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Lorente L, Sabater-Riera J, Rello J. Surveillance and prevention of healthcare-associated infections: best practices to prevent ventilator-associated events. Expert Rev Anti Infect Ther 2024; 22:317-332. [PMID: 38642072 DOI: 10.1080/14787210.2024.2345877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Ventilator associated pneumonia (VAP) leads to an increase in morbidity, mortality, and healthcare costs. In addition to increased evidence from the latest European and American guidelines (published in 2017 and 2022, respectively), in the last two years, several important clinical experiences have added new prevention tools to be included to improve the management of VAP. AREAS COVERED This paper is a narrative review of new evidence on VAP prevention. We divided VAP prevention measures into pharmacological, non-pharmacological, and ventilator care bundles. EXPERT OPINION Most of the effective strategies that have been shown to decrease the incidence of complications are easy to implement and inexpensive. The implementation of care bundles, accompanied by educational measures and a multidisciplinary team should be part of optimal management. In addition to ventilator care bundles for the prevention of VAP, it could possibly be beneficial to use ventilator care bundles for the prevention of noninfectious ventilator associated events.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Spain
| | - Joan Sabater-Riera
- IDIBELL, Hospitalet de Llobregat, Spain, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Spain
| | - Jordi Rello
- CRIPS (Clinical Research in Pneumonia & Sepsis); Vall d'Hebron Institute of Research, Barcelona, Spain
- Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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2
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Carlet J. Selective digestive decontamination: We must make an international decision on this 40-year old controversy. Intensive Care Med 2024; 50:272-274. [PMID: 38117320 DOI: 10.1007/s00134-023-07289-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/18/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Jean Carlet
- ESICM and Waaar (World Alliance Against Antibiotic Resistance), Créteil, France.
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3
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Cho NA, Strayer K, Dobson B, McDonald B. Pathogenesis and therapeutic opportunities of gut microbiome dysbiosis in critical illness. Gut Microbes 2024; 16:2351478. [PMID: 38780485 PMCID: PMC11123462 DOI: 10.1080/19490976.2024.2351478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
For many years, it has been hypothesized that pathological changes to the gut microbiome in critical illness is a driver of infections, organ dysfunction, and other adverse outcomes in the intensive care unit (ICU). The advent of contemporary microbiome methodologies and multi-omics tools have allowed researchers to test this hypothesis by dissecting host-microbe interactions in the gut to better define its contribution to critical illness pathogenesis. Observational studies of patients in ICUs have revealed that gut microbial communities are profoundly altered in critical illness, characterized by markedly reduced alpha diversity, loss of commensal taxa, and expansion of potential pathogens. These key features of ICU gut dysbiosis have been associated with adverse outcomes including life-threatening hospital-acquired (nosocomial) infections. Current research strives to define cellular and molecular mechanisms connecting gut dysbiosis with infections and other outcomes, and to identify opportunities for therapeutic modulation of host-microbe interactions. This review synthesizes evidence from studies of critically ill patients that have informed our understanding of intestinal dysbiosis in the ICU, mechanisms linking dysbiosis to infections and other adverse outcomes, as well as clinical trials of microbiota-modifying therapies. Additionally, we discuss novel avenues for precision microbial therapeutics to combat nosocomial infections and other life-threatening complications of critical illness.
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Affiliation(s)
- Nicole A Cho
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn Strayer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Breenna Dobson
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Candel FJ, Salavert M, Estella A, Ferrer M, Ferrer R, Gamazo JJ, García-Vidal C, del Castillo JG, González-Ramallo VJ, Gordo F, Mirón-Rubio M, Pérez-Pallarés J, Pitart C, del Pozo JL, Ramírez P, Rascado P, Reyes S, Ruiz-Garbajosa P, Suberviola B, Vidal P, Zaragoza R. Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review. J Clin Med 2023; 12:6526. [PMID: 37892664 PMCID: PMC10607368 DOI: 10.3390/jcm12206526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.
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Affiliation(s)
- Francisco Javier Candel
- Clinical Microbiology and Infectious Diseases, Transplant Coordination, IdISSC & IML Health Research Institutes, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, La Fe (IIS) Health Research Institute, Hospital Universitario y Politécnico La Fe, 46026 València, Spain
| | - Angel Estella
- Intensive Medicine Service, Hospital Universitario de Jerez, 11407 Jerez, Spain
- Departamento de Medicina, INIBICA, Universidad de Cádiz, 11003 Cádiz, Spain
| | - Miquel Ferrer
- UVIR, Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic de Barcelona, IDIBAPS, CibeRes (CB06/06/0028), Universitat de Barcelona, 08007 Barcelona, Spain;
| | - Ricard Ferrer
- Intensive Medicine Service, Hospital Universitario Valle de Hebrón, 08035 Barcelona, Spain;
| | - Julio Javier Gamazo
- Servicio de Urgencias, Hospital Universitario de Galdakao, 48960 Bilbao, Spain;
| | | | | | | | - Federico Gordo
- Intensive Medicine Service, Hospital Universitario del Henares, 28822 Coslada, Spain;
| | - Manuel Mirón-Rubio
- Servicio de Hospitalización a Domicilio, Hospital Universitario de Torrejón, 28850 Torrejón de Ardoz, Spain;
| | - Javier Pérez-Pallarés
- Division of Respiratory Medicine, Hospital Universitario Santa Lucía, 30202 Cartagena, Spain;
| | - Cristina Pitart
- Department of Clinical Microbiology, ISGlobal, Hospital Clínic-University of Barcelona, CIBERINF, 08036 Barcelona, Spain;
| | - José Luís del Pozo
- Servicio de Enfermedades Infecciosas, Servicio de Microbiología, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Paula Ramírez
- Intensive Medicine Service, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | - Pedro Rascado
- Intensive Care Unit, Complejo Hospitalario Universitario Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Soledad Reyes
- Neumology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Borja Suberviola
- Intensive Medicine Service, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria IDIVAL, 39011 Santander, Spain;
| | - Pablo Vidal
- Intensive Medicine Service, Complexo Hospitalario Universitario de Ourense, 32005 Ourense, Spain;
| | - Rafael Zaragoza
- Intensive Care Unit, Hospital Dr. Peset, 46017 Valencia, Spain;
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Tejerina-Álvarez EE, de la Cal López MÁ. Selective decontamination of the digestive tract: concept and application. Med Intensiva 2023; 47:603-615. [PMID: 37858367 DOI: 10.1016/j.medine.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/20/2023] [Indexed: 10/21/2023]
Abstract
Selective digestive decontamination (SDD) is a prophylactic strategy aimed at preventing or eradicating bacterial overgrowth in the intestinal flora that precedes the development of most infections in the Intensive Care Unit. SDD prevents serious infections, reduces mortality, is cost-effective, has no adverse effects, and its short- or long-term use is not associated with any significant increase in antimicrobial resistance. SDD is one of the most widely evaluated interventions in critically ill patients, yet its use is not widespread. The present article offers a narrative review of the most relevant evidence and an update of the pathophysiological concepts of infection control supporting the use of SDD.
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Affiliation(s)
- Eva Esther Tejerina-Álvarez
- Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo, Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain.
| | - Miguel Ángel de la Cal López
- Department of Intensive Care Medicine, Hospital Universitario de Getafe, Carretera de Toledo, Getafe, Madrid, Spain.
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De Waele JJ, Leroux-Roels I, Depuydt P. Selective digestive decontamination - Pro. Intensive Care Med 2023; 49:979-981. [PMID: 37209122 DOI: 10.1007/s00134-023-07100-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/08/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | - Isabel Leroux-Roels
- Department of Medical Microbiology, Ghent University Hospital, Ghent, Belgium
- Department of Infection Control, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Pieter Depuydt
- Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Roson-Calero N, Ballesté-Delpierre C, Fernández J, Vila J. Insights on Current Strategies to Decolonize the Gut from Multidrug-Resistant Bacteria: Pros and Cons. Antibiotics (Basel) 2023; 12:1074. [PMID: 37370393 DOI: 10.3390/antibiotics12061074] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
In the last decades, we have witnessed a steady increase in infections caused by multidrug-resistant (MDR) bacteria. These infections are associated with higher morbidity and mortality. Several interventions should be taken to reduce the emergence and spread of MDR bacteria. The eradication of resistant pathogens colonizing specific human body sites that would likely cause further infection in other sites is one of the most conventional strategies. The objective of this narrative mini-review is to compile and discuss different strategies for the eradication of MDR bacteria from gut microbiota. Here, we analyse the prevalence of MDR bacteria in the community and the hospital and the clinical impact of gut microbiota colonisation with MDR bacteria. Then, several strategies to eliminate MDR bacteria from gut microbiota are described and include: (i) selective decontamination of the digestive tract (SDD) using a cocktail of antibiotics; (ii) the use of pre and probiotics; (iii) fecal microbiota transplantation; (iv) the use of specific phages; (v) engineered CRISPR-Cas Systems. This review intends to provide a state-of-the-art of the most relevant strategies to eradicate MDR bacteria from gut microbiota currently being investigated.
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Affiliation(s)
- Natalia Roson-Calero
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- Department of Basic Clinical Practice, School of Medicine, University of Barcelona, 08036 Barcelona, Spain
| | - Clara Ballesté-Delpierre
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, 08036 Barcelona, Spain
- European Foundation for the Study of Chronic Liver Failure (EF-Clif), 08021 Barcelona, Spain
| | - Jordi Vila
- Barcelona Institute for Global Health (ISGlobal), 08036 Barcelona, Spain
- Department of Basic Clinical Practice, School of Medicine, University of Barcelona, 08036 Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto Salud Carlos III, 28029 Madrid, Spain
- Department of Clinical Microbiology, Biomedical Diagnostic Center, Hospital Clinic, 08036 Barcelona, Spain
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Abstract
PURPOSE OF REVIEW Study of organ crosstalk in critical illness has uncovered complex biological communication between different organ systems, but the role of microbiota in organ crosstalk has received limited attention. We highlight the emerging understanding of the gut-lung axis, and how the largest biomass of the human body in the gut may affect lung physiology in critical illness. RECENT FINDINGS Disruption of healthy gut microbial communities and replacement by disease-promoting pathogens (pathobiome) generates a maladaptive transmitter of messages from the gut to the lungs, connected via the portal venous and the mesenteric lymphatic systems. Gut barrier impairment allows for microbial translocation (living organisms or cellular fragments) to the lungs. Host-microbiota interactions in the gut mucosa can also impact lung physiology through microbial metabolite secretion or host-derived messengers (hormones, cytokines or immune cells). Clinical examples like the prevention of ventilator-associated pneumonia by selective decontamination of the digestive tract show that the gut-lung axis can be manipulated therapeutically. SUMMARY A growing body of evidence supports the pathophysiological relevance of the gut-lung axis, yet we are only at the brink of understanding the therapeutic and prognostic relevance of the gut microbiome, metabolites and host-microbe interactions in critical illness.
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Affiliation(s)
- Sridesh Nath
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine
| | - Georgios D Kitsios
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine
- Acute Lung Injury Center of Excellence
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lieuwe D J Bos
- Intensive Care
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Massart N, Dupin C, Legris E, Fedun Y, Barbarot N, Legay F, Wattecamps G, Le Gall F, La Combe B, Bouju P, Frerou A, Muller L, Rieul G, Fillatre P. Multiple-site decontamination in mechanically ventilated ICU patients: A real-life study. Infect Dis Now 2023; 53:104666. [PMID: 36736667 DOI: 10.1016/j.idnow.2023.104666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/17/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Decontamination regimen decreases acquired infection (ICU-AI) incidence but has remained controversial, mostly because it contains a course of intravenous antibiotic. Multiple-site decontamination (MSD), which does not include systemic antibiotics, has been less widely studied but is associated with lower risks of ventilator-associated pneumonia (VAP), bloodstream infection (BSI) and multidrug resistant micro-organism (MDRO) acquisition. We aimed to confirm these favorable outcomes. METHODS A prospective pre/post-observational study was conducted in 5 ICUs in western France. Among them, 4 implemented MSD, whereas the fifth applied standard care (SC) throughout the study period. Patients who required intubation were eligible for study and divided into two groups: the MSD group if they were admitted to an ICU that already implemented MSD, or the SC group. The primary objective was to measure ICU-AI incidence. RESULTS Close to 1400 (1346) patients were available for analysis (334 in the MSD and 1012 patients in the SC group). In a multivariable Poisson regression model, MSD was independently associated with decreased incidence of ICU-AI (IRR = 0.33; 95 %CI [0.18-0.60] p < 0.001). Non-parsimonious propensity-score matching resulted in 334 patient-pairs with well-balanced baseline characteristics. There was a lower incidence of ICU-AI(6.3 % vs 20.7 % p < 0.001), VAP (3.6 % vs 16.2 % p < 0.001) and BSI (3.0 % vs 7.2 % p = 0.029) in the MSD group as compared with the SC group. Five (1.5 %) and 11 (3.3 %) patients respectively acquired MDRO (p = 0.206). CONCLUSION MSD is associated with decreased risk of ICU-AI, VAP and BSI, with no increase in MDRO acquisition.
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Affiliation(s)
- Nicolas Massart
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust 22000 Saint-Brieuc, France.
| | - Clarisse Dupin
- Service de Microbiologie, CH de St BRIEUC, 10, rue marcel Proust 22000 Saint-Brieuc, France
| | - Eleonore Legris
- Service de Pharmacie, CH de St BRIEUC, 10, rue marcel Proust 22000 Saint-Brieuc, France
| | - Yannick Fedun
- Service de Réanimation, CH de Vannes, 20, bd Maurice Guillaudot,56000 Vannes, France
| | - Nicolas Barbarot
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust 22000 Saint-Brieuc, France
| | - François Legay
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust 22000 Saint-Brieuc, France
| | - Guilhem Wattecamps
- Service de Réanimation, CH de QUIMPER, 14bis Avenue Yves Thépot, 29107 Quimper, France
| | - Florence Le Gall
- Service de Microbiologie, CH de QUIMPER, 14bis Avenue Yves Thépot, 29107 Quimper, France
| | - Béatrice La Combe
- Service de Réanimation, CH bretagne SUD, LORIENT, 5 avenue de choiseul, 56322 Lorient, France
| | - Pierre Bouju
- Service de Réanimation, CH bretagne SUD, LORIENT, 5 avenue de choiseul, 56322 Lorient, France
| | - Aurélien Frerou
- Service de Réanimation, CH de Saint-Malo, 1 rue de la marne 35400 Saint-Malo, France
| | - Laura Muller
- Service de Réanimation, CH de Saint-Malo, 1 rue de la marne 35400 Saint-Malo, France
| | - Guillaume Rieul
- Service de Réanimation, CH de Vannes, 20, bd Maurice Guillaudot,56000 Vannes, France
| | - Pierre Fillatre
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust 22000 Saint-Brieuc, France
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Massart N, Dupin C, Auger G, Magalhaes E, Fillatre P. Decontamination regimens: do not forget half of the protocol. Intensive Care Med 2023; 49:115-116. [PMID: 36350353 DOI: 10.1007/s00134-022-06915-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Nicolas Massart
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France.
| | - Clarisse Dupin
- Service de Microbiologie, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Gabriel Auger
- Service de Pharmacologie, CHU Pontchaillou, 2, rue Leon Marcel, 35000, Rennes, France
| | - Eric Magalhaes
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Pierre Fillatre
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
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Briegel J, Krueger WA, Wang B, Hinske LC, Grabein B. Decontamination regimens: do not forget half of the protocol. Author's reply. Intensive Care Med 2023; 49:117-118. [PMID: 36443607 PMCID: PMC9852143 DOI: 10.1007/s00134-022-06932-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/06/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Josef Briegel
- Department of Anesthesiology, Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität (LMU), University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | | | - Baocheng Wang
- Department of Anesthesiology, Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität (LMU), University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ludwig Christian Hinske
- Department of Anesthesiology, Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität (LMU), University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Beatrice Grabein
- Clinical Microbiology and Hospital Hygiene, University Hospital, LMU Munich, Munich, Germany
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12
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Xiang Y, Ren X, Xu Y, Cheng L, Cai H, Hu T. Anti-Inflammatory and Anti-Bacterial Effects of Mouthwashes in Intensive Care Units: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:733. [PMID: 36613055 PMCID: PMC9819176 DOI: 10.3390/ijerph20010733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
Mouthwashes are used as oral care for critical care patients to prevent infections. However, there are conflicting data concerning whether mouthwashes are needed as a part of daily oral care for critical care patients. This study aimed to evaluate the anti-inflammatory and anti-bacterial effects of mouthwashes for critical care patients. The PubMed, EMBASE, CENTRAL, and grey literature databases were searched by descriptors combining population (intensive care unit patients) and intervention (mouthwashes). After the screening, only randomized controlled trials (RCTs) evaluating the anti-inflammatory and anti-bacterial effects of mouthwashes in patient critical care were included. From the 1531 articles, 16 RCTs satisfied the eligibility criteria for systematic review and 10 were included in the meta-analyses. A significant difference was found in the incidence of ventilator associated pneumonia (VAP) (odds ratio [OR] 0.53, 95% confidential interval [95% CI] 0.33 to 0.86) between the mouthwash and placebo groups, while no significant difference was found in the mortality (OR 1.49, 95%CI 0.92 to 2.40); the duration of mechanical ventilation (weighted mean difference [WMD] -0.10, 95%CI -2.01 to 1.81); and the colonization of Staphylococcus aureus (OR 0.88, 95%CI 0.34 to 2.30), Escherichia coli (OR 1.19, 95%CI 0.50 to 2.82), and Pseudomonas aeruginosa (OR 1.16, 95%CI 0.27 to 4.91) between the two groups. In conclusion, mouthwashes were effective in decreasing the incidence of VAP. Thus, mouthwashes can be used as part of daily oral care for critical care patients.
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Affiliation(s)
| | | | | | | | - He Cai
- Correspondence: (H.C.); (T.H.); Tel.: +86-028-8550-3486 (H.C.); +86-028-8550-3486 (T.H.)
| | - Tao Hu
- Correspondence: (H.C.); (T.H.); Tel.: +86-028-8550-3486 (H.C.); +86-028-8550-3486 (T.H.)
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13
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Gut to lung translocation and antibiotic mediated selection shape the dynamics of Pseudomonas aeruginosa in an ICU patient. Nat Commun 2022; 13:6523. [PMID: 36414617 PMCID: PMC9681761 DOI: 10.1038/s41467-022-34101-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 10/13/2022] [Indexed: 11/23/2022] Open
Abstract
Bacteria have the potential to translocate between sites in the human body, but the dynamics and consequences of within-host bacterial migration remain poorly understood. Here we investigate the link between gut and lung Pseudomonas aeruginosa populations in an intensively sampled ICU patient using a combination of genomics, isolate phenotyping, host immunity profiling, and clinical data. Crucially, we show that lung colonization in the ICU was driven by the translocation of P. aeruginosa from the gut. Meropenem treatment for a suspected urinary tract infection selected for elevated resistance in both the gut and lung. However, resistance was driven by parallel evolution in the gut and lung coupled with organ specific selective pressures, and translocation had only a minor impact on AMR. These findings suggest that reducing intestinal colonization of Pseudomonas may be an effective way to prevent lung infections in critically ill patients.
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Myburgh JA, Seppelt IM, Goodman F, Billot L, Correa M, Davis JS, Gordon AC, Hammond NE, Iredell J, Li Q, Micallef S, Miller J, Mysore J, Taylor C, Young PJ, Cuthbertson BH, Finfer SR. Effect of Selective Decontamination of the Digestive Tract on Hospital Mortality in Critically Ill Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA 2022; 328:1911-1921. [PMID: 36286097 PMCID: PMC9607966 DOI: 10.1001/jama.2022.17927] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/14/2022] [Indexed: 11/14/2022]
Abstract
Importance Whether selective decontamination of the digestive tract (SDD) reduces mortality in critically ill patients remains uncertain. Objective To determine whether SDD reduces in-hospital mortality in critically ill adults. Design, Setting, and Participants A cluster, crossover, randomized clinical trial that recruited 5982 mechanically ventilated adults from 19 intensive care units (ICUs) in Australia between April 2018 and May 2021 (final follow-up, August 2021). A contemporaneous ecological assessment recruited 8599 patients from participating ICUs between May 2017 and August 2021. Interventions ICUs were randomly assigned to adopt or not adopt a SDD strategy for 2 alternating 12-month periods, separated by a 3-month interperiod gap. Patients in the SDD group (n = 2791) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191) received standard care. Main Outcomes and Measures The primary outcome was in-hospital mortality within 90 days. There were 8 secondary outcomes, including the proportion of patients with new positive blood cultures, antibiotic-resistant organisms (AROs), and Clostridioides difficile infections. For the ecological assessment, a noninferiority margin of 2% was prespecified for 3 outcomes including new cultures of AROs. Results Of 5982 patients (mean age, 58.3 years; 36.8% women) enrolled from 19 ICUs, all patients completed the trial. There were 753/2791 (27.0%) and 928/3191 (29.1%) in-hospital deaths in the SDD and standard care groups, respectively (mean difference, -1.7% [95% CI, -4.8% to 1.3%]; odds ratio, 0.91 [95% CI, 0.82-1.02]; P = .12). Of 8 prespecified secondary outcomes, 6 showed no significant differences. In the SDD vs standard care groups, 23.1% vs 34.6% had new ARO cultures (absolute difference, -11.0%; 95% CI, -14.7% to -7.3%), 5.6% vs 8.1% had new positive blood cultures (absolute difference, -1.95%; 95% CI, -3.5% to -0.4%), and 0.5% vs 0.9% had new C difficile infections (absolute difference, -0.24%; 95% CI, -0.6% to 0.1%). In 8599 patients enrolled in the ecological assessment, use of SDD was not shown to be noninferior with regard to the change in the proportion of patients who developed new AROs (-3.3% vs -1.59%; mean difference, -1.71% [1-sided 97.5% CI, -∞ to 4.31%] and 0.88% vs 0.55%; mean difference, -0.32% [1-sided 97.5% CI, -∞ to 5.47%]) in the first and second periods, respectively. Conclusions and Relevance Among critically ill patients receiving mechanical ventilation, SDD, compared with standard care without SDD, did not significantly reduce in-hospital mortality. However, the confidence interval around the effect estimate includes a clinically important benefit. Trial Registration ClinicalTrials.gov Identifier: NCT02389036.
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Affiliation(s)
- John A Myburgh
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- St George Hospital, Sydney, Australia
| | - Ian M Seppelt
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of Sydney, Australia
- Nepean Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Fiona Goodman
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Laurent Billot
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Maryam Correa
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Joshua S Davis
- John Hunter Hospital, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Menzies School of Heath Research, Newcastle, Australia
| | - Anthony C Gordon
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, Imperial College London, London, England
| | - Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - Jon Iredell
- Faculty of Medicine, University of Sydney, Australia
- Centre for Infectious Disease and Microbiology Westmeath Institute of Medical Research, Sydney, Australia
| | - Qiang Li
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Sharon Micallef
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Jennene Miller
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- St George Hospital, Sydney, Australia
- Liverpool Hospital, Sydney, Australia
| | - Jayanthi Mysore
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Colman Taylor
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Paul J Young
- Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Brian H Cuthbertson
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Simon R Finfer
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Faculty of Medicine, Imperial College London, London, England
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COVID-19 Secondary Infections in ICU Patients and Prevention Control Measures: A Preliminary Prospective Multicenter Study. Antibiotics (Basel) 2022; 11:antibiotics11081016. [PMID: 36009884 PMCID: PMC9405068 DOI: 10.3390/antibiotics11081016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
The incidence of secondary infections in critically ill coronavirus disease 2019 (COVID-19) patients is worrisome. We investigated whether selective digestive decontamination (SDD) added to infection control measures during an intensive care unit (ICU) stay modified these infection rates. Methods: A retrospective observational cohort study was carried out in four ICUs in Spain. All consecutive ventilated patients with a SARS-CoV-2 infection engaged in national infection control programs between 1 March and 10 December 2020 were investigated. Patients were grouped into two cohorts according to the site of ICU admission. Secondary relevant infections were included. Infection densities corresponding to ventilator-associated pneumonia (VAP), catheter bacteremia, secondary bacteremia, and multi-resistant germs were obtained as the number of events per 1000 days of exposure and were compared between SDD and non-SDD groups using Poisson regression. Factors that had an independent association with mortality were identified using multidimensional logistic analysis. Results: There were 108 patients in the SDD cohort and 157 in the non-SDD cohort. Patients in the SDD cohort showed significantly lower rates (p < 0.001) of VAP (1.9 vs. 9.3 events per 1000 ventilation days) and MDR infections (0.57 vs. 2.28 events per 1000 ICU days) and a non-significant reduction in secondary bacteremia (0.6 vs. 1.41 events per 1000 ICU days) compared with those in the non-SDD cohort. Infections caused by MDR pathogens occurred in 5 patients in the SDD cohort and 21 patients in the non-SDD cohort (p = 0.006). Differences in mortality according to SDD were not found. Conclusion: The implementation of SDD in infection control programs significantly reduced the incidence of VAP and MDR infections in critically ill SARS-CoV-2 infected patients.
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16
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Leone M, Righy C, Póvoa P. Antibiotic prophylaxis in ICU patients: should I do or not? Intensive Care Med 2022; 48:1215-1217. [PMID: 35713666 DOI: 10.1007/s00134-022-06764-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Hospital Nord, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France
| | - Cássia Righy
- Instituto Nacional de Infectologia, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.,Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Hospital Copa Star, Rio de Janeiro, Brazil
| | - Pedro Póvoa
- NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal. .,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark. .,Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Estrada do Forte do Alto do Duque, 1449-005, Lisbon, Portugal.
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17
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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18
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Potruch A, Schwartz A, Ilan Y. The role of bacterial translocation in sepsis: a new target for therapy. Therap Adv Gastroenterol 2022; 15:17562848221094214. [PMID: 35574428 PMCID: PMC9092582 DOI: 10.1177/17562848221094214] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/28/2022] [Indexed: 02/04/2023] Open
Abstract
Sepsis is a leading cause of death in critically ill patients, primarily due to multiple organ failures. It is associated with a systemic inflammatory response that plays a role in the pathogenesis of the disease. Intestinal barrier dysfunction and bacterial translocation (BT) play pivotal roles in the pathogenesis of sepsis and associated organ failure. In this review, we describe recent advances in understanding the mechanisms by which the gut microbiome and BT contribute to the pathogenesis of sepsis. We also discuss several potential treatment modalities that target the microbiome as therapeutic tools for patients with sepsis.
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19
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Buitinck SH, Koopmans M, Determann RM, Jansen RR, van der Voort PHJ. Enteral Vancomycin to Eliminate MRSA Carriership of the Digestive Tract in Critically Ill Patients. Antibiotics (Basel) 2022; 11:antibiotics11020263. [PMID: 35203865 PMCID: PMC8868137 DOI: 10.3390/antibiotics11020263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Carriership with methicillin resistant Staphylococcus aureus (MRSA) is a risk for the development of secondary infections in critically ill patients. Previous studies suggest that enteral vancomycin is able to eliminate enteral carriership with MRSA. Data on individual effects of this treatment are lacking. Methods: Retrospective analysis of a database containing 15 year data of consecutive patients from a mixed medical-(cardio)surgical 18 bedded intensive care unit was conducted. All consecutive critically ill patients with enteral MRSA carriership detected in throat and/or rectal samples were collected. We analyzed those with follow-up cultures to determine the success rate of enteral vancomycin. Topical application of 2% vancomycin in a sticky oral paste was performed combined with a vancomycin solution of 500 mg four times daily in the nasogastric tube. This treatment was added to a regimen of selective digestive tract decontamination (SDD) to prevent ICU acquired infection. Results: Thirteen patients were included. The mean age was 65 years and the median APACHE II score was 21. MRSA was present in the throat in 8 patients and in both throat and rectum in 5 patients. In all patients MRSA was successfully eliminated from both throat and rectum, which took 2–11 days with a median duration until decontamination of 4 days. Secondary infections with MRSA did not occur. Conclusions: Topical treatment with vancomycin in a 2% sticky oral paste four times daily in the nasogastric tube was effective in all patients in the elimination of MRSA and prevented secondary MRSA infections.
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Affiliation(s)
- Sophie H. Buitinck
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands; (S.H.B.); (M.K.); (R.M.D.)
| | - Matty Koopmans
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands; (S.H.B.); (M.K.); (R.M.D.)
| | - Rogier M. Determann
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands; (S.H.B.); (M.K.); (R.M.D.)
| | - Rogier R. Jansen
- Department of Medical Microbiology, OLVG Hospital, Oosterpark 9, 1091 AC Amsterdam, The Netherlands;
| | - Peter H. J. van der Voort
- Department of Critical Care Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
- Correspondence: ; Tel.: +31-50-3610874
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20
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Buitinck SH, Jansen R, Bosman RJ, van der Meer NJM, van der Voort PHJ. Eradication of Resistant and Susceptible Aerobic Gram-Negative Bacteria From the Digestive Tract in Critically Ill Patients; an Observational Cohort Study. Front Microbiol 2022; 12:779805. [PMID: 35185812 PMCID: PMC8853443 DOI: 10.3389/fmicb.2021.779805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/22/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Selective Decontamination of the Digestive tract (SDD) aims to prevent nosocomial infections, by eradication of potentially pathogenic micro-organisms from the digestive tract. OBJECTIVES To estimate the rate of and the time to eradication of resistant vs. susceptible facultative aerobic gram-negative bacteria (AGNB) in patients treated with SDD. METHODS This observational and retrospective study included patients admitted to the ICU between January 2001 and August 2017. Patients were included when treated with SDD (tobramycin, polymyxin B, and amphotericin B) and colonized in the upper or lower gastro-intestinal (GI) tract with at least one AGNB present on admission. Decontamination was determined after the first negative set of cultures (rectal and throat). An additional analysis was performed of two consecutive negative cultures. RESULTS Of the 281 susceptible AGNB in the throat and 1,087 in the rectum on admission, 97.9 and 93.7%, respectively, of these microorganisms were successfully eradicated. In the upper GI-tract no differences in eradication rates were found between susceptible and resistant microorganisms. However, the median duration until eradication was significantly longer for aminoglycosides resistant vs. susceptible microorganisms (5 vs. 4 days, p < 0.01). In the lower GI-tract, differences in eradication rates between susceptible and resistant microorganisms were found for cephalosporins (90.0 vs. 95.6%), aminoglycosides (84.4 vs. 95.5%) and ciprofloxacin (90.0 vs. 95.2%). Differences in median duration until eradication between susceptible and resistant microorganisms were found for aminoglycosides and ciprofloxacin (both 5 days vs. 6 days, p = 0.001). Decontamination defined as two negative cultures was achieved in a lower rate (77-98% for the upper GI tract and 64-77% for the lower GI tract) and a median of 1 day later. CONCLUSION The vast majority of both susceptible and resistant microorganisms are effectively eradicated from the upper and lower GI tract. In the lower GI tract decontamination rates of susceptible microorganisms are significantly higher and achieved in a shorter time period compared to resistant strains.
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Affiliation(s)
- Sophie H. Buitinck
- Department of Intensive Care, OLVG Hospital, Amsterdam, Netherlands
- TIAS School for Business and Society, Tilburg, Netherlands
| | - Rogier Jansen
- Department of Medical Microbiology, OLVG Hospital, Amsterdam, Netherlands
| | - Rob J. Bosman
- Department of Intensive Care, OLVG Hospital, Amsterdam, Netherlands
| | | | - Peter H. J. van der Voort
- TIAS School for Business and Society, Tilburg, Netherlands
- Department of Critical Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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21
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Abstract
Severe pneumonia is associated with high mortality (short and long term), as well as pulmonary and extrapulmonary complications. Appropriate diagnosis and early initiation of adequate antimicrobial treatment for severe pneumonia are crucial in improving survival among critically ill patients. Identifying the underlying causative pathogen is also critical for antimicrobial stewardship. However, establishing an etiological diagnosis is challenging in most patients, especially in those with chronic underlying disease; those who received previous antibiotic treatment; and those treated with mechanical ventilation. Furthermore, as antimicrobial therapy must be empiric, national and international guidelines recommend initial antimicrobial treatment according to the location's epidemiology; for patients admitted to the intensive care unit, specific recommendations on disease management are available. Adherence to pneumonia guidelines is associated with better outcomes in severe pneumonia. Yet, the continuing and necessary research on severe pneumonia is expansive, inviting different perspectives on host immunological responses, assessment of illness severity, microbial causes, risk factors for multidrug resistant pathogens, diagnostic tests, and therapeutic options.
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Affiliation(s)
- Catia Cillóniz
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Antoni Torres
- Department of pneumology, Hospital Clinic of Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Biomedical Research Networking Centers in Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Michael S Niederman
- Weill Cornell Medical College, Department of Pulmonary Critical Care Medicine, New York, NY, USA
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22
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Mills JP, Marchaim D. Multidrug-Resistant Gram-Negative Bacteria: Infection Prevention and Control Update. Infect Dis Clin North Am 2021; 35:969-994. [PMID: 34752228 DOI: 10.1016/j.idc.2021.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Multidrug-resistant gram-negative bacteria (MDR-GNB) pose one of the greatest challenges to health care today because of their propensity for human-to-human transmission and lack of therapeutic options. Containing the spread of MDR-GNB is challenging, and the application of multifaceted infection control bundles during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article will review the utility of various infection control measures in containing the spread of various MDR-GNB and will provide the supporting evidence for these interventions.
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Affiliation(s)
- John P Mills
- Division of Infectious Diseases, University of Michigan Medical School, F4177 University Hospital South, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-5226, USA.
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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23
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Long-term survival of mechanically ventilated patients with severe COVID-19: an observational cohort study. Ann Intensive Care 2021; 11:143. [PMID: 34601646 PMCID: PMC8487336 DOI: 10.1186/s13613-021-00929-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/16/2021] [Indexed: 12/28/2022] Open
Abstract
Background Information is lacking regarding long-term survival and predictive factors for mortality in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) and undergoing invasive mechanical ventilation. We aimed to estimate 180-day mortality of patients with COVID-19 requiring invasive ventilation, and to develop a predictive model for long-term mortality. Methods Retrospective, multicentre, national cohort study between March 8 and April 30, 2020 in 16 intensive care units (ICU) in Spain. Participants were consecutive adults who received invasive mechanical ventilation for COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection detected in positive testing of a nasopharyngeal sample and confirmed by real time reverse-transcriptase polymerase chain reaction (rt-PCR). The primary outcomes was 180-day survival after hospital admission. Secondary outcomes were length of ICU and hospital stay, and ICU and in-hospital mortality. A predictive model was developed to estimate the probability of 180-day mortality. Results 868 patients were included (median age, 64 years [interquartile range [IQR], 56–71 years]; 72% male). Severity at ICU admission, estimated by SAPS3, was 56 points [IQR 50–63]. Prior to intubation, 26% received some type of noninvasive respiratory support. The unadjusted overall 180-day survival rates was 59% (95% CI 56–62%). The predictive factors measured during ICU stay, and associated with 180-day mortality were: age [Odds Ratio [OR] per 1-year increase 1.051, 95% CI 1.033–1.068)), SAPS3 (OR per 1-point increase 1.027, 95% CI 1.011–1.044), diabetes (OR 1.546, 95% CI 1.085–2.204), neutrophils to lymphocytes ratio (OR per 1-unit increase 1.008, 95% CI 1.001–1.016), failed attempt of noninvasive positive pressure ventilation prior to orotracheal intubation (OR 1.878 (95% CI 1.124–3.140), use of selective digestive decontamination strategy during ICU stay (OR 0.590 (95% CI 0.358–0.972) and administration of low dosage of corticosteroids (methylprednisolone 1 mg/kg) (OR 2.042 (95% CI 1.205–3.460). Conclusion The long-term survival of mechanically ventilated patients with severe COVID-19 reaches more than 50% and may help to provide individualized risk stratification and potential treatments. Trial registration: ClinicalTrials.gov Identifier: NCT04379258. Registered 10 April 2020 (retrospectively registered) Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00929-y.
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Tavernier E, Barbier F, Meziani F, Quenot JP, Herbrecht JE, Landais M, Roux D, Seguin P, Schnell D, Veinstein A, Veber B, Lasocki S, Lu Q, Beduneau G, Ferrandiere M, Dahyot-Fizelier C, Plantefeve G, Nay MA, Merdji H, Andreu P, Vecellio L, Muller G, Cabrera M, Le Pennec D, Respaud R, Lanotte P, Gregoire N, Leclerc M, Helms J, Boulain T, Lacherade JC, Ehrmann S. Inhaled amikacin versus placebo to prevent ventilator-associated pneumonia: the AMIKINHAL double-blind multicentre randomised controlled trial protocol. BMJ Open 2021; 11:e048591. [PMID: 34521664 PMCID: PMC8442072 DOI: 10.1136/bmjopen-2020-048591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Pre-emptive inhaled antibiotics may be effective to reduce the occurrence of ventilator-associated pneumonia among critically ill patients. Meta-analysis of small sample size trials showed a favourable signal. Inhaled antibiotics are associated with a reduced emergence of antibiotic resistant bacteria. The aim of this trial is to evaluate the benefit of a 3-day course of inhaled antibiotics among patients undergoing invasive mechanical ventilation for more than 3 days on the occurrence of ventilator-associated pneumonia. METHODS AND ANALYSIS Academic, investigator-initiated, parallel two group arms, double-blind, multicentre superiority randomised controlled trial. Patients invasively ventilated more than 3 days will be randomised to receive 20 mg/kg inhaled amikacin daily for 3 days or inhaled placebo (0.9% Sodium Chloride). Occurrence of ventilator-associated pneumonia will be recorded based on a standardised diagnostic framework from randomisation to day 28 and adjudicated by a centralised blinded committee. ETHICS AND DISSEMINATION The protocol and amendments have been approved by the regional ethics review board and French competent authorities (Comité de protection des personnes Ouest I, No.2016-R29). All patients will be included after informed consent according to French law. Results will be disseminated in international scientific journals. TRIAL REGISTRATION NUMBERS EudraCT 2016-001054-17 and NCT03149640.
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Affiliation(s)
| | | | - Ferhat Meziani
- Service de Réanimation, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, Lipness Team, INSERM Research Centre LNC-UMR1231, LabExLipSTIC, and INSERM CIC 1432, Clinical Epidemiology, François Mitterrand University Hospital, University of Burgundy, Dijon, France
| | - Jean-Etienne Herbrecht
- Médecine Intensive Réanimation, Hôpital Hautepierre, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Mickael Landais
- Réanimation médico-chirurgicale, CH du Mans, Le Mans, France
| | - Damien Roux
- Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique - Hopitaux de Paris, Colombes, France
| | | | - David Schnell
- Réanimation Polyvalente, CH Angouleme, Angouleme, France
| | - Anne Veinstein
- Médecine Intensive Réanimation, CHU de Poitiers, Poitiers, France
| | - Benoît Veber
- Réanimation Chirurgicale, CHU de Rouen, Université de Rouen Normandie, Rouen, France
| | | | - Qin Lu
- Multidisciplinary Critical Care Unit, Department of Anaesthesiology and Critical Care Medicine, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Gaetan Beduneau
- Medical Intensive Care Unit, EA 3830, Normandie Université, UNIROUEN, Rouen University Hospital, Rouen, France
| | | | | | - Gaetan Plantefeve
- Réanimation Polyvalente et Unité de Surveillance Continue, CH Victor Dupouy, Argenteuil, France
| | - Mai-Anh Nay
- Médecine Intensive Réanimation, CHR d'Orléans, Orleans, France
| | - Hamid Merdji
- Service de Réanimation, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Pascal Andreu
- Department of Intensive Care, Lipness Team, INSERM Research Centre LNC-UMR1231, LabExLipSTIC, and INSERM CIC 1432, Clinical Epidemiology, François Mitterrand University Hospital, University of Burgundy, Dijon, France
| | - Laurent Vecellio
- Centre d'Etude des Pathologies Respiratoires, CEPR, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Grégoire Muller
- Médecine Intensive Réanimation, CHR d'Orléans, Orleans, France
| | - Maria Cabrera
- Centre d'Etude des Pathologies Respiratoires, CEPR, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Deborah Le Pennec
- Centre d'Etude des Pathologies Respiratoires, CEPR, INSERM U1100, Faculté de médecine, Université de Tours, Tours, France
| | - Renaud Respaud
- Pharmacie, Centre d'Etude des Pathologies Respiratoires, CEPR, INSERM U1100, CHRU de Tours, Faculté de médecine, Université de Tours, Tours, France
| | - Philippe Lanotte
- Service de Bactériologie-Virologie, INRAE, ISP, CHRU de Tours, Université de Tours, Tours, France
| | - Nicolas Gregoire
- INSERM UMR S1070, Laboratoire pharmacologie des anti-infectieux; Laboratoire de toxicologie-phamacologie, Université de Poitiers; CHU de Poitiers, Poitiers, France
| | - Marie Leclerc
- Délégation à la Recherche Clinique et à l'Innovation, CHRU Tours, Tours, France
| | - Julie Helms
- Service de Réanimation, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Thierry Boulain
- Médecine Intensive Réanimation, CHR d'Orléans, Orleans, France
| | | | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC 1415, Centre d'Etude des Pathologies Respiratoires, CEPR, INSERM U1100, CHRU de Tours, Faculté de médecine, Université de Tours, Tours, France
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Hurley JC. Selective digestive decontamination, a seemingly effective regimen with individual benefit or a flawed concept with population harm? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:323. [PMID: 34470654 PMCID: PMC8408564 DOI: 10.1186/s13054-021-03744-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/24/2021] [Indexed: 02/07/2023]
Abstract
Selective digestive decontamination (SDD) regimens, variously constituted with topical antibiotic prophylaxis (TAP) and protocolized parenteral antibiotic prophylaxis (PPAP), appear highly effective for preventing ICU-acquired infections but only within randomized concurrent control trials (RCCT's). Confusingly, SDD is also a concept which, if true, implies population benefit. The SDD concept can finally be reified in humans using the broad accumulated evidence base, including studies of TAP and PPAP that used non-concurrent controls (NCC), as a natural experiment. However, this test implicates overall population harm with higher event rates associated with SDD use within the ICU context.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia. .,Division of Internal Medicine, Ballarat Health Services, PO Box 577, Ballarat, VIC, 3353, Australia.
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Janssen AB, van Hout D, Bonten MJM, Willems RJL, van Schaik W. Microevolution of acquired colistin resistance in Enterobacteriaceae from ICU patients receiving selective decontamination of the digestive tract. J Antimicrob Chemother 2021; 75:3135-3143. [PMID: 32712659 DOI: 10.1093/jac/dkaa305] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/11/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Colistin is an antibiotic that targets the LPS molecules present in the membranes of Gram-negative bacteria. It is used as a last-resort drug to treat infections with MDR strains. Colistin is also used in selective decontamination of the digestive tract (SDD), a prophylactic therapy used in patients hospitalized in ICUs to selectively eradicate opportunistic pathogens in the oropharyngeal and gut microbiota. OBJECTIVES To unravel the mechanisms of acquired colistin resistance in Gram-negative opportunistic pathogens obtained from SDD-treated patients. RESULTS Routine surveillance of 428 SDD-treated patients resulted in 13 strains with acquired colistin resistance (Escherichia coli, n = 9; Klebsiella aerogenes, n = 3; Enterobacter asburiae, n = 1) from 5 patients. Genome sequence analysis showed that these isolates represented multiple distinct colistin-resistant clones but that colistin-resistant strains within the same patient were clonally related. We identified previously described mechanisms that lead to colistin resistance, i.e. a G53 substitution in the response regulator PmrA/BasR and the acquisition of the mobile colistin resistance gene mcr-1.1, but we also observed novel variants of basR with an 18 bp deletion and a G19E substitution in the sensor histidine kinase BasS. We experimentally confirmed that these variants contribute to reduced colistin susceptibility. In a single patient, we observed that colistin resistance in a single E. coli clone evolved through two unique variants in basRS. CONCLUSIONS We show that prophylactic use of colistin during SDD can select for colistin resistance in species that are not intrinsically colistin resistant. This highlights the importance of continued surveillance for strains with acquired colistin resistance in patients treated with SDD.
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Affiliation(s)
- Axel B Janssen
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Denise van Hout
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Rob J L Willems
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Willem van Schaik
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX Utrecht, The Netherlands.,Institute of Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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Aardema H, Bult W, van Hateren K, Dieperink W, Touw DJ, Alffenaar JWC, Zijlstra JG. Continuous versus intermittent infusion of cefotaxime in critically ill patients: a randomized controlled trial comparing plasma concentrations. J Antimicrob Chemother 2021; 75:441-448. [PMID: 31697336 DOI: 10.1093/jac/dkz463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In critical care patients, reaching optimal β-lactam concentrations poses challenges, as infections are caused more often by microorganisms associated with higher MICs, and critically ill patients typically have an unpredictable pharmacokinetic/pharmacodynamic profile. Conventional intermittent dosing frequently yields inadequate drug concentrations, while continuous dosing might result in better target attainment. Few studies address cefotaxime concentrations in this population. OBJECTIVES To assess total and unbound serum levels of cefotaxime and an active metabolite, desacetylcefotaxime, in critically ill patients treated with either continuously or intermittently dosed cefotaxime. METHODS Adult critical care patients with indication for treatment with cefotaxime were randomized to treatment with either intermittent dosing (1 g every 6 h) or continuous dosing (4 g/24 h, after a loading dose of 1 g). We defined a preset target of reaching and maintaining a total cefotaxime concentration of 4 mg/L from 1 h after start of treatment. CCMO trial registration number NL50809.042.14, Clinicaltrials.gov NCT02560207. RESULTS Twenty-nine and 30 patients, respectively, were included in the continuous dosing group and the intermittent dosing group. A total of 642 samples were available for analysis. In the continuous dosing arm, 89.3% met our preset target, compared with 50% in the intermittent dosing arm. Patients not reaching this target had a significantly higher creatinine clearance on the day of admission. CONCLUSIONS These results support the application of a continuous dosing strategy of β-lactams in critical care patients and the practice of therapeutic drug monitoring in a subset of patients with higher renal clearance and need for prolonged treatment for further optimization, where using total cefotaxime concentrations should suffice.
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Affiliation(s)
- Heleen Aardema
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands
| | - Wouter Bult
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Kai van Hateren
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Willem Dieperink
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands.,University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia.,Westmead Hospital, Sydney, Australia
| | - Jan G Zijlstra
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands
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Asymmetric Effects of Decontamination Using Topical Antibiotics for the ICU Patient. Symmetry (Basel) 2021. [DOI: 10.3390/sym13061027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There are several antiseptic, antibiotic and non-decontamination-based interventions for preventing intensive care unit (ICU) acquired infection. These have been evaluated in >200 studies. Infection prevention using topical antibiotic prophylaxis (TAP) appears to be the most effective. Whether antibiotic use in the ICU may influence the risk of infection among concurrent control patients within the same ICU and result in asymmetrical herd effects cannot be resolved with individual studies examined in isolation. The collective observations within control and intervention groups from numerous ICU infection prevention studies simulates a multi-center natural experiment enabling the herd effects of antibiotics to be evaluated. Among the TAP control groups, the incidences for both ventilator associated pneumonia (VAP) and mortality are unusually high in comparison to literature-derived benchmarks. Paradoxically, amongst the TAP intervention groups, the incidences of mortality are also unusually high and the VAP incidences are similar (i.e., not lower) compared to the incidences among studies of other interventions. By contrast, the mortality incidences among the intervention groups of other studies are similar to those among the intervention groups of TAP studies. Using topical antibiotics to prevent infections acquired within the ICU environment may result in profoundly asymmetrical effects.
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Selective Digestive Decontamination Is Neither Safe Nor Efficacious for Critically Ill Patients. Crit Care Med 2021; 48:732-735. [PMID: 31567405 DOI: 10.1097/ccm.0000000000004047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Atamna-Mawassi H, Huberman-Samuel M, Hershcovitz S, Karny-Epstein N, Kola A, Cortés LEL, Leibovici L, Yahav D. Interventions to reduce infections caused by multidrug resistant Enterobacteriaceae (MDR-E): A systematic review and meta-analysis. J Infect 2021; 83:156-166. [PMID: 34000343 DOI: 10.1016/j.jinf.2021.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We aimed to evaluate different interventions to reduce multidrug-resistant Enterobacteriaceae (MDR-E) infection/colonization. METHODS A systematic review and meta-analysis evaluating interventions for prevention of MDR-E infection/colonization among hospitalized adult patients. The co-primary outcomes were mortality and MDR-E infections. PubMed, Cochrane library, and LILACS databases were searched up till December 2019, as well as grey literature sources. We included randomized controlled trials and observational studies. Infection/colonization/acquisition outcomes were reported per patient-days as pooled incidence ratios (IRs) with 95% confidence intervals (CIs). Interrupted time series (ITS) analysis studies were reported separately. RESULTS Sixty-three studies were included, 16 RCTs, 33 observational studies, and 14 ITS. For the intervention of antimicrobial stewardship program (ASP), 23 studies were included. No differences in mortality or MDR-E infections were observed with ASP, however, MDR-E colonization was significantly reduced (IR 0.69, 95% CI 0.57-0.82). Seventeen studies examined decolonization without significant difference in outcomes. Other interventions were scarcely represented. Among 14 ITS publications, most evaluating ASP, 11 showed benefit of the intervention. CONCLUSIONS ASP is an effective measure in preventing MDR-E colonization. Decolonization did not show significant benefit in reducing infection or colonization. Studies are needed to evaluate the cost effectiveness of ASP and assess bundles of interventions.
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Affiliation(s)
| | | | | | | | - Axel Kola
- Institute for Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of Nosocomial Infections, Charité-University Hospital, Berlin, Germany
| | - Luis Eduardo López Cortés
- Department of Infectious Diseases, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Leonard Leibovici
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel; Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.
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Hurley JC. Is selective decontamination (SDD/SOD) safe in the ICU context? J Antimicrob Chemother 2021; 74:1167-1172. [PMID: 30753529 DOI: 10.1093/jac/dky573] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Multiple individual studies of selective digestive decontamination/selective oropharyngeal decontamination (SDD/SOD) among ICU patients appear to show potent infection prevention effects. Surprisingly, the event rates for multiple endpoints including ventilator-associated pneumonia, bacteraemia and candidaemia among concurrent control groups within SDD/SOD studies appear unusually high versus other rates in the literature. These paradoxical observations raise concern that the contextual effects of SDD/SOD, as postulated in the original SDD/SOD study, not only exist but also are strong. Until these effects are addressed within an optimally designed study, the safety of SDD/SOD within the 'whole of ICU' remains questionable.
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Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Division of Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
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Wittekamp BH, Plantinga NL. Less daily oral hygiene is more in the ICU: no. Intensive Care Med 2021; 47:331-333. [PMID: 33558968 PMCID: PMC7870028 DOI: 10.1007/s00134-021-06359-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Bastiaan H Wittekamp
- Intensive Care, Ziekenhuisgroep Twente (Hospital Group Twente), Almelo, The Netherlands.
| | - Nienke L Plantinga
- Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Minozzi S, Pifferi S, Brazzi L, Pecoraro V, Montrucchio G, D'Amico R. Topical antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving mechanical ventilation. Cochrane Database Syst Rev 2021; 1:CD000022. [PMID: 33481250 PMCID: PMC8094382 DOI: 10.1002/14651858.cd000022.pub4] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients treated with mechanical ventilation in intensive care units (ICUs) have a high risk of developing respiratory tract infections (RTIs). Ventilator-associated pneumonia (VAP) has been estimated to affect 5% to 40% of patients treated with mechanical ventilation for at least 48 hours. The attributable mortality rate of VAP has been estimated at about 9%. Selective digestive decontamination (SDD), which consists of the topical application of non-absorbable antimicrobial agents to the oropharynx and gastroenteric tract during the whole period of mechanical ventilation, is often used to reduce the risk of VAP. A related treatment is selective oropharyngeal decontamination (SOD), in which topical antibiotics are applied to the oropharynx only. This is an update of a review first published in 1997 and updated in 2002, 2004, and 2009. OBJECTIVES To assess the effect of topical antibiotic regimens (SDD and SOD), given alone or in combination with systemic antibiotics, to prevent mortality and respiratory infections in patients receiving mechanical ventilation for at least 48 hours in ICUs. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, PubMed, and Embase on 5 February 2020. We also searched the WHO ICTRP and ClinicalTrials.gov for ongoing and unpublished studies on 5 February 2020. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and cluster-RCTs assessing the efficacy and safety of topical prophylactic antibiotic regimens in adults receiving intensive care and mechanical ventilation. The included studies compared topical plus systemic antibiotics versus placebo or no treatment; topical antibiotics versus no treatment; and topical plus systemic antibiotics versus systemic antibiotics. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included a total of 41 trials involving 11,004 participants (five new studies were added in this update). The minimum duration of mechanical ventilation ranged from 2 (19 studies) to 6 days (one study). Thirteen studies reported the mean length of ICU stay, ranging from 11 to 33 days. The percentage of immunocompromised patients ranged from 0% (10 studies) to 22% (1 study). The reporting quality of the majority of included studies was very poor, so we judged more than 40% of the studies as at unclear risk of selection bias. We judged all studies to be at low risk of performance bias, though 47.6% were open-label, because hospitals usually have standardised infection control programmes, and possible subjective decisions on who should be tested for the presence or absence of RTIs are unlikely in an ICU setting. Regarding detection bias, we judged all included studies as at low risk for the outcome mortality. For the outcome RTIs, we judged all double-blind studies as at low risk of detection bias. We judged five open-label studies as at high risk of detection bias, as the diagnosis of RTI was not based on microbiological exams; we judged the remaining open-label studies as at low risk of detection bias, as a standardised set of diagnostic criteria, including results of microbiological exams, were used. Topical plus systemic antibiotic prophylaxis reduces overall mortality compared with placebo or no treatment (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.73 to 0.96; 18 studies; 5290 participants; high-certainty evidence). Based on an illustrative risk of 303 deaths in 1000 people this equates to 48 (95% CI 15 to 79) fewer deaths with topical plus systemic antibiotic prophylaxis. Topical plus systemic antibiotic prophylaxis probably reduces RTIs (RR 0.43, 95% CI 0.35 to 0.53; 17 studies; 2951 participants; moderate-certainty evidence). Based on an illustrative risk of 417 RTIs in 1000 people this equates to 238 (95% CI 196 to 271) fewer RTIs with topical plus systemic antibiotic prophylaxis. Topical antibiotic prophylaxis probably reduces overall mortality compared with no topical antibiotic prophylaxis (RR 0.96, 95% CI 0.87 to 1.05; 22 studies, 4213 participants; moderate-certainty evidence). Based on an illustrative risk of 290 deaths in 1000 people this equates to 19 (95% CI 37 fewer to 15 more) fewer deaths with topical antibiotic prophylaxis. Topical antibiotic prophylaxis may reduce RTIs (RR 0.57, 95% CI 0.44 to 0.74; 19 studies, 2698 participants; low-certainty evidence). Based on an illustrative risk of 318 RTIs in 1000 people this equates to 137 (95% CI 83 to 178) fewer RTIs with topical antibiotic prophylaxis. Sixteen studies reported adverse events and dropouts due to adverse events, which were poorly reported with sparse data. The certainty of the evidence ranged from low to very low. AUTHORS' CONCLUSIONS Treatments based on topical prophylaxis probably reduce respiratory infections, but not mortality, in adult patients receiving mechanical ventilation for at least 48 hours, whereas a combination of topical and systemic prophylactic antibiotics reduces both overall mortality and RTIs. However, we cannot rule out that the systemic component of the combined treatment provides a relevant contribution in the observed reduction of mortality. No conclusion can be drawn about adverse events as they were poorly reported with sparse data.
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Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Silvia Pifferi
- Department of Anesthesiology and Intensive Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anaesthesia, Intensive Care and Emergency, 'Città della salute e della Scienza' Hospital, Turin, Italy
| | - Valentina Pecoraro
- Department of Laboratory Medicine, Ospedale Civile Sant'Agostino Estense, Modena, Italy
| | - Giorgia Montrucchio
- Department of Anaesthesia, Intensive Care and Emergency, 'Città della salute e della Scienza' Hospital, Turin, Italy
| | - Roberto D'Amico
- Italian Cochrane Centre, University of Modena and Reggio Emilia, Modena, Italy
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
- Unit of Methodological/Statistical Support to Clinical Research, Azienda-Ospedaliero Universitaria, Modena, Italy
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Pérez-Granda MJ, Alonso B, Zavala R, Latorre MC, Hortal J, Samaniego R, Bouza E, Muñoz P, Guembe M. Selective digestive decontamination solution used as "lock therapy" prevents and eradicates bacterial biofilm in an in vitro bench-top model. Ann Clin Microbiol Antimicrob 2020; 19:44. [PMID: 32972419 PMCID: PMC7513905 DOI: 10.1186/s12941-020-00387-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background Most preventing measures for reducing ventilator-associated pneumonia (VAP) are based mainly on the decolonization of the internal surface of the endotracheal tubes (ETTs). However, it has been demonstrated that bacterial biofilm can also be formed on the external surface of ETTs. Our objective was to test in vitro the efficacy of selective digestive decontamination solution (SDDs) onto ETT to prevent biofilm formation and eradicate preformed biofilms of three different microorganisms of VAP. Methods We used an in vitro model in which we applied, at the subglottic space of ETT, biofilms of either P. aeruginosa ATCC 15442, or E. coli ATCC 25922, or S. aureus ATCC 29213, and the SDDs at the same time (prophylaxis) or after 72 h of biofilm forming (treatment). ETT were incubated during 5 days with a regimen of 2 h-locks. ETT fragments were analyzed by sonication and confocal laser scanning microscopy to calculate the percentage reduction of cfu and viable cells, respectively. Results Median (IQR) percentage reduction of live cells and cfu/ml counts after treatment were, respectively, 53.2% (39.4%—64.1%) and 100% (100%–100.0%) for P. aeruginosa, and 67.9% (46.7%–78.7%) and 100% (100%–100.0%) for E. coli. S. aureus presented a complete eradication by both methods. After prophylaxis, there were absence of live cells and cfu/ml counts for all microorganisms. Conclusions SDDs used as “lock therapy” in the subglottic space is a promising prophylactic approach that could be used in combination with the oro-digestive decontamination procedure in the prevention of VAP.
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Affiliation(s)
- María Jesús Pérez-Granda
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain.,CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain
| | - Beatriz Alonso
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain. .,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain. .,Servicio de Microbiología Clínica y Enfermedades Infecciosas, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario "Gregorio Marañón", C/. Dr. Esquerdo, 46, Madrid, 28007, Spain.
| | - Ricardo Zavala
- Biology Department, School of Biology, Universidad Complutense de Madrid, Madrid, 28040, Spain
| | - María Consuelo Latorre
- Biology Department, School of Biology, Universidad Complutense de Madrid, Madrid, 28040, Spain
| | - Javier Hortal
- Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain.,CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain
| | - Rafael Samaniego
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain.,Confocal Laser Scanning Microscopy Unit, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain
| | - Emilio Bouza
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, 28040, Spain
| | - Patricia Muñoz
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain.,CIBER Enfermedades Respiratorias-CIBERES, CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, 28040, Spain
| | - María Guembe
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, 28009, Spain. .,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, 28007, Spain. .,Servicio de Microbiología Clínica y Enfermedades Infecciosas, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario "Gregorio Marañón", C/. Dr. Esquerdo, 46, Madrid, 28007, Spain.
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An overview of guidelines for the management of hospital-acquired and ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria. Curr Opin Infect Dis 2020; 32:656-662. [PMID: 31567412 DOI: 10.1097/qco.0000000000000596] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Multidrug-resistant (MDR) Gram-negative pathogens in hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are associated with poor clinical outcomes. These pathogens represent a global threat with few therapeutic options. In this review, we discuss current guidelines for the empiric management of HAP/VAP caused by MDR Gram-negative pathogens. RECENT FINDINGS The incidence of MDR Gram-negative bacteria is rising among cases of nosocomial pneumonia, such that it is now becoming a significant challenge for clinicians. Adherence to international guidelines may ensure early and adequate antimicrobial therapy, guided by local microbiological data and awareness of the risk factors for MDR bacteria. SUMMARY Due to the increasing prevalence of HAP/VAP caused by MDR Gram-negative pathogens, management should be guided by the local ecology and the patient's risk factors for MDR pathogens. The main risk factors are prior hospitalization for at least 5 days, prior use of broad-spectrum antibiotics, prior colonization with resistant pathogens, admission to hospital settings with high rates of MDR pathogens, and septic shock at the time of diagnosis with nosocomial pneumonia.
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Decreased duration of intravenous cephalosporins in intensive care unit patients with selective digestive decontamination: a retrospective before-and-after study. Eur J Clin Microbiol Infect Dis 2020; 39:2115-2120. [PMID: 32617694 PMCID: PMC7330883 DOI: 10.1007/s10096-020-03966-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/25/2020] [Indexed: 12/18/2022]
Abstract
Selective digestive decontamination (SDD) reduces the rate of infection and improves the outcomes of patients admitted to an intensive care unit (ICU). A risk associated with its use is the development of multi-drug-resistant organisms. We hypothesized that a 1-day reduction in systemic antimicrobial exposure in the SDD regimen would not affect the outcomes of our patients. In this before-and-after study design, 199 patients and 248 patients were included in a 3-day SDD group and a 2-day SDD group, respectively. The rates of hospital-acquired pneumonia and ICU infections were similar in both groups. The rates of bloodstream infection and bacteriuria were significantly lower in the 2-day SDD group than in the 3-day SDD group. Compared with the patients in the 3-day group, the patients in the 2-day SDD group received fewer antibiotics and less exposure to mechanical ventilation, and they used fewer ICU resources. The rates of ICU mortality and 28-day mortality were similar in both groups. The incidence of multi-drug-resistant organisms was similar in both groups. Within the limitations inherent to our study design, reducing the exposure of prophylactic systemic antibiotics in the SDD setting from 3 days to 2 days was not associated with impaired outcomes. Future randomized controlled trials should be conducted to test this hypothesis and investigate the effects on the development of multi-drug resistant organisms.
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Cotoia A, Spadaro S, Gambetti G, Koulenti D, Cinnella G. Pathogenesis-Targeted Preventive Strategies for Multidrug Resistant Ventilator-Associated Pneumonia: A Narrative Review. Microorganisms 2020; 8:microorganisms8060821. [PMID: 32486132 PMCID: PMC7356213 DOI: 10.3390/microorganisms8060821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/20/2020] [Accepted: 05/28/2020] [Indexed: 11/18/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection in the intensive care unit (ICU), accounting for relevant morbidity and mortality among critically ill patients, especially when caused by multidrug resistant (MDR) organisms. The rising problem of MDR etiologies, which has led to a reduction in treatment options, have increased clinician’s attention to the employment of effective prevention strategies. In this narrative review we summarized the evidence resulting from 27 original articles that were identified through a systematic database search of the last 15 years, focusing on several pathogenesis-targeted strategies which could help preventing MDR-VAP. Oral hygiene with Chlorhexidine (CHX), CHX body washing, selective oral decontamination (SOD) and/or digestive decontamination (SDD), multiple decontamination regimens, probiotics, subglottic secretions drainage (SSD), special cuff material and shape, silver-coated endotracheal tubes (ETTs), universal use of gloves and contact isolation, alcohol-based hand gel, vaporized hydrogen peroxide, and bundles of care have been addressed. The most convincing evidence came from interventions directly addressed against the key factors of MDR-VAP pathogenesis, especially when they are jointly implemented into bundles. Further research, however, is warranted to identify the most effective combination.
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Affiliation(s)
- Antonella Cotoia
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
- Correspondence:
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Anesthesia and Intensive Care Section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant’Anna, Via Aldo Moro 8, 44124 Ferrara, Italy;
| | - Guido Gambetti
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
| | - Despoina Koulenti
- 2nd Critical Care Department, Attikon University Hospital, 12462 Athens, Greece;
- UQCCR, Faculty of Medicine, The University of Queensland, Brisbane QLD 4029, Australia
| | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Viale Pinto 241, 71122 Foggia, Italy; (G.G.); (G.C.)
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Abstract
Supplemental Digital Content is available in the text. Objectives: To compare methods to adjust for confounding by disease severity during multicenter intervention studies in ICU, when different disease severity measures are collected across centers. Design: In silico simulation study using national registry data. Setting: Twenty mixed ICUs in The Netherlands. Subjects: Fifty-five–thousand six-hundred fifty-five ICU admissions between January 1, 2011, and January 1, 2016. Interventions: None. Measurements and Main Results: To mimic an intervention study with confounding, a fictitious treatment variable was simulated whose effect on the outcome was confounded by Acute Physiology and Chronic Health Evaluation IV predicted mortality (a common measure for disease severity). Diverse, realistic scenarios were investigated where the availability of disease severity measures (i.e., Acute Physiology and Chronic Health Evaluation IV, Acute Physiology and Chronic Health Evaluation II, and Simplified Acute Physiology Score II scores) varied across centers. For each scenario, eight different methods to adjust for confounding were used to obtain an estimate of the (fictitious) treatment effect. These were compared in terms of relative (%) and absolute (odds ratio) bias to a reference scenario where the treatment effect was estimated following correction for the Acute Physiology and Chronic Health Evaluation IV scores from all centers. Complete neglect of differences in disease severity measures across centers resulted in bias ranging from 10.2% to 173.6% across scenarios, and no commonly used methodology—such as two-stage modeling or score standardization—was able to effectively eliminate bias. In scenarios where some of the included centers had (only) Acute Physiology and Chronic Health Evaluation II or Simplified Acute Physiology Score II available (and not Acute Physiology and Chronic Health Evaluation IV), either restriction of the analysis to Acute Physiology and Chronic Health Evaluation IV centers alone or multiple imputation of Acute Physiology and Chronic Health Evaluation IV scores resulted in the least amount of relative bias (0.0% and 5.1% for Acute Physiology and Chronic Health Evaluation II, respectively, and 0.0% and 4.6% for Simplified Acute Physiology Score II, respectively). In scenarios where some centers used Acute Physiology and Chronic Health Evaluation II, regression calibration yielded low relative bias too (relative bias, 12.4%); this was not true if these same centers only had Simplified Acute Physiology Score II available (relative bias, 54.8%). Conclusions: When different disease severity measures are available across centers, the performance of various methods to control for confounding by disease severity may show important differences. When planning multicenter studies, researchers should make contingency plans to limit the use of or properly incorporate different disease measures across centers in the statistical analysis.
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Papazian L, Klompas M, Luyt CE. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med 2020; 46:888-906. [PMID: 32157357 PMCID: PMC7095206 DOI: 10.1007/s00134-020-05980-0] [Citation(s) in RCA: 337] [Impact Index Per Article: 84.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/19/2020] [Indexed: 12/15/2022]
Abstract
Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.
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Affiliation(s)
- Laurent Papazian
- Médecine Intensive Réanimation, Hôpital Nord, Hôpitaux de Marseille, Chemin des Bourrely, 13015, Marseille, France. .,Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Groupe de recherche en Réanimation et Anesthésie de Marseille pluridisciplinaire (GRAM +), Faculté de médecine, Aix-Marseille Université, 13005, Marseille, France.
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, USA
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,INSERM, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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Heuker M, Koser U, Ott A, Karrenbeld A, van Dijl JM, van Dam GM, de Smet AMGA, van Oosten M. Yeast Infections after Esophagectomy: A Retrospective Analysis. Sci Rep 2020; 10:4343. [PMID: 32152398 PMCID: PMC7062806 DOI: 10.1038/s41598-020-61113-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 02/06/2020] [Indexed: 12/03/2022] Open
Abstract
Esophageal malignancy is a disease with poor prognosis. Curative therapy incorporates surgery and is burdensome with high rates of infection morbidity and mortality. The role of yeast as causative organisms of post-esophagectomy infections is poorly defined. Consequently, the benefits of specific antifungal prophylactic therapy in improving patient outcome are unclear. Therefore, this study aimed at investigating the incidence of yeast infections at the University Medical Center Groningen among 565 post-esophagectomy patients between 1991 and 2017. The results show that 7.3% of the patients developed a yeast infection after esophageal resection with significantly increased incidence among patients suffering from diabetes mellitus. For patients with yeast infections, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, more frequent intensive care unit readmissions, prolonged hospital stays and higher mortality rates were observed. One-year survival was significantly lower for patients with a yeast infection, as well as diabetes mellitus and yeast-positive pleural effusion. We conclude that the incidence of yeast infections following esophagectomy is considerable, and that patients with diabetes mellitus are at increased risk. Furthermore, yeast infections are associated with higher complication rates and mortality. These observations encourage further prospective investigations on the possible benefits of antifungal prophylactic therapy for esophagectomy patients.
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Affiliation(s)
- Marjolein Heuker
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Usma Koser
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Alewijn Ott
- Department of Medical Microbiology, Certe, PO Box 909, 9700 AX, Groningen, The Netherlands
| | - Arend Karrenbeld
- Department of Pathology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Gooitzen M van Dam
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
- Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Marleen van Oosten
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands.
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Discrepancies in Control Group Mortality Rates Within Studies Assessing Topical Antibiotic Strategies to Prevent Ventilator-Associated Pneumonia: An Umbrella Review. Crit Care Explor 2020; 2:e0076. [PMID: 32166296 PMCID: PMC7063908 DOI: 10.1097/cce.0000000000000076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: To test the postulate that concurrent control patients within ICUs studying topical oropharyngeal antibiotics to prevent ventilator-associated pneumonia and mortality would experience spillover effects from the intervention. Data Sources: Studies cited in 15 systematic reviews of various topical antibiotic and other infection prevention interventions among ICU patients. Study Selection: Studies of topical antibiotics, stratified into concurrent control versus nonconcurrent control designs. Studies of nondecontamination-based infection prevention interventions provide additional points of reference. Studies with no infection prevention intervention provide the mortality benchmark. Data from additional studies and data reported as intention to treat were used within sensitivity tests. Data Extraction: Mortality incidence proportion data, mortality census, study characteristics, group mean age, ICU type, and study publication year. Data Synthesis: Two-hundred six studies were included. The summary effect sizes for ventilator-associated pneumonia and mortality prevention derived in the 15 systematic reviews were replicated. The mean ICU mortality incidence for concurrent control groups of topical antibiotic studies (28.5%; 95% CI, 25.0–32.3; n = 41) is higher versus the benchmark (23.7%; 19.2–28.5%; n = 34), versus nonconcurrent control groups (23.5%; 19.3–28.3; n = 14), and versus intervention groups (24.4%; 22.1–26.9; n = 62) of topical antibiotic studies. In meta-regression models adjusted for group-level characteristics such as group mean age and publication year, concurrent control group membership within a topical antibiotic study remains associated with higher mortality (p = 0.027), whereas other group memberships, including membership within an antiseptic study, are each neutral (p = not significant). Conclusions: Within topical antibiotic studies, the concurrent control group mortality incidence proportions are inexplicably high, whereas the intervention group mortality proportions are paradoxically similar to a literature-derived benchmark. The unexplained ventilator-associated pneumonia and mortality excess in the concurrent control groups implicates spillover effects within studies of topical antibiotics. The apparent ventilator-associated pneumonia and mortality prevention effects require cautious interpretation.
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Wittekamp BHJ, Oostdijk EAN, Cuthbertson BH, Brun-Buisson C, Bonten MJM. Selective decontamination of the digestive tract (SDD) in critically ill patients: a narrative review. Intensive Care Med 2019; 46:343-349. [PMID: 31820032 PMCID: PMC7042187 DOI: 10.1007/s00134-019-05883-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/26/2019] [Indexed: 01/06/2023]
Abstract
Selective decontamination of the digestive tract (SDD) is an infection prevention measure for intensive care unit (ICU) patients that was proposed more than 30 years ago, and that is currently considered standard of care in the Netherlands, but only used sporadically in ICUs in other countries. In this narrative review, we first describe the rationale of the individual components of SDD and then review the evidence base for patient-centered outcomes, where we distinguish ICUs with low prevalence of antibiotic resistance from ICUs with moderate–high prevalence of resistance. In settings with low prevalence of antibiotic resistance, SDD has been associated with improved patient outcome in three cluster-randomized studies. These benefits were not confirmed in a large international cluster-randomized study in settings with moderate-to-high prevalence of antibiotic resistance. There is no evidence that SDD increases antibiotic resistance. We end with future directions for research.
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Affiliation(s)
- Bastiaan H J Wittekamp
- Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Evelien A N Oostdijk
- Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, University Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Christian Brun-Buisson
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), Inserm UVSQ, Institut Pasteur, Paris, France
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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The added value of the selective SuperPolymyxin™ medium in detecting rectal carriage of Gram-negative bacteria with acquired colistin resistance in intensive care unit patients receiving selective digestive decontamination. Eur J Clin Microbiol Infect Dis 2019; 39:265-271. [PMID: 31691864 PMCID: PMC7010615 DOI: 10.1007/s10096-019-03718-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/20/2019] [Indexed: 12/02/2022]
Abstract
The objective of this study was to determine the value of using SuperPolymyxin™ selective medium (ELITech Group, Puteaux, France) in addition to conventional non-selective inoculation methods in the detection of acquired colistin resistance in a Dutch intensive care unit (ICU) that routinely uses selective decontamination of the digestive tract (SDD). We performed a cross-sectional study with prospective data collection in a tertiary-care ICU. All consecutive surveillance rectal swabs of ICU-patients receiving SDD were included and cultured in an observer-blinded approach using (1) a conventional culture method using non-selective media and (2) SuperPolymyxin™ selective medium. MIC values for colistin of non-intrinsically colistin-resistant Gram-negative isolates were determined with broth microdilution (BMD) using Sensititre™ and colistin resistance was confirmed using BMD according to EUCAST guidelines. One thousand one hundred five rectal swabs of 428 unique ICU-patients were inoculated using both culture methods, yielding 346 and 84 Gram-negative isolates for BMD testing with the conventional method and SuperPolymyxin™ medium, of which 308 and 80 underwent BMD, respectively. The number of identified rectal carriers of isolates with acquired colistin resistance was 3 (0.7%) for the conventional method, 4 (0.9%) for SuperPolymyxin™, and 5 (1.2%) for both methods combined. The number of isolates with acquired colistin resistance was 4 (1.0%) for the conventional method, 8 (2.1%) for SuperPolymyxin™ and 9 (2.3%) for both methods combined. In a surveillance setting of low prevalence of acquired colistin resistance in patients that receive SDD in a Dutch tertiary-care ICU, SuperPolymyxin™ had a higher diagnostic yield than conventional inoculation methods, but the combination of both had the highest diagnostic yield.
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van Hout D, Plantinga NL, Bruijning-Verhagen PC, Oostdijk EAN, de Smet AMGA, de Wit GA, Bonten MJM, van Werkhoven CH. Cost-effectiveness of selective digestive decontamination (SDD) versus selective oropharyngeal decontamination (SOD) in intensive care units with low levels of antimicrobial resistance: an individual patient data meta-analysis. BMJ Open 2019; 9:e028876. [PMID: 31494605 PMCID: PMC6731916 DOI: 10.1136/bmjopen-2018-028876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of selective digestive decontamination (SDD) as compared to selective oropharyngeal decontamination (SOD) in intensive care units (ICUs) with low levels of antimicrobial resistance. DESIGN Post-hoc analysis of a previously performed individual patient data meta-analysis of two cluster-randomised cross-over trials. SETTING 24 ICUs in the Netherlands. PARTICIPANTS 12 952 ICU patients who were treated with ≥1 dose of SDD (n=6720) or SOD (n=6232). INTERVENTIONS SDD versus SOD. PRIMARY AND SECONDARY OUTCOME MEASURES The incremental cost-effectiveness ratio (ICER; ie, costs to prevent one in-hospital death) was calculated by comparing differences in direct healthcare costs and in-hospital mortality of patients treated with SDD versus SOD. A willingness-to-pay curve was plotted to reflect the probability of cost-effectiveness of SDD for a range of different values of maximum costs per prevented in-hospital death. RESULTS The ICER resulting from the fixed-effect meta-analysis, adjusted for clustering and differences in baseline characteristics, showed that SDD significantly reduced in-hospital mortality (adjusted absolute risk reduction 0.0195, 95% CI 0.0050 to 0.0338) with no difference in costs (adjusted cost difference €62 in favour of SDD, 95% CI -€1079 to €935). Thus, SDD yielded significantly lower in-hospital mortality and comparable costs as compared with SOD. At a willingness-to-pay value of €33 633 per one prevented in-hospital death, SDD had a probability of 90.0% to be cost-effective as compared with SOD. CONCLUSION In Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD. These data support the implementation of SDD in settings with low levels of antimicrobial resistance.
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Affiliation(s)
- Denise van Hout
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
| | - Nienke L Plantinga
- University Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Patricia C Bruijning-Verhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
- Center for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Evelien A N Oostdijk
- University Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Marie G A de Smet
- University Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Marc J M Bonten
- University Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
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Amornphimoltham P, Yuen PST, Star RA, Leelahavanichkul A. Gut Leakage of Fungal-Derived Inflammatory Mediators: Part of a Gut-Liver-Kidney Axis in Bacterial Sepsis. Dig Dis Sci 2019; 64:2416-2428. [PMID: 30863955 DOI: 10.1007/s10620-019-05581-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/06/2019] [Indexed: 02/07/2023]
Abstract
Sepsis is a life-threatening response to systemic infection. In addition to frank gastrointestinal (GI) rupture/puncture, sepsis can also be exacerbated by translocation of pathogen-associated molecular patterns (PAMPs) from the GI tract to the systemic circulation (gut origin of sepsis). In the human gut, Gram-negative bacteria and Candida albicans are abundant, along with their major PAMP components, endotoxin (LPS) and (1 → 3)-β-D-glucan (BG). Whereas the influence of LPS in bacterial sepsis has been studied extensively, exploration of the role of BG in bacterial sepsis is limited. Post-translocation, PAMPs enter the circulation through lymphatics and the portal vein, and are detoxified and then excreted via the liver and the kidney. Sepsis-induced liver and kidney injury might therefore affect the kinetics and increase circulating PAMPs. In this article, we discuss the current knowledge of the impact of PAMPs from both gut mycobiota and microbiota, including epithelial barrier function and the "gut-liver-kidney axis," on bacterial sepsis severity.
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Affiliation(s)
| | - Peter S T Yuen
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Robert A Star
- Renal Diagnostics and Therapeutics Unit, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Asada Leelahavanichkul
- Immunology Unit, Department of Microbiology, Chulalongkorn University, Bangkok, 10330, Thailand. .,Center of Excellence in Immunology and Immune-mediated Diseases, Department of Microbiology, Chulalongkorn University, Bangkok, Thailand.
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Abstract
PURPOSE OF REVIEW The host-microbiota relationship is integral in human health and can be rapidly disrupted in ways that may contribute to poor recovery from surgery or acute illness. We review key studies by organ system to understand the effect of perioperative and critical illness stress on the microbiota. Throughout the review, our focus is on potential interventions that may be mediated by the microbiome. RECENT FINDINGS Although any perioperative intervention can have a profound impact on the gut microbiota, it is less clear how such changes translate into altered health outcomes. Preoperative stress (anxiety, lack of sleep, fasting), intraoperative stress (surgery itself, volatile anesthetics, perioperative antibiotics, blood transfusions), and postoperative stress (sepsis, surgical site infections, acute respiratory distress syndrome, catecholamines, antibiotics, opioids, proton pump inhibitors) have all been associated with alterations of the commensal microflora. These factors (e.g. administration of antibiotics or opioids) can create a favorable environment for emergence of pathogen virulence and development of serious infections and multiorgan failure. Data to recommend therapies aimed at restoring a disrupted microbiota, such as probiotics/prebiotics and fecal microbiota transplants is currently scarce. SUMMARY The microbiome is likely to play an important role in the perioperative and ICU setting but existing data is largely descriptive. There is an expanding number of mechanistic studies that attempt to disentangle the complicated bi-directional relationship between the host and the resident microbiota. When these results are combined with ongoing clinical studies, we should be able to offer better therapies aimed at restoring the microbiota in the future.
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48
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Chan MXF, Buitinck S, Stooker W, Haak EAF, Wester JPJ, Bosman RJ, van der Voort PHJ. Clinical Effects of Perioperative Selective Decontamination of the Digestive Tract (SDD) in Cardiac Surgery: A Propensity Score Matched Cohort Analysis. J Cardiothorac Vasc Anesth 2019; 33:3001-3009. [PMID: 31101508 DOI: 10.1053/j.jvca.2019.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the clinical effects of perioperative endotoxin reduction in the gut lumen in patients undergoing cardiac surgery with cardiopulmonary bypass. DESIGN Retrospective cohort analysis with propensity score matching according to treatment group. SETTING Tertiary center for cardiopulmonary diseases and intensive care medicine. PARTICIPANTS Included were patients who underwent cardiac surgery with cardiopulmonary bypass between 2008 and 2017. Excluded were readmitted patients. INTERVENTIONS Endotoxin reduction in the gut lumen by ingestion of oral tobramycin 80 mg and polymyxin B 100 mg 4 times daily (TP) as part of selective digestive tract decontamination, which contains amphotericin B 500 mg as well. MEASUREMENTS AND MAIN RESULTS A total of 6,394 patients were included, of whom 2,044 patients were in the intervention group. A total of 835 patients received both pre- and postoperative TP (Pre+/Post+), and 1,165 patients received TP only postoperatively (Pre-/Post+). The control group, not treated with TP at any moment, consisted of 4,350 patients (Pre-/Post-). After matching, 652 Pre+/Post+ patients were compared with an equal number of controls (Pre-/Post-). Pre+/Post+ group did not do better for any clinical outcome. A total of 682 Pre+/Post+ patients matched with an equal number of Pre-/Post+ patients. The latter group had a 0.3 points higher mean Sequential Organ Failure Assessment score and in the regression analysis a significantly higher intensive care unit mortality but not hospital mortality. A significant reduction in length of stay and length of mechanical ventilation for the Pre+/Post+ group was shown compared with Pre-/Post+, but these differences can be explained by unbalanced differences in the severity of illness. CONCLUSION Cardiosurgical patients who receive tobramycin and polymyxin orally preoperatively to reduce the gut endotoxin level do not expose convincing and relevant beneficial effects on clinical outcomes in this retrospective propensity score matching cohort study.
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Affiliation(s)
| | - Sophie Buitinck
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | - Wim Stooker
- Department of Cardio-thoracic Surgery, OLVG, Amsterdam, the Netherlands
| | - Eric A F Haak
- Department of Clinical Pharmacy, OLVG, Amsterdam, the Netherlands
| | - Jos P J Wester
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | - Rob J Bosman
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | - Peter H J van der Voort
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands; TIAS School for Business and Society, Tilburg University, Tilburg, the Netherlands.
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Lloréns-Villar Y, Tusell F, Canut A, Barrasa H, Corral E, Martín A, Rodríguez-Gascón A. Antibiotic susceptibility trend before and after long-term use of selective digestive decontamination: a 16 year ecological study. J Antimicrob Chemother 2019; 74:2289-2294. [DOI: 10.1093/jac/dkz186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
The aim of this study was to compare antimicrobial susceptibility rates in a Spanish ICU before and after the introduction of selective digestive decontamination (SDD) and also to compare these with susceptibility data from other Spanish ICUs without SDD.
Methods
We performed a retrospective study in the ICU of the University Hospital of Alava, where SDD was implemented in 2002. The SDD protocol consisted of a 2% mixture of gentamicin, colistin and amphotericin B applied on the buccal mucosa and a suspension of the same drugs in the gastrointestinal tract; additionally, for the first 3 days, systemic ceftriaxone was administered. From 1998 to 2013 we analysed the susceptibility rates for 48 antimicrobial/organism combinations. Interrupted time series using a linear dynamic model with SDD as an intervention was used. Data from other ICUs were obtained from the ENVIN-HELICS national registry.
Results
Only amoxicillin/clavulanic acid against Escherichia coli and Proteus mirabilis, and a high concentration of gentamicin against Enterococcus faecalis, resulted in a significant decrease in the susceptibility rate after the implementation of SDD, with a drop of 20%, 27% and 32%, respectively. Compared with other Spanish ICUs without SDD, the susceptibility rate was higher in the ICU of our hospital in most cases. When it was lower, differences were <10%, except for a high concentration of streptomycin against Enterococcus faecium, for which the difference was 19%.
Conclusions
No relevant changes in the overall susceptibility rate after the implementation of SDD were detected. Susceptibility rates were not lower than those in the Spanish ICUs without SDD.
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Affiliation(s)
- Yanire Lloréns-Villar
- Servicio de Farmacia Hospitalaria, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain
| | - Fernando Tusell
- Departamento de Economía Aplicada III, Facultad de Ciencias Económicas y Empresariales, Universidad del País Vasco UPV/EHU, Bilbao, Spain
| | - Andrés Canut
- Servicio de Microbiología, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain
| | - Helena Barrasa
- Servicio de Medicina Intensiva, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain
| | - Esther Corral
- Servicio de Medicina Intensiva, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain
| | - Alejandro Martín
- Servicio de Medicina Intensiva, Hospital Universitario de Álava, Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Farmacia y Tecnología Farmacéutica, Facultad de Farmacia, Centro de investigación Lascaray ikergunea, Universidad del País Vasco UPV/EHU, Vitoria, Spain
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Nahar J, Buitinck S, Jansen R, Haak EA, van der Voort PH. Use of enteral amikacin to eliminate carriership with multidrug resistant Enterobacteriaceae. J Infect 2019; 78:409-421. [DOI: 10.1016/j.jinf.2019.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/08/2019] [Accepted: 02/18/2019] [Indexed: 11/25/2022]
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