplement the 2D echocardiographic evaluation to further risk-stratify patients presenting with chest pain.

Assessment of Fluid Responsiveness via Central Venous Ultrasound Measurement: A Network Meta-Analysis

Background: Ultrasonographic assessment of the diameters of various veins and their indices are among the most applied diagnostic tools for evaluating fluid responsiveness in clinical practice. Despite their widespread use, there is no definitive answer on which is preferable. Our study aimed to investigate the diagnostic accuracy of different venous diameters and their indices to assess fluid responsiveness. Methods: We conducted a systematic review and network meta-analysis, analyzing prospective studies evaluating the diagnostic accuracy of venous diameters (inferior vena cava [IVC], internal jugular vein [IJV], superior vena cava, and subclavian vena) and their indices for fluid responsiveness. Electronic databases were searched from inception until March 2024; this search was supplemented by snowballing methods. The risk of bias was evaluated with QUADAS-2, and evidence certainty was assessed using the GRADE approach. Nine prospective cohort studies (560 patients) were included. Results: The network meta-analysis revealed that the ΔCaval index exhibited a significant performance advantage over other "venous" test parameters. The caval index significantly outperformed IJV min/max and IVCmax. IJV index and IVCmin significantly outperformed IJVmin/max. The caval index was comparable to the IJV index. The caval index was comparable during mechanical ventilation and spontaneous breathing. Conclusions: In this meta-analysis, the ΔCaval index test showed higher diagnostic accuracy for fluid responsiveness compared with other venous tests. Caval and jugular indices displayed similar accuracy, and caval indices were consistent under mechanical ventilation and spontaneous breathing. Indices generally outperformed absolute values, except for IVCmin, which equaled the caval index in efficacy. This study was registered on the International Platform for Registered Protocols for Systematic Reviews and Meta-Analyses: INPLASY202430104.

Modified National Early Warning Scores (MNEWS) for Predicting the Outcomes of Suspected Sepsis Patients; A Prospective Cohort Study

Introduction

The National Early Warning Score (NEWS) is commonly used to identify patients at high mortality risk. However, it has notable limitations. In this study, to enhance the accuracy, we revised it and evaluated the performance of modified NEWS (MNEWS) in predicting the outcomes of suspected sepsis patients.

Methods

This single-center, prospective cohort study was conducted on patients with suspected sepsis to evaluate the accuracy of MNEWS in predicting mortality, survival to discharge, vasopressor requirements, and the need for mechanical ventilation. The MNEWS comprises the NEWS variables plus age, chronic major organ dysfunction, malignancy, functional status, and specific infected organ involvement. Sensitivity, specificity, likelihood ratio (LR), and area under the receiver operating characteristic curve (AUROC) were used to evaluate the performance of the MNEWS in predicting the studied outcomes.

Results

Of the 1,393 patients included in this study, 209 died. Mean MNEWS was significantly higher in non-survivors than survivors (19.8 vs. 14.9, p<0.001). The AUROC of MNEWS in predicting 30-day mortality was 0.82 (95% CI: 0.79-0.85). MNEWS ≥ 18 had the highest accuracy for 30-day mortality prediction with 76.1% sensitivity, 75% specificity, positive LR of 3.13, and AUROC of 0.76 (95% CI: 0.73-0.79). The AUROC of MNEWS ≥18 for predicting survival until discharge, need for vasopressors, and need for mechanical ventilation were 0.75 (95% CI: 0.72-0.78), 0.72 (95% CI: 0.69-0.75), and 0.76 (95% CI: 0.73-0.79), respectively. Additionally, MNEWS ≥18 demonstrated superior predictive performance, compared with NEWS ≥7 and qSOFA ≥2 for various clinical outcomes.

Conclusions

The MNEWS was similar to the NEWS in overall predictive accuracy for 30-day mortality but exhibited a higher predictive accuracy than did the qSOFA score. Notably, MNEWS ≥18 was a significant indicator of 30-day mortality risk, as well as the likelihood of requiring vasopressors, survival to discharge, and 7-day mortality.

Changes in pulse pressure variation induced by passive leg raising test to predict preload responsiveness in mechanically ventilated patients with low tidal volume in ICU: a systematic review and meta-analysis

BACKGROUND

Pulse pressure variation (PPV) is limited in low tidal volume mechanical ventilation. We conducted this systematic review and meta-analysis to evaluate whether passive leg raising (PLR)-induced changes in PPV can reliably predict preload/fluid responsiveness in mechanically ventilated patients with low tidal volume in the intensive care unit.

METHODS

PubMed, Embase, and Cochrane databases were screened for diagnostic research relevant to the predictability of PPV change after PLR in low-tidal volume mechanically ventilated patients. The QUADAS-2 scale was used to assess the risk of bias of the included studies. In-between study heterogeneity was assessed through the I2 indicator. Publication bias was assessed by the Deeks' funnel plot asymmetry test. Summary receiving operating characteristic curve (SROC), pooled sensitivity, and specificity were calculated.

RESULTS

Five studies with a total of 474 patients were included in this meta-analysis. The SROC of the absolute PPV change resulted in an area under the curve of 0.91 (95% CI 0.88-0.93), with overall pooled sensitivity and specificity of 0.88 (95% CI 0.82-0.91) and 0.83 (95% CI 0.76-0.89), respectively. The diagnostic odds ratio was 35 (95% CI 19-67). The mean and median cutoff values of PLR-induced absolute change in absolute PPV were both -2 points and ranged from -2.5 to -1 points. Overall, there was no significant heterogeneity with I2 = 0%. There was no significant publication bias. Fagan's nomogram showed that with a pre-test probability of 50%, the post-test probability reached 84% and 17% for the positive and negative tests, respectively.

CONCLUSIONS

PLR-induced change in absolute PPV has good diagnostic performance in predicting preload/fluid responsiveness in ICU patients on mechanical ventilation with low tidal volume. Trial registration PROSPERO (CRD42024496901). Registered on 15 January 2024.

Utilizing deep learning-based causal inference to explore vancomycin's impact on continuous kidney replacement therapy necessity in blood culture-positive intensive care unit patients

Patients with positive blood cultures in the intensive care unit (ICU) are at high risk for septic acute kidney injury requiring continuous kidney replacement therapy (CKRT), especially when treated with vancomycin. This study developed a machine learning model to predict CKRT and examined vancomycin's impact using deep learning-based causal inference. We analyzed ICU patients with positive blood cultures, utilizing the Medical Information Mart for Intensive Care III data set. The primary outcome was defined as the initiation of CKRT during the ICU stay. The machine learning models were developed to predict the outcome. The deep learning-based causal inference model was utilized to quantitatively demonstrate the impact of vancomycin on the probability of CKRT initiation. Logistic regression was performed to analyze the relationship between the variables and the susceptibility of vancomycin. A total of 1,318 patients were included in the analysis, with 41 requiring CKRT. The Random Forest and Light Gradient Boosting Machine exhibited the best performance, with Area Under Curve of Receiver Operating Characteristic Curve values of 0.905 and 0.886, respectively. The deep learning-based causal inference model demonstrated an average 7.7% increase in the probability of CKRT occurrence when administrating vancomycin in total data set. Additionally, that younger age, lower diastolic blood pressure, higher heart rate, higher baseline creatinine, and lower bicarbonate levels sensitized the probability of CKRT application in response to vancomycin treatment. Deep learning-based causal inference models showed that vancomycin administration increases CKRT risk, identifying specific patient characteristics associated with higher susceptibility.IMPORTANCEThis study assesses the impact of vancomycin on the risk of continuous kidney replacement therapy (CKRT) in intensive care unit (ICU) patients with blood culture-positive infections. Utilizing deep learning-based causal inference and machine learning models, the research quantifies how vancomycin administration increases CKRT risk by an average of 7.7%. Key variables influencing susceptibility include baseline creatinine, diastolic blood pressure, heart rate, and bicarbonate levels. These findings offer insights into managing vancomycin-induced kidney risk and may inform patient-specific treatment strategies in ICU settings.

Investigation of Teicoplanin Trough Concentrations and Safety Following High-Dose Loading in a Pediatric Population

BACKGROUND

Therapeutic drug monitoring-informed teicoplanin dosage adjustments are recommended for safe and effective use. The authors' group previously reported that only half of children reached the recommended blood concentration range at the standard teicoplanin loading dose. It has been suggested that higher loading doses are necessary; however, the usefulness and safety of high-dose loading in pediatric patients in clinical practice are unknown.

METHODS

This retrospective cohort study was conducted between January 2018 and June 2021 using electronic medical records. The analysis included 2- to 16-year-old patients treated with teicoplanin who met the eligibility criteria. We assessed the trough concentration of teicoplanin and its safety after high-dose loading in pediatric patients.

RESULTS

Overall, 86 patients received a high-dose loading regimen (15 mg/kg every 12 hours for 3 doses, followed by 10 mg/kg once daily). Notably, 55 of the 86 patients (64%) achieved the target trough concentration (>15 mg/L) at significantly higher rates without increasing the incidence of organ damage compared with the standard loading regimen. Multivariate analysis revealed significant differences in age and renal function as factors that inhibited the attainment of the target trough concentration. Simulation analysis using a nomogram stratified by age and renal function revealed that the predicted teicoplanin trough levels were within the target trough values in 73% of patients.

CONCLUSIONS

High-dose teicoplanin loading safely increases trough blood concentrations in the pediatric population. For further optimization, the dose selection should be stratified according to age and renal function.

Therapeutic drug monitoring (TDM) of β-lactam/β-lactamase inhibitor (BL/BLI) drug combinations: insights from a pharmacometric simulation study

BACKGROUND

The emergence of β-lactamase-producing bacteria has led to the use of β-lactam (BL) antibiotic and β-lactamase inhibitor (BLI) drug combinations. Despite therapeutic drug monitoring (TDM) being endorsed for BLs, the impact of TDM on BLIs remains unclear.

OBJECTIVES

Evaluate whether BLIs are available in effective exposures at the site of infection and assess if TDM of BLIs could be of interest.

METHODS

Population pharmacokinetic models for 9 BL and BLI compounds were used to simulate drug concentrations at infection sites following EMA-approved dose regimens, considering plasma protein binding and tissue penetration. Predicted target site concentrations were used for probability of target attainment (PTA) analysis.

RESULTS

Using EUCAST targets, satisfactory (≥90%) PTA was observed for BLs in patients with typical renal clearance (CrCL of 80 mL/min) across various sites of infection. However, results varied for BLIs. Avibactam achieved satisfactory PTA only in plasma, with reduced PTAs in abdomen (78%), lung (73%) and prostate (23%). Similarly, tazobactam resulted in unsatisfactory PTAs in intra-abdominal infections (79%), urinary tract infections (64%) and prostatitis (34%). Imipenem-relebactam and meropenem-vaborbactam achieved overall satisfactory PTAs, except in prostatitis and high-MIC infections for the latter combination.

CONCLUSIONS

This study highlights the risk of solely relying on TDM of BLs, as this can indicate acceptable exposures of the BL while the BLI concentration, and consequently the combination, can result in suboptimal performance in terms of bacterial killing. Thus, dose adjustments also based on plasma concentration measurements of BLIs, in particular for avibactam and tazobactam, can be valuable in clinical practice to obtain effective exposures at the target site.

Antibiotic Length of Therapy: Is Shorter Better in Older Adults?

Background Antibiotic lengths of therapy (LOT) vary widely, based on infection type, antibiotic regimen, and patient characteristics. Longer LOT are associated with increased risk of antibiotic resistance, adverse effects, and health care costs. There are increasing data supporting shorter LOT for many infections based on randomized, controlled trials (RCTs). Objective To evaluate RCTs supporting shorter antibiotic LOT for common infections, with an emphasis on applying the data to older adults. Data Sources A list of RCTs that evaluated shorter LOT for common infections was first gathered from the website of Brad Spellberg, MD, at https://www.bradspellberg.com/shorter-is-better. The list was then verified through a PubMed search using the terms for each infection and LOT. Data Synthesis Of the 28 identified RCTs, 27 supported shorter antibiotic LOT. These trials were categorized by disease states: complicated urinary tract infections including pyelonephritis (n = 9), community-acquired pneumonia (n = 6), hospital-acquired pneumonia/ ventilator-associated pneumonia (n = 3), skin and soft tissue infections (n = 4), complicated intra-abdominal infections (n = 2), and gram-negative bacteremia (n = 3). The single incongruent trial was conducted on male patients with complicated urinary tract infections, and the results could be explained by a lower than usual dose of antibiotic utilized in the study. Discussion Many RCTs have demonstrated the safety and efficacy of shorter antibiotic LOT for the disease states included in this review. Several of these trials enrolled older adults. Conclusion There are sufficient data to support using shorter antibiotic LOT in older patients. Implementing this strategy can help pharmacists and other health care professionals optimize antibiotic use in older adults.

Prognostic Value of Advanced Echocardiography in Patients with Ischemic Heart Disease: A Comprehensive Review

Cardiovascular (CV) diseases caused 20.5 million deaths in 2021, making up nearly one-third of global mortality. This highlights the need for practical prognostic markers to better classify patients and guide treatment, especially in ischemic heart disease (IHD), which represents one of the leading causes of CV mortality. Transthoracic echocardiography (TTE) is a key, non-invasive imaging tool widely used in cardiology for diagnosing and managing a range of CV conditions. It is the first choice for diagnosing and monitoring patients with acute coronary syndrome (ACS). Alongside well-established echocardiographic measures, new techniques have proven useful for predicting adverse events in IHD patients, such as three-dimensional (3D) and tissue Doppler imaging (TDI), and speckle tracking technology. This review aims to explore the latest echocardiographic tools that could provide new prognostic markers for patients in the acute phase and during follow-up after an acute myocardial infarction (AMI). We focus on new imaging methods like TDI, myocardial work index (MWI), speckle-tracking strain, and 3D technologies using TTE, which are easy to use and widely available at all stages of coronary artery disease (CAD).

Life-threatening spontaneous splenic rupture in congenital afibrinogenemia: Two case reports and systematic literature review

BACKGROUND

Spontaneous splenic rupture is a rare life-threatening finding with a challenging diagnosis which is largely ignored in the literature. Hematological disorders such as afibrinogenemia are reported to cause bleeding disorders mostly cerebral hemorrhage. Despite being a life-threatening condition, data about spontaneous splenic rupture in patients with Afibrinogenemia remain scarce. Such fatal incidents should warrant diligent efforts to establish and adopt prevention measures in this particularly vulnerable population. We report two new cases of spontaneous splenic rupture in two siblings, diagnosed with congenital afibrinogenemia since early childhood. In addition, we report the results of a systematic review of the literature of cases that have reported the occurrence of splenic rupture in afibrinogenemia, with the aim of filling the gap in the clinical course of such an uncommon event.

METHODS

We conduced a systematic review of English and French language publications cataloged in Pubmed, and Google Scholar up to December 2022. We opted to include articles written in other languages if an English language abstract was available and contained the information needed for our report. The following MeSH (medical subject heading) search criteria were used: ''splenic rupture'' AND ''afibrinogenemia.'' The above search strategy was further combined with a supplementary strategy that included the MeSH terms ''spleen'', AND ''rupture'' AND ''Afibrinogenemia''. In order to reduce the selection bias in searching on the Google Scholar database, we searched for articles containing these MeSH terms in their titles.

RESULTS

We reported two cases of splenic rupture in two family members who were diagnosed with afibrinogenemia at the age of 1 year. The splenic rupture was misdiagnosed by clinicians in the brother's case, resulting in his death and presenting as a forensic case. However, the sister underwent a splenectomy one week before her brother's death following the onset of asthenia and acute abdominal pain. Then we conducted a literature review of relevant studies of spontaneous splenic rupture in Afibrinogenemia. A selection of 13 relevant studies was included in the final review, describing a total of 25 cases of spontaneous splenic rupture in Afibrinogenemia. One paper was an international cross-sectional study across 25 different countries involving 211 patients with fibrinogen disorders, showing that 11 patients with afibrinogenemia had developed spontaneous splenic rupture. The remaining 12 articles were case reports or case series, describing a total of 14 cases of atraumatic splenic rupture in afibrinogenemia, ranging from 0 to 28 years old, with a median age of 14.5 years, where the majority were infants (age inferior to 18) with the most cases occurred in the age group of 10-15 years old.

CONCLUSION

Congenital afibrinogenemia is a rare disease with a wide range of clinical symptoms and with challenging management. While the most common presenting symptoms are bleeding and thrombosis, spontaneous spleen rupture is rare and probably underdiagnosed which consequently may lead to death. Studies about the topic remain scarce, hence, further studies are needed to ascertain this risk and establish target preventive measures for this vulnerable population.

Factors influencing the turnover of nurses in French intensive care unit-A multicenter interview survey

BACKGROUND

Nurse retention is a major concern in healthcare settings, especially among intensive care units (ICU), in which nurses are highly specialized. The objective was to describe the nurse courses after their entrance into the ICU, their motivation for leaving the ICU, and to identify the independent factors that influenced the nurse resignation from their units.

METHODS

In 3 different centers, every ICU nurse working between 2013 and 2023 was telephonically contacted and was asked to describe their career and, when appropriate, the reasons that influenced their resignation from their units; they rated on a Likert scale of 14 factors that influenced their decision.

RESULTS

Among the 405 nurses who worked in these ICUs between 2013 and 2023, 265 (65.0%) were included in the study, and 93 (35.1%) were still working in their unit. The median time of professional experience of the nurses in their ICU was 5.8 [5.0-7.0] years, and at 10 years, 26.3% [20.4-33.9] of the nurses remained in their unit, 23.8% [17.3-32.8] left the ICU but were still in-hospital nurses, and 22.4% [15.8-31.7] underwent specialization. A minority of nurses resigned and changed their careers (9.5% [5.3-17.0]). The main factors influencing the nurse's resignation from their unit were belonging to Generation Y or Z (HR 1.89 [1.35;2.64]), experiencing symptoms of burnout (2.37 [1.63;3.46]), and pregnancy during the ICU (1.77 [1.41;2.23]). The COVID-19 period was inconsistently associated with nurse resignation depending on the center. The main motivations to leave the unit were organizational (variability of schedule, night shift), personal (willingness to change, personal event), and related to the ICU workload.

CONCLUSION

Nurse retention is an increasing concern, associated with the generational aspects and increased prevalence of burnout. Structural changes will have to be made to reduce the turnover.

Cardiac Function and Functional Capacity in Patients With Long COVID: A Comparison to Propensity-Matched Community Controls

BACKGROUND

Cardiac impairment has been associated with acute COVID-19 since the earliest reports of the pandemic. However, its role in postacute sequelae of COVID-19 ("long COVID") is undefined, and many existing observations about cardiovascular involvement in postacute sequelae of COVID-19 are uncontrolled.

OBJECTIVE

To compare the prevalence of cardiac dysfunction in patients with long COVID and noninfected controls from the same community and explore their association with functional capacity.

METHODS

Echocardiography was used to assess cardiac structure and function, including the measurement of global longitudinal strain (GLS), in 190 participants with long COVID. All underwent assessment of functional impairment by subjective (Duke Activity Status Index) and objective tests (6-minute walk test). The 190 participants from the long COVID group were matched with those from 979 patients who underwent the same tests in the pre-COVID-19 era, using a propensity score.

RESULTS

The 190 patients with long COVID had similar age and risk factor profiles to those of their matched controls. Left ventricular dimensions and geometry, but not diastolic parameters, were significantly altered in the long COVID group. The long COVID group had subclinical systolic dysfunction (GLS 18.5% ± 2.6% vs 19.3% ± 2.7%, P = .005), and more long COVID patients had abnormal (<16%) GLS (13% vs 8%, P = .035). The association of long COVID with abnormal GLS (odds ratio, 1.49 [1.04, 2.45]) was independent of-and had a similar or greater effect size than-age and risk factors. There was no interaction of long COVID with the association of risk factors with GLS. As expected, the long COVID group had significant subjective (<85% predicted METS; 72% vs 5%, P < .001) and objective functional impairment (29% vs 24%, P = .026), but GLS was only weakly associated with both subjective (r = 0.30, P = .005) and objective (r = 0.21, P = .05) functional impairment. The presence of long COVID was independently associated with subjective (odds ratio = 159.7 [95% CI, 61.6-414.2]) and objective functional impairment (odds ratio = 2.8 [95% CI, 1.5-5.2]).

CONCLUSIONS

Impaired GLS and left ventricular dimensions are the echocardiographic features that are overrepresented in long COVID, and this association is similar to and independent of other risk factors. Impaired GLS is weakly associated with functional impairment.

Epidemiology, timing, technique, and outcomes of tracheostomy in patients with trauma: a multi-centre retrospective study

BACKGROUND

Tracheostomy is performed in patients with trauma who need prolonged ventilation for respiratory failure or airway management. Although it has benefits, such as reduced sedation and easier care, it also has risks. This study explored the unclear timing, technique, and patient selection criteria for tracheostomy in patients with trauma.

METHODS

We included 220 adult patients with trauma who underwent tracheostomy after endotracheal intubation between January 2019 and December 2022. We compared clinical outcomes between patients who underwent early (within 10 days) and late (after 10 days) tracheostomy and between patients who underwent percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST). Factors associated with hospital and intensive care unit (ICU) length of stay (LOS), ICU-free days, duration of mechanical ventilation, and ventilator-free days (VFDs) were identified using multiple linear regression analysis.

RESULTS

The patients' mean age was 61.5 years; 75.9% were men. Most tracheostomies were performed after 10 days (n = 135, 61.4%), with PDT serving as the more common approach during this period. Contrastingly, early tracheostomies (n = 85, 38.6%) were predominantly performed using ST. Early tracheostomy was significantly associated with reduced hospital (P = 0.038) and ICU LOS (P = 0.047), decreased duration of mechanical ventilation (P = 0.001), and increased VFDs (P < 0.001). However, no significant association was found with ICU-free days (P = 0.072) or in-hospital mortality (P = 0.917).

CONCLUSION

Early tracheostomy was associated with reduced hospital and ICU LOS, decreased duration of mechanical ventilation, and increased VFDs.

Profile of Serum Inflammatory Biomarkers in Children with Peritonitis and their Role in Predicting the Severity and Outcome

Aims and Objectives

The aim of this study was to determine whether the levels of serum inflammatory markers (C-reactive protein [CRP], interleukin-6 [IL-6], calprotectin, and N terminal pro-B-type natriuretic peptide [NT-proBNP]) predict the severity and outcome in children with peritonitis. The primary objective was to evaluate the profile of these serum inflammatory biomarkers in children with peritonitis. The secondary objectives were to correlate the level of these biomarkers with pediatric sequential organ failure assessment (pSOFA) severity score at admission and predict the outcome (mortality).

Methods

In this prospective observational study, the level of above serum inflammatory biomarkers in children with peritonitis was measured at the time of admission. The disease severity was assessed using pSOFA score and the association of these biomarkers with the outcomes was studied.

Results

A total of 80 children with peritonitis (M: F:: 9:7, mean age: 6.22 ± 3.7 years) were included. The median values of serum CRP, IL-6, calprotectin, and NT-proBNP were 196.88 mg/L (interquartile range [IQR]: 124.37, 285.6), 6.74 pg/ml (IQR: 1.87, 12.54), 46750 μg/L (IQR: 17937.5, 84075), and 365.2 ng/L (IQR: 170, 1034), respectively. Serum CRP and NT-proBNP correlated with pSOFA score. The pSOFA score >4 and serum NT-proBNP were significant in predicting mortality in children with peritonitis (p < 0.001).

Conclusion

In children with peritonitis, serum levels of inflammatory biomarkers, i.e. CRP, calprotectin, and NT-proBNP were found to be raised, whereas IL-6 was not raised. The pSOFA score >4 predicted mortality. The serum levels of NT-proBNP were significantly raised in nonsurvivors in children with peritonitis, therefore, can be used as a predictor of severity and mortality in children with peritonitis.

Management of disease-related abdominal abscesses in Crohn's disease

INTRODUCTION

Crohn's disease (CD)-related abdominal abscesses require tailored management strategies taking into consideration the variability in abscess size, location, and underlying CD activity.

AREAS COVERED

This review discusses current approaches to CD-related abscesses. Literature review was performed through the PubMed and Medline databases to identify studies pertinent to the wide-ranging focus of this review.

EXPERT OPINION

Early, individualized treatment combining medical and surgical strategies is crucial for optimizing outcomes in patients with CD-related abdominal abscesses. Antibiotics are effective for smaller abscesses in hemodynamically stable patients; however, recurrence is common, necessitating close monitoring. Percutaneous drainage (PD) provides a less invasive alternative to surgery, offering high initial success rates but variable long-term results, as many patients ultimately need a definitive surgical intervention. For larger or complex abscesses, surgery may be necessary to address both the abscess and underlying CD. Despite its invasiveness, surgery is associated with high success rates and reduced recurrence risk. Biologic therapies, particularly anti-TNF agents, have shown promise in managing CD-associated abscesses, and can reduce abscess recurrence risk without surgery. While biologics may help delay or avoid surgery in select patients, interdisciplinary collaboration is essential to mitigate the risks associated with immunosuppression in the presence of intra-abdominal infections.

Establishment and Validation of a Machine-Learning Prediction Nomogram Based on Lymphocyte Subtyping for Intra-Abdominal Candidiasis in Septic Patients

This study aimed to develop and validate a nomogram based on lymphocyte subtyping and clinical factors for the early and rapid prediction of Intra-abdominal candidiasis (IAC) in septic patients. A prospective cohort study of 633 consecutive patients diagnosed with sepsis and intra-abdominal infection (IAI) was performed. We assessed the clinical characteristics and lymphocyte subsets at the onset of IAI. A machine-learning random forest model was used to select important variables, and multivariate logistic regression was used to analyze the factors influencing IAC. A nomogram model was constructed, and the discrimination, calibration, and clinical effectiveness of the model were verified. High-dose corticosteroids receipt, the CD4+T/CD8+ T ratio, total parenteral nutrition, gastrointestinal perforation, (1,3)-β-D-glucan (BDG) positivity and broad-spectrum antibiotics receipt were independent predictors of IAC. Using the above parameters to establish a nomogram, the area under the curve (AUC) values of the nomogram in the derivation and validation cohorts were 0.822 (95% CI 0.777-0.868) and 0.808 (95% CI 0.739-0.876), respectively. The AUC in the derivation cohort was greater than the Candida score [0.822 (95% CI 0.777-0.868) vs. 0.521 (95% CI 0.478-0.563), p < 0.001]. The calibration curve showed good predictive values and observed values of the nomogram; the Decision Curve Analysis (DCA) results showed that the nomogram had high clinical value. In conclusion, we established a nomogram based on the CD4+/CD8+ T-cell ratio and clinical risk factors that can help clinical physicians quickly rule out IAC or identify patients at greater risk for IAC at the onset of infection.

2025 Expert Consensus Recommendations for the Diagnostic Requirements in Routine Practices of Transthoracic Echocardiography

Transthoracic echocardiography plays a crucial role in clinical diagnosis and is increasingly being used around the world. Comprehensive echocardiographic examinations require accurate measurements and the operators to have excellent technical skills. Despite the availability of several published echocardiographic guidelines, the absence of recommended operational manuals in daily practice has resulted in significant variation in the content of echocardiography reports across different medical institutions. This variability has created communication barriers between medical institutions and also hampered the development of a national echocardiography database in Taiwan. Balancing quality and efficiency is a critical concern in echocardiography, and most published guidelines for echocardiography primarily focus on disease categorization. In the current document, we focus on information about the scanning sequence, including scanning techniques, common pitfalls, simple disease interpretation, and the recommended intensity. Based on a growing body of research, we particularly emphasize right-sided imaging and measurement information. We also discuss equipment settings, which have often been overlooked but are essential to obtaining good imaging and accurate measurements. Our recommendations could enhance clinicians' and sonographers' understanding of the core aspects of echocardiography and were developed with consideration of the health-care payment system in Taiwan. Implementing our recommendations may subsequently enable the establishment of a national echocardiography database in Taiwan.

Dose optimization of piperacillin/tazobactam, cefepime, and ceftazidime for carbapenem-resistant Pseudomonas aeruginosa isolates in Türkiye

INTRODUCTION

Although CRPA may test susceptible to other β-lactams such as ceftazidime (CAZ), cefepime (FEP), and piperacillin/tazobactam (TZP), reduced potency has been observed. We assessed the adequacy of EUCAST Susceptible (S) or Susceptible Increased Exposure (SIE)/(I) doses for CAZ, FEP, and TZP against CRPA clinical isolates.

METHODS

CRPA isolates were collected from patients at three Turkish hospitals. CAZ, FEP, and TZP MICs were determined using broth microdilution. Monte Carlo simulations were performed to determine the probability of target attainment (PTA) for a free time above the MIC (fT > MIC) targets for various doses of each agent against isolates defined as susceptible. fT > MIC targets were 70% for CAZ or FEP and 50% for TZP. Cumulative fraction of response (CFR) was calculated. Optimal PTA and CFR was 90% target achievement.

RESULTS

The percentages of isolates SIE/I to CAZ, FEP, and TZP were 49,8%, 47%, and 31,8% respectively. Reduced potency was noted with 54,1% of CAZ-S isolates having MICs of 4 or 8 mg/L. Of the FEP and TZP-S isolates, MICs at the breakpoint (8 and 16 mg/L, respectively) were the mode with 45,2 and 53,9% of isolates for each, respectively. At an MIC of 8 mg/L for CAZ, the EUCAST standard dose was insufficient (CFR of 85%). 3 h infusions of EUCAST SIE doses were required for 90% PTA at MIC of 8 mg/L and an optimized CFR of 100%. For FEP, the SIE dose of 2 g q8h 0.5 h infusion of was effective (CFR 96%), utilization of an extended 3 h infusion further optimized the PTA at 8 mg/L (CFR 99%). For TZP, the standard dose of 4.5 q6h administered as a 0.5 h infusion was inadequate (CFR 86%). A standard TZP dose with an extended infusion (4.5 g q8h over 4 h) and the SIE dose 4.5 g q6h 3 h infusion resulted in CFRs > 95%.

CONCLUSION

These data support the EUCAST SIE breakpoints for FEP and TZP. To optimize PTA at the SIE breakpoint for CAZ, prolonged infusion is required.