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Deng Q, Wang W, Ming J, Zhou L, Lv Y, Liu J, Lu H. Frequency, characteristics, and outcome of adult patients with multiple consecutive health care-associated infections undergoing extracorporeal membrane oxygenation: A retrospective analysis. Am J Infect Control 2024; 52:1188-1194. [PMID: 38885791 DOI: 10.1016/j.ajic.2024.06.008] [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: 01/05/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Data on multiple consecutive health care-associated infections (HAIs) in patients undergoing extracorporeal membrane oxygenation (ECMO) are limited. We aim to identify the characteristics and outcomes of multiple, consecutive HAIs. METHODS This retrospective study included adult patients who underwent ECMO in a single cardiac ICU in China from May 2015 to December 2022. The incidence, clinical characteristics, risk factors, and impact on in-hospital mortality among patients with non-HAI, single HAI, and multiple HAIs were analyzed. Pathogens and infection sites for each new episode were compared. RESULTS Of 192 patients, 92 (47.92%) developed 141 separate infections, with 41 (21.35%) experiencing multiple infections during a single ECMO period. Respiratory tract infections (RTIs) constituted the majority (75.89%), and gram-negative bacteria were the predominant pathogens (71.63%). RTIs decreased from 86.9% in the first infection to 14.3% in the third (P < .001), while bloodstream infections increased from 10.9 % to 57.1% (P < .001). The proportion of gram-positive bacteria increased from 9.8% to 42.9% (P = .032). Prolonged ECMO duration was the only independent risk factor for multiple consecutive HAIs (odds ratio (OR)=1.220, P < .001). CONCLUSIONS Multiple consecutive HAIs during ECMO were frequent, with distinct microbiological changes between initial and subsequent HAIs.
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Affiliation(s)
- Qidan Deng
- Department of Intensive Care Unit, Affiliated Qingyuan Hospital, Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, China
| | - Wen Wang
- Department of Gastrointestinal Surgery, Affiliated Qingyuan Hospital, Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, China
| | - Jianqing Ming
- Department of Intensive Care Unit, Affiliated Qingyuan Hospital, Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, China
| | - Linrong Zhou
- Hospital-Acquired Infection Control Department, Affiliated Qingyuan Hospital, Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, China
| | - Yunhao Lv
- Department of Intensive Care Unit, Affiliated Qingyuan Hospital, Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, China
| | - Jianling Liu
- Department of Intensive Care Unit, Affiliated Qingyuan Hospital, Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, China.
| | - Huihui Lu
- Department of Nursing, Affiliated Qingyuan Hospital, Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, China.
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2
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Poth JM, Schmandt M, Schewe JC, Lehmann F, Kreyer S, Kohistani Z, Bakhtiary F, Hischebeth G, Putensen C, Weller J, Ehrentraut SF. Prevalence and prognostic relevance of invasive fungal disease during veno-arterial ECMO: A retrospective single-center study. J Crit Care 2024; 83:154831. [PMID: 38797056 DOI: 10.1016/j.jcrc.2024.154831] [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: 03/21/2024] [Revised: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
PURPOSE To assess the prevalence and relevance of invasive fungal disease (IFD) during veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO). METHODS Retrospective analysis from January 2013 to November 2023 of adult V-A ECMO cases at a German University Hospital. Parameters relating to IFD, demographics, length of stay (LoS), days on ECMO and mechanical ventilation, prognostic scores and survival were assessed. Multivariable logistic regression analyses with IFD and death as dependent variables were performed. Outcome was assessed after propensity score matching IFD-patients to non-IFD-controls. RESULTS 421 patients received V-A ECMO. 392 patients with full electronic datasets were included. The prevalence of IFD, invasive candidiasis and probable invasive pulmonary aspergillosis was 4.6%, 3.8% and 1.0%. Severity of acute disease, pre-existing moderate-to-severe renal disease and continuous kidney replacement therapy were predictive of IFD. In-hospital mortality (94% (17/18) compared to 67% (252/374) in non-IFD patients (p = 0.0156)) was predicted by female sex, SOFA score at admission, SAVE score and IFD (for IFD: OR: 8.31; CI: 1.60-153.18; p: 0.044). There was no difference in outcome after matching IFD-cases to non-IFD-controls. CONCLUSIONS IFD are detected in about one in 20 patients on V-A ECMO, indicating mortality >90%. However, IFD do not contribute to prognosis in this population.
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Affiliation(s)
- Jens M Poth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Mathias Schmandt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Rostock, 18057 Rostock, Germany
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Zaki Kohistani
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, 53127 Bonn, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, 53127 Bonn, Germany
| | - Gunnar Hischebeth
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, 53127 Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Johannes Weller
- Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan F Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany.
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Boscolo A, Bruni A, Giani M, Garofalo E, Sella N, Pettenuzzo T, Bombino M, Palcani M, Rezoagli E, Pozzi M, Falcioni E, Pistollato E, Biamonte E, Murgolo F, D'Arrigo G, Gori M, Tripepi GL, Gottin L, Longhini F, Grasso S, Navalesi P, Foti G. Retrospective ANalysis of multi-drug resistant Gram-nEgative bacteRia on veno-venous extracorporeal membrane oxygenation. The multicenter RANGER STUDY. Crit Care 2024; 28:279. [PMID: 39192287 PMCID: PMC11351604 DOI: 10.1186/s13054-024-05068-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 08/15/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is a rapidly expanding life-support technique worldwide. The most common indications are severe hypoxemia and/or hypercapnia, unresponsive to conventional treatments, primarily in cases of acute respiratory distress syndrome. Concerning potential contraindications, there is no mention of microbiological history, especially related to multi-drug resistant (MDR) bacteria isolated before V-V ECMO placement. Our study aims to investigate: (i) the prevalence and incidence of MDR Gram-negative (GN) bacteria in a cohort of V-V ECMOs; (ii) the risk of 1-year mortality, especially in the case of predetected MDR GN bacteria; and (iii) the impact of annual hospital V-V ECMO volume on the probability of acquiring MDR GN bacteria. METHODS All consecutive adults admitted to the Intensive Care Units of 5 Italian university-affiliated hospitals and requiring V-V ECMO were screened. Exclusion criteria were age < 18 years, pregnancy, veno-arterial or mixed ECMO-configuration, incomplete records, survival < 24 h after V-V ECMO. A standard protocol of microbiological surveillance was applied and MDR profiles were identified using in vitro susceptibility tests. Cox-proportional hazards models were applied for investigating mortality. RESULTS Two hundred and seventy-nine V-V ECMO patients (72% male) were enrolled. The overall MDR GN bacteria percentage was 50%: 21% (n.59) detected before and 29% (n.80) after V-V ECMO placement. The overall 1-year mortality was 42%, with a higher risk observed in predetected patients (aHR 2.14 [1.33-3.47], p value 0.002), while not in 'V-V ECMO-acquired MDR GN bacteria' group (aHR 1.51 [0.94-2.42], p value 0.090), as compared to 'non-MDR GN bacteria' group (reference). Same findings were found considering only infections. A larger annual hospital V-V ECMO volume was associated with a lower probability of acquiring MDR GN bacteria during V-V ECMO course (aOR 0.91 [0.86-0.97], p value 0.002). CONCLUSIONS 21% of MDR GN bacteria were detected before; while 29% after V-V ECMO connection. A history of MDR GN bacteria, isolated before V-V ECMO, was an independent risk factor for mortality. The annual hospital V-V ECMO volume affected the probability of acquiring MDR GN bacteria. Trial Registration ClinicalTrial.gov Registration Number NCTNCT06199141, date 12.26.2023.
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Affiliation(s)
- Annalisa Boscolo
- Department of Medicine (DIMED), University of Padua, 13 Gallucci Street, 35121, Padua, Italy
- Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Andrea Bruni
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Marco Giani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
| | - Eugenio Garofalo
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nicolò Sella
- Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy
| | - Tommaso Pettenuzzo
- Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy
| | - Michela Bombino
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
| | - Matteo Palcani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
| | - Matteo Pozzi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
| | - Elena Falcioni
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
- Cardiothoracic and Vascular Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Elisa Pistollato
- Department of Medicine (DIMED), University of Padua, 13 Gallucci Street, 35121, Padua, Italy
| | - Eugenio Biamonte
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Francesco Murgolo
- Department of Precision and Regenerative Medicine and Ionian Area, School of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Graziella D'Arrigo
- CNR-IFC, Institute of Clinical Physiology of Reggio Calabria, Reggio Calabria, Italy
| | - Mercedes Gori
- CNR-IFC, Institute of Clinical Physiology of Rome, Rome, Italy
| | | | - Leonardo Gottin
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
- Cardiothoracic and Vascular Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Salvatore Grasso
- Department of Precision and Regenerative Medicine and Ionian Area, School of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Paolo Navalesi
- Department of Medicine (DIMED), University of Padua, 13 Gallucci Street, 35121, Padua, Italy.
- Institute of Anesthesia and Critical Care, Padua University Hospital, Padua, Italy.
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Critical Care, IRCSS San Gerardo Dei Tintori, Monza, Italy
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Sah R, Shah S, Subedi P, Kashyap A, Kc A, Wosti D, Sanghavi D, Bhattacharyya A, Guru P, Chaudhary S. Antibiotic Prophylaxis in Patients on Extracorporeal Membrane Oxygenation: A Systematic Review. ASAIO J 2024; 70:e103-e107. [PMID: 38502730 DOI: 10.1097/mat.0000000000002192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
Despite the frequent use of prophylactic antibiotics in hospitals for extracorporeal membrane oxygenation (ECMO) patients, the Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force does not recommend routine antibiotic prophylaxis due to a lack of compelling evidence. We assessed the effectiveness of prophylactic antibiotics in ECMO patients. We conducted a comprehensive search of multiple databases from their inception up to September 6, 2023, on various databases using keywords like "antibiotics," "prophylaxis," "extracorporeal membrane oxygenation," and "ECMO." Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included research. We collected data using Microsoft Excel version 2016, mean and standard deviations were calculated for continuous data, while frequencies and percentages were calculated for binomial data. A total of three studies was included in the review with a total of 8,954 participants, of which 4,483 (50.06%) received antibiotic prophylaxis, and 1,131 (25.22%) were female. The administration of antibiotics prophylactically was associated with reduction in rate of mortality, the risk of infections, and complications like acute kidney injury and diarrhea. Although there have been some benefits on antibiotic prophylaxis, prospective research, and possibly the creation of tailored, ECMO-specific bundles will be needed to identify efficient ways to prevent ECMO infection.
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Affiliation(s)
- Ranjit Sah
- From the Department of Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
- Faculty of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Sangam Shah
- Tribhuvan University, Institute of Medicine, Maharajgunj, Nepal
| | - Prativa Subedi
- Kist Medical College and Teaching Hospital, Imadole, Lalitpur
| | | | - Anil Kc
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Deepa Wosti
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Pramod Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
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Kriegl L, Hatzl S, Schilcher G, Zollner-Schwetz I, Boyer J, Geiger C, Hoenigl M, Krause R. Antifungals in Patients With Extracorporeal Membrane Oxygenation: Clinical Implications. Open Forum Infect Dis 2024; 11:ofae270. [PMID: 38887481 PMCID: PMC11181180 DOI: 10.1093/ofid/ofae270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 05/05/2024] [Indexed: 06/20/2024] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving technique used in critical care medicine for patients with severe respiratory or cardiac failure. This review examines the treatment and prophylaxis of fungal infections in ECMO patients, proposing specific regimens based on available data for different antifungals (azoles, echinocandins, amphotericin B/liposomal amphotericin B) and invasive fungal infections. Currently, isavuconazole and posaconazole have the most supported data, while modified dosages of isavuconazole are recommended in ECMO. Echinocandins are preferred for invasive candidiasis. However, choosing echinocandins is challenging due to limited and varied data on concentration loss in the ECMO circuit. Caution is likewise advised when using liposomal amphotericin B due to uncertain concentrations and potential ECMO dysfunction based on scarce data. We further conclude with the importance of further research on the impact of ECMO on antifungal drug concentrations to optimize dosing regimens in critically ill patients.
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Affiliation(s)
- Lisa Kriegl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Stefan Hatzl
- BioTechMed-Graz, Graz, Austria
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Ines Zollner-Schwetz
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Johannes Boyer
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christina Geiger
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Hoenigl
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Robert Krause
- Division of Infectious Diseases, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
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Ait Hssain A, Vahedian-Azimi A, Ibrahim AS, Hassan IF, Azoulay E, Darmon M. Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysis. Crit Care 2024; 28:158. [PMID: 38730424 PMCID: PMC11088079 DOI: 10.1186/s13054-024-04946-8] [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: 03/26/2024] [Accepted: 05/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND An increasing number of patients requires extracorporeal membrane oxygenation (ECMO) for life support. This supportive modality is associated with nosocomial infections (NIs). This systematic review and meta-analysis aim to assess the incidence and risk factors of NIs in adult. METHODS We searched PubMed, Scopus, Web of Science, and ProQuest databases up to 2022. The primary endpoint was incidence of NI. Secondary endpoints included time to infection, source of infection, ECMO duration, Intensive care and hospital length of stay (LOS), ECMO survival and overall survival. Incidence of NI was reported as pooled proportions and 95% confidence intervals (CIs), while dichotomous outcomes were presented as risk ratios (RR) as the effective index and 95% CIs using a random-effects model. RESULTS Among the 4,733 adult patients who received ECMO support in the 30 included studies, 1,249 ECMO-related NIs per 1000 ECMO-days was observed. The pooled incidence of NIs across 18 studies involving 3424 patients was 26% (95% CI 14-38%).Ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) were the most common NI sources. Infected patients had lower ECMO survival and overall survival rates compared to non-infected patients, with risk ratio values of 0.84 (95% CI 0.74-0.96, P = 0.01) and 0.80 (95% CI 0.71-0.90, P < 0.001), respectively. CONCLUSION Results showed that 16% and 20% lower of ECMO survival and overall survival in patients with NI than patients without NI, respectively. However, NI increased the risk of in-hospital mortality by 37% in infected patients compared with non-infected patients. In addition, this study identified the significant positive correlation between ECMO duration and ECMO-related NI.
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Affiliation(s)
- Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, Doha, Qatar
- College of Health and Life Science, Hamad Bin Khalifa University, Doha, Qatar
| | - Amir Vahedian-Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Sheykh Bahayi Street, Vanak Square, P.O. Box 19575-174, Tehran, Iran.
| | - Abdulsalam Saif Ibrahim
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Ibrahim Fawzy Hassan
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
| | - Michael Darmon
- Médecine Intensive et Réanimation, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
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Joshi DR, Gopalakrishnan R, Selvi C, Sethuraman N, Yamunadevi VR, Ramasubramanian V, Nambi PS, Yogesh M, Ramesh TP. Epidemiology and outcomes of infections during extracorporeal membrane oxygenation in adult patients with COVID-19 ARDS- A single center study. Indian J Med Microbiol 2024; 48:100539. [PMID: 38354980 DOI: 10.1016/j.ijmmb.2024.100539] [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: 08/31/2023] [Revised: 02/07/2024] [Accepted: 02/11/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND There is a scarcity of data regarding nosocomial infections in patients with COVID-19 treated with ECMO. This observational study from India aims to describe the epidemiology and microbiology of infections in patients with COVID-19 associated ECMO. METHODS This is an ambi-directional observational study of COVID-19 ECMO patients admitted from April 2021 to June 2022 in a tertiary care hospital. The total number of sepsis episodes for each patient was recorded and were categorized as bloodstream infections (BSI), pneumonias, skin and soft tissue infections (SSTI), invasive candidiasis (IC), catheter associated urinary tract infection (CAUTI), intra-abdominal infections (IAI), and Clostridioides difficile infections. Details regarding each infection including the microbiological profile and outcomes were recorded. RESULTS 29 patients who received ECMO for COVID-19 pneumonia during the study period were identified. Of the 29 patients, there were a total of 185 septic episodes. The incidence of septic episodes was 72.4 per 1000 ECMO days. Of the 185 sepsis events, 82 (44.3%) were BSI, 72 (39%) were pneumonia, 19 (10.3%) were SSTI, 7 (3.8%) were CAUTI and 5 (2.7%) were IAIs. Of these 29 patients, 16 (55.2%) patients were discharged and 13 (44.8%) died. CONCLUSIONS The most common infections in our patients were bloodstream infections followed by pneumonia. High rates of gram negative infections, including those caused by carbapenem resistant bacteria, reflect the Indian critical care unit epidemiology in general. Despite these high infection rates with antimicrobial resistant set of micro-organisms, we had a successful outcome in 55.2% of patients.
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Affiliation(s)
| | - Ram Gopalakrishnan
- Senior Consultant, Deparmtent of Infectious Diseases, Apollo Hospitals, Chennai.
| | - C Selvi
- Interventional and Transplant Pulmonologist, Apollo Hospitals, Chennai, India.
| | - Nandini Sethuraman
- Consultant and Head, Department of Microbiology, Apollo Hospitals, Chennai, India.
| | - V R Yamunadevi
- Department of Infection Control, Apollo Hospitals, Chennai, India.
| | - V Ramasubramanian
- Senior Consultant, Deparmtent of Infectious Diseases, Apollo Hospitals, Chennai.
| | - P Senthur Nambi
- Senior Consultant, Deparmtent of Infectious Diseases, Apollo Hospitals, Chennai.
| | - M Yogesh
- Transplant Co-ordinator, Dept of Heart and Lung transplant, Apollo Hospitals, Chennai, India.
| | - Thangaraj Paul Ramesh
- Cardiothoracic, Heart and Lung Transplant Surgeon, Apollo Hospitals, Chennai, India.
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8
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Nesseler N, Mansour A, Schmidt M, Para M, Porto A, Falcoz PE, Mongardon N, Fougerou C, Ross JT, Beurton A, Gaide-Chevronnay L, Guinot PG, Lebreton G, Flecher E, Vincentelli A, Massart N. Healthcare-associated infections in patients with severe COVID-19 supported with extracorporeal membrane oxygenation: a nationwide cohort study. Crit Care 2024; 28:54. [PMID: 38374103 PMCID: PMC10877839 DOI: 10.1186/s13054-024-04832-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/10/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Both critically ill patients with coronavirus disease 2019 (COVID-19) and patients receiving extracorporeal membrane oxygenation (ECMO) support exhibit a high incidence of healthcare-associated infections (HAI). However, data on incidence, microbiology, resistance patterns, and the impact of HAI on outcomes in patients receiving ECMO for severe COVID-19 remain limited. We aimed to report HAI incidence and microbiology in patients receiving ECMO for severe COVID-19 and to evaluate the impact of ECMO-associated infections (ECMO-AI) on in-hospital mortality. METHODS For this study, we analyzed data from 701 patients included in the ECMOSARS registry which included COVID-19 patients supported by ECMO in France. RESULTS Among 602 analyzed patients for whom HAI and hospital mortality data were available, 214 (36%) had ECMO-AI, resulting in an incidence rate of 27 ECMO-AI per 1000 ECMO days at risk. Of these, 154 patients had bloodstream infection (BSI) and 117 patients had ventilator-associated pneumonia (VAP). The responsible microorganisms were Enterobacteriaceae (34% for BSI and 48% for VAP), Enterococcus species (25% and 6%, respectively) and non-fermenting Gram-negative bacilli (13% and 20%, respectively). Fungal infections were also observed (10% for BSI and 3% for VAP), as were multidrug-resistant organisms (21% and 15%, respectively). Using a Cox multistate model, ECMO-AI were not found associated with hospital death (HR = 1.00 95% CI [0.79-1.26], p = 0.986). CONCLUSIONS In a nationwide cohort of COVID-19 patients receiving ECMO support, we observed a high incidence of ECMO-AI. ECMO-AI were not found associated with hospital death. Trial registration number NCT04397588 (May 21, 2020).
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Affiliation(s)
- Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France.
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), 35000, Rennes, France.
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, 35000, Rennes, France.
- Hôpital Pontchaillou, Pôle Anesthésie, SAMU, Urgences, Réanimations, Médecine Interne Et Gériatrie (ASUR-MIG), 2 Rue Henri Le Guilloux, 35033, Rennes Cedex 9, France.
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, IRSET, UMR_S 1085, CIC 1414 (Centre d'Investigation Clinique de Rennes), 35000, Rennes, France
| | - Matthieu Schmidt
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, PARIS, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Marylou Para
- Department of Cardiovascular Surgery and Transplantation, Bichat Hospital, AP-HP, Paris, France
- Laboratory of Vascular Translational Science, University of Paris, UMR 1148, Paris, France
| | - Alizée Porto
- Department of Cardiac Surgery, Timone Hospital, APHM, 13005, Marseille, France
| | - Pierre-Emmanuel Falcoz
- INSERM, UMR 1260, Regenerative Nanomedicine (RNM), FMTS, 67000, Strasbourg, France
- Faculté de Médecine et Pharmacie, Université de Strasbourg, 67000, Strasbourg, France
- Hôpitaux Universitaire de Strasbourg, Service de Chirurgie Thoracique - Nouvel Hôpital Civil, Strasbourg, France
| | - Nicolas Mongardon
- Service d'anesthésie-Réanimation, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, 94010, Créteil, France
- Faculté de Santé, Univ Paris Est Créteil, 94010, Créteil, France
- U955-IMRB, Equipe 03 « Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT), Inserm, Univ Paris Est Créteil (UPEC), Ecole Nationale Vétérinaire d'Alfort (EnVA), 94700, Maisons-Alfort, France
| | - Claire Fougerou
- Department of Clinical Pharmacology, University Hospital, Rennes 1 University, 35033, Rennes, France
- Inserm CIC 1414, Clinical Investigation Centre, University Hospital, Rennes 1 University, 35033, Rennes, France
| | - James T Ross
- Department of Surgery, University Hospitals Cleveland and Case Western Reserve University, Cleveland, USA
| | - Antoine Beurton
- Department of Anaesthesia and Critical Care, CHU Bordeaux, Magellan Medico-Surgical Centre, 33000, Bordeaux, France
- UMR 1034, Biology of Cardiovascular Diseases, Univ. Bordeaux, INSERM, 33600, Pessac, France
| | - Lucie Gaide-Chevronnay
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Grenoble, Grenoble, France
| | - Pierre-Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Hospital, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Chirurgie Thoracique et Cardiovasculaire, Institut de Cardiologie, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Signal and Image Treatment Laboratory (LTSI), Pontchaillou University Hospital, University of Rennes 1, Inserm U1099, Rennes, France
| | - André Vincentelli
- Cardiac Surgery, Univ. Lille, CHU Lille, 59000, Lille, France
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, 59000, Lille, France
| | - Nicolas Massart
- Intensive Care Unit, Centre Hospitalier Yves Le Foll, Saint-Brieuc, France
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Peña-López Y, Machado MC, Rello J. Infection in ECMO patients: Changes in epidemiology, diagnosis and prevention. Anaesth Crit Care Pain Med 2024; 43:101319. [PMID: 37925153 DOI: 10.1016/j.accpm.2023.101319] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023]
Abstract
Patients with prolonged duration of extracorporeal membrane oxygenation support (ECMO) are a vulnerable population for sepsis, particularly ventilator-associated pneumonia and bloodstream infections. Rates differ between venous-arterial and venous-venous ECMO patients and according to the cannulation technique used. The presence of particular organisms depends on local epidemiology, antibiotic exposure, and the duration of the intervention; patients undergoing ECMO for more than three weeks present a high risk of persistent candidemia. Recognizing predisposing factors, and establishing the best preventive interventions and therapeutic choices are critical to optimizing the management of these complications. Infection control practices, including shortening the period of the indwelling devices, and reducing antibiotic exposure, must be followed meticulously. Innovations in oxygenator membranes require an updated approach. Hand hygiene and avoiding breaking the circuit-oxygenator sterility are cornerstones. ECMO management would benefit from clearer definitions, optimization of infection control strategies, and updated infectious clinical practice guidelines.
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Affiliation(s)
- Yolanda Peña-López
- Clinical Research/Epidemiology in Pneumonia&Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | | | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia&Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain; Formation, Recherche, Evaluation (FOREVA), Centre Hospitalier Universitaire de Nîmes, Nîmes, France
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10
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Wang L, Ni K, Wang Y, Lu H, Fang J, Chen C. Nosocomial infections in adult patients receiving extracorporeal membrane oxygenation in China: A retrospective cohort study. Am J Infect Control 2023; 51:1237-1241. [PMID: 37059121 DOI: 10.1016/j.ajic.2023.04.010] [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: 01/26/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been increasingly used in China, but nosocomial infections (NI) in patients receiving ECMO remain poorly characterized. Thus, this study aimed to investigate the incidence rate, causative was pathogens, and risk factors of NIs in ECMO patients. METHODS A retrospective cohort study of patients receiving ECMO between January 2015 and October 2021 was conducted in a tertiary hospital. General demographics and clinical data of the included patients were collected from the electronic medical record system and the real-time NI surveillance system. RESULTS A total of 86 infected patients with 110 episodes of NIs were identified in 196 patients receiving ECMO. The incidence of NI was 59.2/1000 ECMO days. The median time for the first NI in ECMO patients was 5 days (interquartile range: 2-8 days). Hospital-acquired pneumonia and bloodstream infections were common types of NIs in ECMO patients, and the main pathogens were gram-negative bacteria. Pre-ECMO invasive mechanical ventilation (OR = 2.40, 95% CI:1.12-5.15) and prolonged duration of ECMO (OR = 1.26, 95% CI:1.15-1.39) were risk factors for NIs during ECMO support. DISCUSSION This study identified the main infection sites and pathogens of NIs in ECMO patients. Although NIs may not affect successful ECMO weaning, additional measures should be implemented to reduce the incidence of NI during ECMO support.
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Affiliation(s)
- Lizhu Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kaiwen Ni
- Department of Infection Control, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Yuwei Wang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haifei Lu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jue Fang
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chengyang Chen
- Department of Critical Care Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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11
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Verkerk K, Pladet LCA, Meuwese CL, Donker DW, Derde LPG, Cremer OL. Interrater agreement in classifying infections during extracorporeal membrane oxygenation. Int J Artif Organs 2023; 46:597-601. [PMID: 37596944 PMCID: PMC10629257 DOI: 10.1177/03913988231193448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/24/2023] [Indexed: 08/21/2023]
Abstract
Infectious complications are common during extracorporeal membrane oxygenation (ECMO) and may negatively impact outcomes. However, there is considerable variation in the reported rates of incidence, which hampers the use of infections as a quality benchmark for ECMO centers. To assess the contributing role of poor interrater agreement, three independent raters reviewed medical records from all intensive care unit (ICU) patients who received ECMO for >24 h in our tertiary center between October 2019 and October 2021 for suspected episodes of infection, which were rated based on their date of onset and presumed site/diagnosis. To establish a gold standard, any discrepancies were resolved using an expert panel consisting of two intensivists/infectious disease specialists. During 83 ECMO-runs in 77 patients, we observed a total of 62 adjudicated infectious episodes (incidence rate 62, 95% CI: 48-80, per 1000 days at risk). Among 81 episodes suspected by at least one observer, 66 (81%) were identified by two, and only 44 (54%) by all three raters, resulting in Fleiss' kappa of 0.10 (95% CI: 0.00-0.19; slight agreement). However, if raters concurred regarding infection onset, subsequent agreement on infection site was good (concordance 89%; kappa 0.85, 95% CI: 0.72-0.98; near perfect agreement). In conclusion, adjudication of infectious episodes during ECMO is associated with poor interrater agreement regarding occurrence-but not site-of infection. This finding might partially explain the significant disparities observed in reported infection rates during ECMO, emphasizing the need for caution when interpreting infection data in this particular population due to the potential for inherent measurement error.
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Affiliation(s)
- Karlijn Verkerk
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lara CA Pladet
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiaan L Meuwese
- Department of Cardiology, Thoraxcenter, Erasmus, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, The Netherlands
| | - Lennie PG Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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12
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Tan C, Hota SS, Fan E, Marquis K, Vicencio E, Vaisman A. Bloodstream infection and ventilator-associated pneumonia in patients with coronavirus disease 2019 (COVID-19) supported by extracorporeal membrane oxygenation. Infect Control Hosp Epidemiol 2023; 44:1443-1450. [PMID: 36451285 PMCID: PMC10507515 DOI: 10.1017/ice.2022.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/27/2022] [Accepted: 11/05/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) has been widely used in the care of patients with respiratory failure from coronavirus disease 2019 (COVID-19). We characterized bloodstream infections (BSIs) and ventilator-associated pneumonias (VAPs) in COVID-19 patients supported with ECMO, and we investigated their impact on patient outcomes. DESIGN Retrospective cohort study from March 1, 2020, to June 30, 2021. SETTING Academic tertiary-care referral center. PATIENTS Consecutive adult patients admitted for COVID-19 who received ECMO. METHODS We identified BSIs and VAPs and described their epidemiology and microbiology. Cumulative antimicrobial use and the specific management of BSIs were determined. Multivariate time-dependent Cox proportional hazards models were constructed to evaluate the impact of BSIs and VAPs on mortality, controlling for age, receipt of COVID-19-specific therapeutics, and new renal replacement therapy. RESULTS We identified 136 patients who received ECMO for COVID-19 pneumonia during the study period. BSIs and VAPs occurred in 81 patients (59.6%) and 93 patients (68.4%), respectively. The incidence of BSIs was 29.5 per 1,000 ECMO days and increased with duration of ECMO cannulation. Enterococci, Enterobacterales, and Staphylococcus aureus were the most common causes of BSIs, whereas S. aureus, Klebsiella species, and Pseudomonas aeruginosa comprised the majority of VAPs. Mean antibiotic use comprised 1,031 days of therapy per 1,000 ECMO days (SD, 496). We did not detect an association between BSIs or VAPs and mortality. CONCLUSIONS BSIs and VAPs are common in COVID-19 ECMO-supported patients. Efforts to optimize their diagnosis, prevention, and management should be prioritized.
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Affiliation(s)
- Charlie Tan
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
| | - Susy S. Hota
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Krista Marquis
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Elisa Vicencio
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
| | - Alon Vaisman
- Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Infection Prevention and Control, University Health Network, Toronto, Ontario, Canada
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13
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Poth JM, Schewe JC, Lehmann F, Weller J, Schmandt MW, Kreyer S, Muenster S, Putensen C, Ehrentraut SF. COVID-19 Is an Independent Risk Factor for Detrimental Invasive Fungal Disease in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: A Retrospective Study. J Fungi (Basel) 2023; 9:751. [PMID: 37504739 PMCID: PMC10381551 DOI: 10.3390/jof9070751] [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: 05/29/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023] Open
Abstract
Invasive fungal disease (IFD) is associated with the mortality of patients on extracorporeal membrane oxygenation (ECMO). Several risk factors for IFD have been identified in patients with or without ECMO. Here, we assessed the relevance of coronavirus disease (COVID-19) for the occurrence of IFD in patients on veno-venous (V-V) ECMO for respiratory failure. In a retrospective analysis of all ECMO cases between January 2013 and December 2022 (2020-2022 for COVID-19 patients), active COVID-19 and the type, timing and duration of IFD were investigated. Demographics, hospital, ICU length of stay (LoS), duration of ECMO, days on invasive mechanical ventilation, prognostic scores (Respiratory ECMO Survival Prediction (RESP) score, Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS)-10, Sequential Organ Failure Assessment (SOFA) score and Simplified Acute Physiology Score (SAPS)-II) and length of survival were assessed. The association of COVID-19 with IFD was investigated using propensity score matching and uni- and multivariable logistic regression analyses. We identified 814 patients supported with ECMO, and 452 patients were included in further analyses. The incidence of IFD was 4.8% and 11.0% in patients without and with COVID-19, respectively. COVID-19 status represented an independent risk factor for IFD (OR 4.30; CI 1.72-10.85; p: 0.002; multivariable regression analysis). In patients with COVID-19, 84.6% of IFD was candidemia and 15.4% represented invasive aspergillosis (IA). All of these patients died. In patients on V-V ECMO, we report that COVID-19 is an independent risk factor for IFD, which is associated with a detrimental prognosis. Further studies are needed to investigate strategies of antifungal therapy or prophylaxis in these patients.
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Affiliation(s)
- Jens Martin Poth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Rostock, 18057 Rostock, Germany
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Johannes Weller
- Department of Neurology, University Hospital Bonn, 53127 Bonn, Germany
| | - Mathias Willem Schmandt
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Muenster
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Stefan Felix Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany
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14
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Andersen HV, Jørgensen VRL, Steensen M, Pedersen FM, Helleberg M. Superinfections in COVID-19 patients receiving extracorporeal membrane oxygenation support. Acta Anaesthesiol Scand 2023; 67:755-761. [PMID: 36906734 DOI: 10.1111/aas.14228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/12/2023] [Accepted: 02/16/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND The risk of superinfections and associations with mortality among patients with corona virus disease 2019 (COVID-19) receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) is poorly elucidated. METHOD We identified all patients with COVID-19 treated with VV-ECMO >24 h at Rigshospitalet, Denmark from March 2020 to December 2021. Data were obtained by review of medical files. Associations between superinfections and mortality were assessed by logistic regression analyses adjusted for sex and age. RESULTS Fifty patients, median age 53 years (interquartile range [IQR] 45-59), 66% male, were included. Median time on VV-ECMO was 14.5 days (IQR 6.3-23.5), 42% were discharged from hospital alive. Bacteremia, ventilator associated pneumonia (VAP), invasive candidiasis, pulmonary aspergillosis, herpes simplex virus, and cytomegalovirus (CMV) were detected in 38%, 42%, 12%, 12%, 14%, and 20% of patients, respectively. No patients with pulmonary aspergillosis survived. CMV was associated with increased risk of death, odds ratio 12.6 (95% confidence interval 1.9-257, p = .05), whereas we found no associations between other superinfections and risk of death. CONCLUSION Bacteremia and VAP are common but does not seem to affect mortality, whereas pulmonary aspergillosis and CMV are associated with poor prognosis among COVID-19 patients treated with VV-ECMO.
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Affiliation(s)
| | - Vibeke R L Jørgensen
- Department of Thoracic Anesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten Steensen
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Finn M Pedersen
- Department of Thoracic Anesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marie Helleberg
- CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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15
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Lyster H, Shekar K, Watt K, Reed A, Roberts JA, Abdul-Aziz MH. Antifungal Dosing in Critically Ill Patients on Extracorporeal Membrane Oxygenation. Clin Pharmacokinet 2023; 62:931-942. [PMID: 37300631 PMCID: PMC10338597 DOI: 10.1007/s40262-023-01264-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 06/12/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an established advanced life support system, providing temporary cardiac and/or respiratory support in critically ill patients. Fungal infections are associated with increased mortality in patients on ECMO. Antifungal drug dosing for critically ill patients is highly challenging because of altered pharmacokinetics (PK). PK changes during critical illness; in particular, the drug volume of distribution (Vd) and clearance can be exacerbated by ECMO. This article discusses the available literature to inform adequate dosing of antifungals in this patient population. The number of antifungal PK studies in critically ill patients on ECMO is growing; currently available literature consists of case reports and studies with small sample sizes providing inconsistent findings, with scant or no data for some antifungals. Current data are insufficient to provide definitive empirical drug dosing guidance and use of dosing strategies derived from critically patients not on ECMO is reasonable. However, due to high PK variability, therapeutic drug monitoring should be considered where available in critically ill patients receiving ECMO to prevent subtherapeutic or toxic antifungal exposures.
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Affiliation(s)
- Haifa Lyster
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- University of Portsmouth, Portsmouth, UK
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - Kevin Watt
- School of Pharmacy, University of Waterloo, 10 Victoria St S. Kitchener, Waterloo, ON, N2G 1C5, Canada
- Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Anna Reed
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- Imperial College London, London, SW3 6NP, UK
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
- Herston Infectious Diseases (HeIDI), Metro North Health, Brisbane, QLD, Australia.
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
| | - Mohd-Hafiz Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
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16
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Li X, Wang X, Wang L, Li C, Hao X, Du Z, Xie H, Yang F, Wang H, Hou X. Impact of Nosocomial Infection on in-Hospital Mortality Rate in Adult Patients Under Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery. Infect Drug Resist 2023; 16:4189-4200. [PMID: 37404257 PMCID: PMC10315138 DOI: 10.2147/idr.s390599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/30/2023] [Indexed: 07/06/2023] Open
Abstract
Objective There was no consensus on the impact of nosocomial infection on In-hospital mortality rate in patients receiving ECMO. This study aimed to investigate the impact of nosocomial infection (NI) on In-hospital mortality rate in adult patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) after cardiac surgery. Materials and Methods This retrospective study included 503 adult patients who underwent VA-ECMO after cardiac surgery. The impact of time-dependent NIs on In-hospital mortality rate within 28 days of ECMO initiation was investigated using a Cox regression model. The cumulative incidence function for death was compared between patients with NIs and those without NIs using a competing risk model. Results Within 28 days after ECMO initiation, 206 (41.0%) patients developed NIs, and 220 (43.7%) patients died. The prevalence rates of NIs were 27.8% and 20.3% during and after ECMO therapy, respectively. The incidence rates of NIs during and after ECMO therapy were 49‰ and 25‰, respectively. Time-dependent NI was an independent risk factor for predicting death (hazard ratio = 1.05, 95% confidence interval = 1.00-1.11). The cumulative incidence of death in patients with NI was significantly higher than that in patients without NI at each time point within 28 days of ECMO initiation. (Z = 5.816, P = 0.0159). Conclusion NI was a common complication in adult patients who received VA-ECMO after cardiac surgery, and time-dependent NI was an independent risk factor for predicting mortality in these patients. Using a competing risk model, we confirmed that NIs increased the risk of In-hospital mortality rate in these patients.
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Affiliation(s)
- Xiyuan Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
- Department of Intensive Care Unit, Aviation General Hospital of China Medical University, Beijing, 100012, People’s Republic of China
| | - Xiaomeng Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Xing Hao
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Haixiu Xie
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
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17
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Massart N, Camus C, Nesseler N, Fillâtre P, Flecher E, Mansour A, Verhoye JP, Le Fevre L, Luyt CE. Multiple-site decontamination to prevent acquired infection in patients with veno-venous ECMO support. Ann Intensive Care 2023; 13:27. [PMID: 37024761 PMCID: PMC10079793 DOI: 10.1186/s13613-023-01120-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/18/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Acute distress respiratory syndrome (ARDS) patients with veno-venous extra corporeal membrane oxygenation (ECMO) support are particularly exposed to ECMO-associated infection (ECMO-AI). Unfortunately, data regarding AI prophylaxis in this setting are lacking. Selective decontamination regimens decrease AI incidence, including ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) in critically ill patients. We hypothesized that a multiple-site decontamination (MSD) regimen is associated with a reduction in the incidence of AI among VV-ECMO patients. METHODS We conducted a retrospective observational study in three French ECMO referral centers from January 2010 to December 2021. All adult patients (> 18 years old) who received VV-ECMO support for ARDS were eligible. In addition to standard care (SC), 2 ICUs used MSD, which consists of the administration of topical antibiotics four times daily in the oropharynx and the gastric tube, once daily chlorhexidine body-wash and a 5-day nasal mupirocin course. AIs were compared between the 2 ICUs using MSD (MSD group) and the last ICU using SC. RESULTS They were 241 patients available for the study. Sixty-nine were admitted in an ICU that applied MSD while the 172 others received standard care and constituted the SC group. There were 19 ECMO-AIs (12 VAP, 7 BSI) in the MSD group (1162 ECMO-days) compared to 143 AIs (104 VAP, 39 BSI) in the SC group (2376 ECMO-days), (p < 0.05 for all infection site). In a Poisson regression model, MSD was independently associated with a lower incidence of ECMO-AI (IRR = 0.42, 95% CI [0.23-0.60] p < 0.001). There were 30 multidrug resistant microorganisms (MDRO) acquisition in the SC group as compared with two in the MSD group (IRR = 0.13, 95% CI [0.03-0.56] p = 0.001). Mortality in ICU was similar in both groups (43% in the SC group vs 45% in the MSD group p = 0.90). Results were similar after propensity-score matching. CONCLUSION In this cohort of patients from different hospitals, MSD appeared to be safe in ECMO patients and may be associated with improved outcomes including lower ECMO-AI and MDRO acquisition incidences. Since residual confounders may persist, these promising results deserve confirmation by randomized controlled trials.
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Affiliation(s)
- Nicolas Massart
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France.
| | - Christophe Camus
- Service de réanimation médicale, CHU de Rennes, 2, rue Henri le Guilloux, 35000, Rennes, France
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, CIC 1414 (Centre d'Investigation Clinique de Rennes), 35000, Rennes, France
| | - Pierre Fillâtre
- Service de Réanimation, CH de St BRIEUC, 10, rue Marcel Proust, 22000, Saint-Brieuc, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital, University of Rennes 1, Signal and Image Treatment Laboratory (LTSI), Inserm U1099, Rennes, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, CIC 1414 (Centre d'Investigation Clinique de Rennes), 35000, Rennes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital, University of Rennes 1, Signal and Image Treatment Laboratory (LTSI), Inserm U1099, Rennes, France
| | - Lucie Le Fevre
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
- Sorbonne-Université, Hôpital Pitié-Salpêtrière, and Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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18
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Peitz GJ, Murry DJ. The Influence of Extracorporeal Membrane Oxygenation on Antibiotic Pharmacokinetics. Antibiotics (Basel) 2023; 12:500. [PMID: 36978367 PMCID: PMC10044059 DOI: 10.3390/antibiotics12030500] [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: 02/04/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is becoming increasingly utilized to support critically ill patients who experience life-threatening cardiac or pulmonary compromise. The provision of this intervention poses challenges related to its complications and the optimization of medication therapy. ECMO's mechanical circulatory support is facilitated via various devices and equipment that have been shown to sequester lipophilic- and protein-bound medications, including anti-infectives. Since infectious outcomes are dependent on achieving specific anti-infectives' pharmacodynamic targets, the understanding of these medications' pharmacokinetic parameters in the setting of ECMO is important to clinicians. This narrative, non-systematic review evaluated the findings of the most recent and robust pharmacokinetic analyses for commonly utilized anti-infectives in the setting of ECMO. The data from available literature indicates that anti-infective pharmacokinetic parameters are similar to those observed in other non-ECMO critically ill populations, but considerable variability in the findings was observed between patients, thus prompting further evaluation of therapeutic drug monitoring in this complex population.
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Affiliation(s)
- Gregory J. Peitz
- Nebraska Medicine, Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Daryl J. Murry
- Clinical Pharmacology Laboratory, Department of Pharmacy Practice and Science, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198, USA
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19
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Tantway TM, Arafat AA, Albabtain MA, Belghith M, Osman AA, Aboughanima MA, Abdullatif MT, Elshoura YA, AlBarak MM. Sepsis in postcardiotomy cardiogenic shock patients supported with veno- arterial extracorporeal membrane oxygenation. Int J Artif Organs 2023; 46:153-161. [PMID: 36744676 DOI: 10.1177/03913988231152978] [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] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sepsis could affect the outcomes of patients with postcardiotomy cardiogenic shock supported with extracorporeal membrane oxygenation (ECMO). Our objectives were to characterize sepsis patients with ECMO support for postcardiotomy cardiogenic shock and assess its predictors and effect on patients' outcomes. METHODS This retrospective study included 103 patients with ECMO for postcardiotomy cardiogenic shock from 2009 to 2020. Patients were divided according to the occurrence and timing of sepsis into three groups. Group 1 included patients with no sepsis (n = 67), Group 2 included patients with ECMO-related sepsis (n = 10), and Group 3 included patients with non-ECMO-related sepsis (n = 26). RESULTS Lactate level before ECMO was highest in the ECMO-associated sepsis group (Group 1 and 2 p = 0.003 and Group 2 and 3 p = 0.003). Dialysis and gastrointestinal bleeding were highest in ECMO-associated sepsis (p = 0.03 and 0.04, respectively). Blood transfusion was higher in ECMO-associated sepsis than in patients with no sepsis (p = 0.01). Mortality was nonsignificantly higher in patients with ECMO-associated sepsis. High BMI (OR: 1.11; p = 0.004), preoperative dialysis (OR: 7.35; p = 0.02), preoperative IABP (OR: 9.9.61; p = 0.01) and CABG (OR: 6.29; p = 0.01) were significantly associated with sepsis. Older age (OR: 1.08; p = 0.004), lower BSA (OR: 0.004; p = 0.003), peripheral cannulation (OR: 29.82; p = 0.03), and high pre ECMO lactate level (OR: 1.24; p = 0.001) were associated with increased mortality. Sepsis did not predict mortality (OR: 1.83; p = 0.21). CONCLUSIONS Sepsis is a dreaded complication in patients with postcardiotomy cardiogenic shock, especially ECMO-associated sepsis. Preoperative risk factors could predict postoperative sepsis in ECMO patients.
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Affiliation(s)
- Tarek M Tantway
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Intensive Care Department, Cairo University, Cairo, Egypt
| | - Amr A Arafat
- Adult Cardiac Surgery Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Monirah A Albabtain
- Cardiology Clinical Pharmacy Department, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
| | - Makhlouf Belghith
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Ahmed A Osman
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Intensive Care Department, Cairo University, Cairo, Egypt
| | | | | | - Youssef A Elshoura
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.,Anesthesia and Critical Care Department, Tanta University, Tanta, Egypt
| | - Mohammed M AlBarak
- Intensive Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
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20
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Abstract
Fungal infections are common and frequently associated with clinical failure in patients receiving extracorporeal membrane oxygenation (ECMO). Antifungal drugs have physicochemical characteristics associated with a higher likelihood of sequestration onto ECMO circuitry potentially leading to a subtherapeutic drug concentration. The percentage of sequestration of the antifungal drugs-caspofungin, posaconazole, and voriconazole-was determined using an ex vivo ECMO model. The circuits were primed with whole human blood, sodium chloride 0.9%, and human albumin solution. Serial 2 ml samples were taken at baseline, 0.5, 1, 2, 6, 12, and 24 hours after drug addition, paired with non-ECMO controls stored in a water bath at 37°C. Mean loss from the blood-primed ECMO circuits and controls at 24 hours relative to baseline were 80% and 61% for caspofungin ( p = ns), 64% and 11% for posaconazole ( p < 0.005), and 27% and 19% for voriconazole ( p < 0.05). Calculated AUC 0-24 showed a 44% for caspofungin ( p = ns), 30.6% posaconazole ( p < 0.005), and 9% loss for voriconazole ( p = 0.003) compared with the controls, suggesting therapeutic concentrations of these antifungal agents cannot be guaranteed with standard dosing in patients on ECMO. Posaconazole exhibited the greatest loss to the ECMO circuit correlating with both high lipophilicity and protein binding of the drug.
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21
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Frankford SA, Sobieszczyk MJ, Markelz AE, Marcus JE. Clearance of blood stream infections in patients receiving extracorporeal membrane oxygenation: a retrospective single-center cohort study. BMC Infect Dis 2023; 23:63. [PMID: 36732697 PMCID: PMC9894522 DOI: 10.1186/s12879-023-08021-5] [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: 11/09/2022] [Accepted: 01/19/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There are limited data on the treatment of blood stream infections (BSIs) in patients receiving extracorporeal membrane oxygenation (ECMO). Current guidance recommends documenting clearance only in fungal and Gram-positive BSIs. This study investigates the incidence and clinical significance of blood stream infections with positive repeat cultures (BSIPRC) in ECMO as well as clinical factors that may predict positive repeat cultures. METHODS All BSIs in patients receiving ECMO at Brooke Army Medical Center between September 2012 and October 2021 were included in this study. BSIPRC was defined as re-isolation of the same organism on repeat blood cultures following an initial positive blood culture. RESULTS A total of 60 patients developed 87 BSI (38.5 BSI per 1000 ECMO days). Of the 80 (92%) BSIs who had repeat blood cultures drawn, patients had BSIPRC in 35 (44%) of cases. Fever, leukocytosis, and vasopressor requirement on day of repeat culture were not associated with persistent positivity. There was no difference in survival to discharge for patients with BSIPRC as compared to single day BSI (58% vs. 63%, p = 0.78). 19% of patients with Gram-negative bacteremia had BSIPRC, and gram-negative bacteremia in general was associated with an 83% morality. CONCLUSIONS There were no clinical findings that differentiated patients with BSIPRC from those who had a single day of positivity. BSI was associated with high mortality in patients with Gram-negative bacteremia. Given high incidence of positive repeat cultures being seen in Gram-negative BSIs, repeat blood cultures have utility for all BSIs in patients receiving ECMO.
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Affiliation(s)
- Stone A. Frankford
- grid.416660.30000 0004 1792 7961Internal Medicine Residency, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, 3551 Roger Brooke Dr, San Antonio, TX 78234 USA
| | - Michal J. Sobieszczyk
- grid.416653.30000 0004 0450 5663Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam Houston, 3551 Roger Brooke Dr, San Antonio, TX 78234 USA ,grid.265436.00000 0001 0421 5525Department of Medicine, Uniformed Services University, Bethesda, MD USA
| | - Ana E. Markelz
- grid.416653.30000 0004 0450 5663Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam Houston, 3551 Roger Brooke Dr, San Antonio, TX 78234 USA ,grid.265436.00000 0001 0421 5525Department of Medicine, Uniformed Services University, Bethesda, MD USA
| | - Joseph E. Marcus
- grid.416653.30000 0004 0450 5663Department of Medicine, Brooke Army Medical Center, JBSA-Fort Sam Houston, 3551 Roger Brooke Dr, San Antonio, TX 78234 USA ,grid.265436.00000 0001 0421 5525Department of Medicine, Uniformed Services University, Bethesda, MD USA
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22
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Kitaya S, Kanamori H, Baba H, Oshima K, Takei K, Seike I, Katsumi M, Katori Y, Tokuda K. Clinical and Epidemiological Characteristics of Persistent Bacteremia: A Decadal Observational Study. Pathogens 2023; 12:pathogens12020212. [PMID: 36839484 PMCID: PMC9960527 DOI: 10.3390/pathogens12020212] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/16/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
Background: Bloodstream infections (BSIs), including persistent bacteremia (PB), are a leading source of morbidity and mortality globally. PB has a higher mortality rate than non- PB, but the clinical aspects of PB in terms of the causative pathogens and the presence of clearance of PB are not well elucidated. Therefore, this study aimed to describe the clinical and epidemiological characteristics of PB in a real-world clinical setting. Methods: We performed a retrospective observational survey of patients who underwent blood culture between January 2012 and December 2021 at Tohoku University Hospital. Cases of PB were divided into three groups depending on the causative pathogen: gram-positive cocci (GPC), gram-negative rods (GNRs), and Candida spp. For each group, we examined the clinical and epidemiological characteristics of PB, including differences in clinical features depending on the clearance of PB. The main outcome variable was mortality, assessed as early (30-day), late (30-90 day), and 90-day mortality. Results: Overall, we identified 31,591 cases of single bacteremia; in 6709 (21.2%) cases, the first blood culture was positive, and in 3124 (46.6%) cases, a follow-up blood culture (FUBC) was performed. Of the cases with FUBCs, 414 (13.2%) were confirmed to be PB. The proportion of PB cases caused by Candida spp. was significantly higher (29.6%, 67/226 episodes) than that for GPC (11.1%, 220/1974 episodes, p < 0.001) and GNRs (12.1%, 100/824 episodes, p < 0.001). The Candida spp. group also had the highest late (30-90 day) and 90-day mortality rates. In all three pathogen groups, the subgroup without the clearance of PB tended to have a higher mortality rate than the subgroup with clearance. Conclusions: Patients with PB due to Candida spp. have a higher late (30-90 day) and 90-day mortality rate than patients with PB due to GPC or GNRs. In patients with PB, FUBCs and confirming the clearance of PB are useful to improve the survival rate.
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Affiliation(s)
- Shiori Kitaya
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Correspondence: (S.K.); (H.K.)
| | - Hajime Kanamori
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Correspondence: (S.K.); (H.K.)
| | - Hiroaki Baba
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Kengo Oshima
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Kentarou Takei
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Issei Seike
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Makoto Katsumi
- Department of Laboratory Medicine, Tohoku University Hospital, Sendai 980-8574, Japan
| | - Yukio Katori
- Department of Otolaryngology, Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
| | - Koichi Tokuda
- Department of Infectious Diseases, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
- Department of Intelligent Network for Infection Control, Tohoku University Graduate School of Medicine, Sendai 980-8574, Japan
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23
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High Incidence of Candidemia in Critically Ill COVID-19 Patients Supported by Veno-Venous Extracorporeal Membrane Oxygenation: A Retrospective Study. J Fungi (Basel) 2023; 9:jof9010119. [PMID: 36675940 PMCID: PMC9861971 DOI: 10.3390/jof9010119] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/07/2023] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The incidence of candidemia in severe COVID-19 patients (0.8-14%) is two- to ten-fold higher than in non-COVID-19 patients. METHODS This retrospective analysis aimed to analyse the incidence of bloodstream infections (BSI) due to Candida in a cohort of COVID-19 patients supported with ECMO. RESULTS Among 138 intubated and ventilated patients hospitalized for ≥10 days in the intensive care unit of a teaching hospital, 45 (32.6%) patients received ECMO support, while 93 patients (67.4%) did not meet ECMO criteria and were considered the control group. In the ECMO group, 16 episodes of candidaemia were observed, while only 13 in patients of the control group (36.0% vs. 14.0%, p-value 0.004). It was confirmed at the survival analysis (SHR: 2.86, 95% CI: 1.39-5.88) and at the multivariable analyses (aSHR: 3.91, 95% CI: 1.73-8.86). A higher candida score seemed to increase the hazard for candidemia occurrence (aSHR: 3.04, 95% CI: 2.09-4.42), while vasopressor therapy was negatively associated with the outcome (aSHR: 0.15, 95% CI: 0.05-0.43). CONCLUSIONS This study confirms that the incidence of candidemia was significantly higher in critically ill COVID-19 patients supported with VV-ECMO than in critically ill COVID patients who did not meet criteria for VV-ECMO.
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24
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Muacevic A, Adler JR, Upadhyay HV, Konat A, Zalavadia P, Padaniya A, Patel P, Patel N, Prajjwal P, Sharma K. Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock. Cureus 2023; 15:e33372. [PMID: 36751242 PMCID: PMC9898582 DOI: 10.7759/cureus.33372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literature and examined various modalities pertaining to the use of ECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.
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25
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Sato S, Kamata W, Fukaguchi K, Tsunoda S, Kamio T, Koyama H, Sugimoto H, Tamai Y. Successful treatment of invasive tracheobronchial pulmonary aspergillosis with venovenous extracorporeal membrane oxygenation and combined systemic, intratracheal instillation of liposomal amphotericin B: a case report. J Med Case Rep 2022; 16:470. [PMID: 36536458 PMCID: PMC9764550 DOI: 10.1186/s13256-022-03692-1] [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: 01/02/2021] [Accepted: 11/26/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Invasive pulmonary Aspergillus and invasive bronchial aspergillosis is a life-threatening opportunistic fungal infection that predominantly affects immunocompromised hosts. A case series and review found that the mortality rate of invasive bronchial aspergillosis is high, at about 40%, and 23.7% of invasive bronchial aspergillosis patients require mechanical ventilator management. There are few reports of life-saving cases with venovenous extracorporeal membrane oxygenation as rescue therapy in invasive pulmonary Aspergillus and invasive bronchial aspergillosis. Here, we report a case of invasive bronchial aspergillosis and invasive pulmonary Aspergillus that was successfully treated with venovenous extracorporeal membrane oxygenation, and combined systemic and intratracheal instillation of liposomal amphotericin B. CASE PRESENTATION We present the case of a 61-year-old Japanese man with invasive tracheobronchial-pulmonary aspergillosis while receiving chemotherapy for malignant lymphoma. Bronchoscopy revealed trachea covered with pseudomembranous necrotizing tissue, the culture revealed Aspergillus fumigatus, and the histological findings of pseudomembranous revealed fungal hyphae. The patient required venovenous extracorporeal membrane oxygenation because of respiratory failure for atelectasis and obstructive pneumoniae. While continuing systemic administration of liposomal amphotericin B, intratracheal instillation liposomal amphotericin B was performed by bronchoscopy three times a week. Although the respiratory conditions improved and the patient was discontinued on venovenous extracorporeal membrane oxygenation, he ultimately died of recurrence of malignant lymphoma. CONCLUSION Intratracheal instillation of liposomal amphotericin B is safe, and liposomal amphotericin B instillation allowed a targeted high local drug concentration, which led to improvement in the invasive bronchial aspergillosis. In addition, since the patient was supported with venovenous extracorporeal membrane oxygenation, we were able to perform safe bronchoscopic debridement of airway lesions and intratracheal instillation of liposomal amphotericin B.
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Affiliation(s)
- Shuku Sato
- grid.415816.f0000 0004 0377 3017Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa 247-8533 Japan
| | - Wataru Kamata
- grid.415816.f0000 0004 0377 3017Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa 247-8533 Japan
| | - Kiyomitsu Fukaguchi
- Division of Critical Care Medicine, Shonan Kamaura General Hospital, Kamakura, Japan
| | - Shun Tsunoda
- grid.415816.f0000 0004 0377 3017Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa 247-8533 Japan
| | - Tadashi Kamio
- Division of Critical Care Medicine, Shonan Kamaura General Hospital, Kamakura, Japan
| | - Hiroshi Koyama
- Division of Critical Care Medicine, Shonan Kamaura General Hospital, Kamakura, Japan
| | - Hideyasu Sugimoto
- grid.415816.f0000 0004 0377 3017Division of Respiratory Medicine, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yotaro Tamai
- grid.415816.f0000 0004 0377 3017Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa 247-8533 Japan
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26
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Montero S, Rivas‐Lasarte M, Huang F, Chommeloux J, Demondion P, Bréchot N, Hékimian G, Franchineau G, Persichini R, Luyt C, Garcia‐Garcia C, Bayes‐Genis A, Lebreton G, Cinca J, Leprince P, Combes A, Alvarez‐Garcia J, Schmidt M. Time course, factors related to, and prognostic impact of venoarterial extracorporeal membrane flow in cardiogenic shock. ESC Heart Fail 2022; 10:568-577. [PMID: 36369748 PMCID: PMC9871705 DOI: 10.1002/ehf2.14132] [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: 03/31/2022] [Revised: 08/06/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is currently one of the most used devices in refractory cardiogenic shock. However, there is a lack of evidence on how to set the 'optimal' flow. We aimed to describe the evolution of VA-ECMO flows in a cardiogenic shock population and determine the risk factors of 'high-ECMO flow'. METHODS AND RESULTS A 7 year database of patients supported with VA-ECMO was used. Based on the median flow during the first 48 h of the VA-ECMO run, patients were classified as 'high-flow' or 'low-flow', respectively, when median ECMO flow was ≥3.6 or <3.6 L/min. Outcomes included rates of ventilator-associated pneumonia, ECMO-related complications, days on ECMO, days on mechanical ventilation, intensive care unit and hospitalization lengths of stay, and in-hospital and 60 day mortality. Risk factors of high-ECMO flow were assessed using univariate and multivariate cox regression. The study population included 209 patients on VA-ECMO, median age was 51 (40-59) years, and 78% were males. The most frequent aetiology leading to cardiogenic shock was end-stage dilated cardiomyopathy (57%), followed by acute myocardial infarction (23%) and fulminant myocarditis (17%). Among the 209 patients, 105 (50%) were classified as 'high-flow'. This group had a higher rate of ischaemic aetiology (16% vs. 30%, P = 0.023) and was sicker at admission, in terms of worse Simplified Acute Physiology Score II score [40 (26-58) vs. 56 (42-74), P < 0.001], higher lactate [3.6 (2.2-5.8) mmol/L vs. 5.2 (3-9.7) mmol/L, P < 0.001], and higher aspartate aminotransferase [97 (41-375) U/L vs. 309 (85-939) U/L, P < 0.001], among others. The 'low-flow' group had less ventilator-associated pneumonia (40% vs. 59%, P = 0.007) and less days on mechanical ventilation [4 (1.5-7.5) vs. 6 (3-12) days, P = 0.009]. No differences were found in lengths of stay or survival according to the ECMO flow. The multivariate analysis showed that risk factors independently associated with 'high-flow' were mechanical ventilation at cannulation [odds ratio (OR) 3.9, 95% confidence interval (CI) 2.1-7.1] and pre-ECMO lactate (OR 1.1, 95% CI 1.0-1.2). CONCLUSIONS In patients with refractory cardiogenic shock supported with VA-ECMO, sicker patients had higher support since early phases, presenting thereafter higher rates of ventilator-associated pneumonia but similar survival compared with patients with lower flows.
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Affiliation(s)
- Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de MedicinaUniversitat Autònoma de BarcelonaBarcelonaSpain,Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France
| | - Mercedes Rivas‐Lasarte
- Advanced Heart Failure and Heart Transplant Unit, Cardiology DepartmentHospital Universitario Puerta de Hierro Majadahonda, CIBERCVMadridSpain
| | - Florent Huang
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France
| | - Juliette Chommeloux
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France
| | - Pierre Demondion
- Thoracic and Cardiovascular DepartmentAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Nicolas Bréchot
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Guillaume Hékimian
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Guillaume Franchineau
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Romain Persichini
- Medical–Surgical Intensive Care UnitCHU de La Réunion, Felix‐Guyon HospitalSaint DenisLa RéunionFrance
| | - Charles‐Édouard Luyt
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Cosme Garcia‐Garcia
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de MedicinaUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Antoni Bayes‐Genis
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de MedicinaUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Guillaume Lebreton
- Thoracic and Cardiovascular DepartmentAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Juan Cinca
- Cardiology DepartmentHospital de la Santa Creu i Sant Pau, Universitat Autònoma de BarcelonaBarcelonaSpain
| | - Pascal Leprince
- Thoracic and Cardiovascular DepartmentAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Alain Combes
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Jesus Alvarez‐Garcia
- Cardiology DepartmentHospital Ramón y Cajal, Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV)MadridSpain
| | - Matthieu Schmidt
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
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27
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Kang S, Yang S, Hahn J, Jang JY, Min KL, Wi J, Chang MJ. Dose Optimization of Meropenem in Patients on Veno-Arterial Extracorporeal Membrane Oxygenation in Critically Ill Cardiac Patients: Pharmacokinetic/Pharmacodynamic Modeling. J Clin Med 2022; 11:jcm11226621. [PMID: 36431106 PMCID: PMC9693387 DOI: 10.3390/jcm11226621] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/23/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
Background: Our objective was to determine an optimal dosage regimen of meropenem in patients receiving veno-arterial extracorporeal membrane oxygenation (V-A ECMO) by developing a pharmacokinetic/pharmacodynamic (PK/PD) model. Methods: This was a prospective cohort study. Blood samples were collected during ECMO (ECMO-ON) and after ECMO (ECMO-OFF). The population pharmacokinetic model was developed using nonlinear mixed-effects modeling. A Monte Carlo simulation was used (n = 10,000) to assess the probability of target attainment. Results: Thirteen adult patients on ECMO receiving meropenem were included. Meropenem pharmacokinetics was best fitted by a two-compartment model. The final pharmacokinetic model was: CL (L/h) = 3.79 × 0.44CRRT, central volume of distribution (L) = 2.4, peripheral volume of distribution (L) = 8.56, and intercompartmental clearance (L/h) = 21.3. According to the simulation results, if more aggressive treatment is needed (100% fT > MIC target), dose increment or extended infusion is recommended. Conclusions: We established a population pharmacokinetic model for meropenem in patients receiving V-A ECMO and revealed that it is not necessary to adjust the dosage depending on V-A ECMO. Instead, more aggressive treatment is needed than that of standard treatment, and higher dosage is required without continuous renal replacement therapy (CRRT). Also, extended infusion could lead to better target attainment, and we could provide updated nomograms of the meropenem dosage regimen.
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Affiliation(s)
- Soyoung Kang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
| | - Seungwon Yang
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul 02447, Korea
- Department of Regulatory Science, College of Pharmacy, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Jongsung Hahn
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- School of Pharmacy, Jeonbuk National University, Jeonju 54896, Korea
| | - June Young Jang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
| | - Kyoung Lok Min
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
| | - Jin Wi
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon 21565, Korea
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: or (J.W.); (M.J.C.); Tel.: +82-32-460-3663 (J.W.); +82-32-749-4517 (M.J.C.); Fax: +82-32-749-4105 (M.J.C.)
| | - Min Jung Chang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Incheon 21983, Korea
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon 21983, Korea
- Graduate Program of Industrial Pharmaceutical Science, Yonsei University, Incheon 21983, Korea
- Correspondence: or (J.W.); (M.J.C.); Tel.: +82-32-460-3663 (J.W.); +82-32-749-4517 (M.J.C.); Fax: +82-32-749-4105 (M.J.C.)
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28
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Shih E, Michael DiMaio J, Squiers JJ, Banwait JK, Kussman HM, Meyers DP, Meidan TG, Sheasby J, George TJ. Bloodstream and respiratory coinfections in patients with COVID-19 on ECMO. J Card Surg 2022; 37:3609-3618. [PMID: 36073136 PMCID: PMC9538542 DOI: 10.1111/jocs.16909] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although several studies have characterized the risk of coinfection in COVID pneumonia, the risk of the bloodstream and respiratory coinfection in patients with COVID-19 pneumonia on extracorporeal membrane oxygenation (ECMO) supports severe acute respiratory distress syndrome (ARDS) is poorly understood. METHODS This is a retrospective analysis of patients with COVID-19 ARDS on ECMO at a single center between January 2020 and December 2021. Patient characteristics and clinical outcomes were compared. RESULTS Of 44 patients placed on ECMO support for COVID-19 ARDS, 30 (68.2%) patients developed a coinfection, and 14 (31.8%) patients did not. Most patients underwent venovenous ECMO (98%; 43/44) cannulation in the right internal jugular vein (98%; 43/44). Patients with coinfection had a longer duration of ECMO (34 [interquartile range, IQR: 19.5, 65] vs. 15.5 [IQR 11, 27.3] days; p = .02), intensive care unit (ICU; 44 [IQR: 27,75.5] vs 31 [IQR 20-39.5] days; p = .03), and hospital (56.5 [IQR 27,75.5] vs 37.5 [IQR: 20.5-43.3]; p = .02) length of stay. When stratified by the presence of a coinfection, there was no difference in hospital mortality (37% vs. 29%; p = .46) or Kaplan-Meier survival (logrank p = .82). Time from ECMO to first positive blood and respiratory culture were 12 [IQR: 3, 28] and 10 [IQR: 1, 15] days, respectively. Freedom from any coinfection was 50 (95% confidence interval: 37.2-67.2)% at 15 days from ECMO initiation. CONCLUSIONS There is a high rate of co-infections in patients placed on ECMO for COVID-19 ARDS. Although patients with coinfections had a longer duration of extracorporeal life support, and longer length of stays in the ICU and hospital, survival was not inferior.
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Affiliation(s)
- Emily Shih
- Department of General Surgery, Baylor University Medical Center, Dallas, Texas, USA.,Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - J Michael DiMaio
- Baylor Scott and White Research Institute, Dallas, Texas, USA.,Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | - John J Squiers
- Department of General Surgery, Baylor University Medical Center, Dallas, Texas, USA.,Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | | | - Howard M Kussman
- Infectious Disease, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | - David P Meyers
- Critical Care Medicine, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | - Talia G Meidan
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Jenelle Sheasby
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Timothy J George
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
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29
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Rosas MM, Sobieszczyk MJ, Warren W, Mason P, Walter RJ, Marcus JE. Outcomes of Fungemia in Patients Receiving Extracorporeal Membrane Oxygenation. Open Forum Infect Dis 2022; 9:ofac374. [PMID: 35949400 PMCID: PMC9356672 DOI: 10.1093/ofid/ofac374] [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: 06/24/2022] [Accepted: 07/22/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
There are limited data on the treatment of fungal infections complicating extracorporeal membrane oxygenation (ECMO). In 14 patients who developed fungal bloodstream infections on ECMO, eight (57%) survived to discharge. Of the 5 patients completing treatment prior to decannulation, two (40%) developed recurrent fungal infections.
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Affiliation(s)
- Melissa M Rosas
- Pulmonary and Critical Care Division, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Michal J Sobieszczyk
- Pulmonary and Critical Care Division, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Whittney Warren
- Pulmonary and Critical Care Division, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Phillip Mason
- Critical Care Division, Emergency Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Robert J Walter
- Pulmonary and Critical Care Division, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Texas, USA
| | - Joseph E Marcus
- Correspondence: Joseph E. Marcus, MD, 3551 Roger Brooke Drive, Joint Base San Antonio–Fort Sam Houston, TX 78234, USA ()
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30
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Jain A, Mehta Y. Sepsis Associated with Extracorporeal Membrane Oxygenation. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1757392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
AbstractSepsis in patients on extracorporeal membrane oxygenation (ECMO) remains a serious complication. Its presence is a poor prognostic marker and increases overall mortality. Adult patients with prolonged duration on ECMO are at high risk of developing sepsis. Ventilator-associated pneumonia and bloodstream infections are the main sources of infection these patients. A strong early suspicion, drawing adequate volume for blood cultures, and early and timely administration of empirical antibiotics can help control the infection and decrease the morbidity and mortality. The diagnostic and the treatment are both challenging. Cardiac patients have increased risk of nosocomial infection while on ECMO, which may be in part due to longer cannulation times, as well as increased likelihood of undergoing major procedures or having an open chest.
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Affiliation(s)
- Aashish Jain
- Medanta Institute of Critical Care and Anaesthesia, Medanta The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Medanta Institute of Critical Care and Anaesthesia, Medanta The Medicity, Gurugram, Haryana, India
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31
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Xu W, Fu Y, Yao Y, Zhou J, Zhou H. Nosocomial Infections in Nonsurgical Patients Undergoing Extracorporeal Membrane Oxygenation: A Retrospective Analysis in a Chinese Hospital. Infect Drug Resist 2022; 15:4117-4126. [PMID: 35937786 PMCID: PMC9347224 DOI: 10.2147/idr.s372913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background The effect of nosocomial infections (NIs) in adult patients undergoing ECMO has been rarely reported in China. Moreover, the effect of NIs on ECMO patients’ mortality is still unclear and inconclusive according to literature data. In this study, we examined the prevalence, risk factors, causative organisms, and effects on outcomes of NIs in ECMO patients. Methods A total of 79 nonsurgical patients (mean age 53.3±15.2 year (yr); 66% male) who underwent ECMO between January 2011 and September 2020 were enrolled in this retrospective study. Patients’ demographic and clinical data and ECMO parameters were collected from all patients. Results Among 79 patients who underwent ECMO for a total of 1253 ECMO days (mean time 15.9±14.1 d), 42 developed NIs. We observed 30 ventilator-associated pneumonia (VAP), 19 bloodstream infections (BSIs), and 4 urinary tract infections, corresponding to 23.9/1000 ECMO days, 15.2/1000 ECMO days, and 3.2/1000 ECMO days, respectively. ECMO duration (22.0±16.5 VS 8.9±5.3 d, P < 0.001), invasive mechanical ventilation (IMV) duration (27.4±20.5 VS 11.4±10.1 d, P < 0001), and ICU length of stay (35.9±22.9 VS 15.7±9.2 d, P < 0.001) were longer in patients with NIs. The independent risk factors for NIs were ECMO duration (Odds Ratio [OR], 1.414; 95% Confidence Interval [CI], (1.051–1.238); P = 0.002) and viral pneumonia (OR, 5.788; 95% CI, (1.551–21.596); P = 0.009). Gram-negative bacteria were the most common causative organisms of NIs; Acinetobacter baumannii (A. baumannii), Klebsiella pneumoniae (K. pneumoniae), and Pseudomonas aeruginosa (P. aeruginosa) were the most common bacteria. BSI (OR, 8.106; 95% CI, (1.384–47.474); P = 0.02) was an independent predictor for mortality. Conclusion NIs are common complications in patients during ECMO treatment, especially VAP, followed by BSI. Also, BSI can negatively affect the survival rate.
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Affiliation(s)
- Wenzeng Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China
| | - Yiqi Fu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China
| | - Yake Yao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China
| | - Jianying Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China
| | - Hua Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China
- Correspondence: Hua Zhou; Jianying Zhou, Email ;
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32
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Blaize M, Raoelina A, Kornblum D, Kamus L, Lampros A, Berger M, Demeret S, Constantin JM, Monsel A, Mayaux J, Luyt CE, Piarroux R, Fekkar A. Occurrence of Candidemia in Patients with COVID-19 Admitted to Five ICUs in France. J Fungi (Basel) 2022; 8:jof8070678. [PMID: 35887435 PMCID: PMC9320616 DOI: 10.3390/jof8070678] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 12/26/2022] Open
Abstract
Whether severe COVID-19 is by itself a significant risk factor for the development of candidemia currently remains an open question as conflicting results have been published. We aim to assess the occurrence of candidemia in patients with severe COVID-19 admitted to the intensive care unit (ICU). We conducted a retrospective study on patients with severe SARS-CoV-2-related pneumonia admitted to 5 ICUs in France who were specifically screened for fungal complications between March 2020 and January 2021. The study population included a total of 264 patients; the median age was 56 years old and most of them were male (n = 186; 70.5%) and immunocompetent (n = 225; 87.5%), and 62.7% (n = 153/244) were on extracorporeal membrane oxygenation support. Microbiological analysis included 4864 blood culture samples and beta-glucan test performed on 975 sera. Candidemia was diagnosed in 13 (4.9%) patients. The species involved were mainly C. albicans (n = 6) and C. parapsilosis (n = 5). Almost all patients (12/13; 92.3%) had a colonization by yeasts. ICU mortality was not significantly impacted by the occurrence of candidemia. Unrelated positive beta-glucan tests were observed in 49 patients (23.4%), including 6 with mold infections and 43 with false positive results. In our series, patients with severe SARS-CoV-2-related pneumonia seemed at low risk of developing invasive candidiasis.
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Affiliation(s)
- Marion Blaize
- Sorbonne Université, INSERM, CNRS, Centre d’Immunologie et des Maladies Infectieuses, Cimi-Paris, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013 Paris, France;
| | - Audrey Raoelina
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013 Paris, France; (A.R.); (D.K.); (L.K.); (A.L.); (M.B.); (R.P.)
| | - Dimitri Kornblum
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013 Paris, France; (A.R.); (D.K.); (L.K.); (A.L.); (M.B.); (R.P.)
| | - Laure Kamus
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013 Paris, France; (A.R.); (D.K.); (L.K.); (A.L.); (M.B.); (R.P.)
| | - Alexandre Lampros
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013 Paris, France; (A.R.); (D.K.); (L.K.); (A.L.); (M.B.); (R.P.)
| | - Marie Berger
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013 Paris, France; (A.R.); (D.K.); (L.K.); (A.L.); (M.B.); (R.P.)
| | - Sophie Demeret
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Réanimation Neurologique, F-75013 Paris, France;
| | - Jean-Michel Constantin
- Sorbonne Université, GRC 29, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Département d’Anesthésie Réanimation, F-75013 Paris, France;
| | - Antoine Monsel
- Sorbonne Université, INSERM, Immunology Immunopathology Immunotherapy (I3), Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Département d’Anesthésie Réanimation, F-75013 Paris, France;
| | - Julien Mayaux
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Réanimation Médicale, F-75013 Paris, France;
| | - Charles-Edouard Luyt
- Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition, Assistance Publique–Hôpitaux de Paris (APHP), Médecine Intensive Réanimation-Institut de Cardiologie, F-75013 Paris, France;
| | - Renaud Piarroux
- Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013 Paris, France; (A.R.); (D.K.); (L.K.); (A.L.); (M.B.); (R.P.)
| | - Arnaud Fekkar
- Sorbonne Université, INSERM, CNRS, Centre d’Immunologie et des Maladies Infectieuses, Cimi-Paris, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier La Pitié-Salpêtrière, Parasitologie Mycologie, F-75013 Paris, France;
- Correspondence: ; Tel.: +33-1-42-16-01-84
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33
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Li X, Wang L, Wang H, Hou X. Outcome and Clinical Characteristics of Nosocomial Infection in Adult Patients Undergoing Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. Front Public Health 2022; 10:857873. [PMID: 35812481 PMCID: PMC9268548 DOI: 10.3389/fpubh.2022.857873] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/21/2022] [Indexed: 11/28/2022] Open
Abstract
Objective This study conducts a meta-analysis of clinical outcomes of nosocomial infection in adult patients receiving extracorporeal membrane oxygenation (ECMO) and systematically evaluates clinical epidemiological characteristics. Methods Document retrieval strategies were determined, and all adult patients treated by ECMO were included. The prevalence, incidence, mortality, ECMO use time, intensive care unit (ICU) stay time, hospital stay time, and risk factors of nosocomial infection were systematically evaluated. Subsequently, a meta-analysis of the impact of nosocomial infection on risk of in-hospital mortality was conducted. Results A total of 25 retrospective studies were included, and 19 studies were included in the meta-analysis. The prevalence of nosocomial infection was 8.8–64.0%, incidence was 1.7–85.4‰ (per 1,000 ECMO days), and in-hospital mortality was 31.5–75.4%. The duration of ECMO usage and length of ICU stay were longer for infected patients. Compared with non-infected patients, the meta-analysis revealed that nosocomial infection increased the relative risk of death of adult patients receiving ECMO by 32%. The risk factors included the duration of ECMO usage and disease severity score. Conclusions Adult patients treated by ECMO have high prevalence of nosocomial infection. In addition, their ECMO use time and ICU stays are longer. Nosocomial infection significantly increases the relative risk of in-hospital mortality.
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Affiliation(s)
- Xiyuan Li
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Intensive Care Unit, Aviation General Hospital of China Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- *Correspondence: Xiaotong Hou
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34
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Yagani S, Singh SP, Sahu MK, Choudhary SK, Chowdhury UK, Hote MP, Singh U, Reddy PR, Panday S. Infections Acquired During Venoarterial Extracorporeal Membrane Oxygenation Postcardiac Surgery in Children: A Retrospective Observational Study. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1750113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) is increasingly being used in refractory cardiac and pulmonary dysfunction as a rescue modality. The common indications for establishing venoarterial ECMO (VA-ECMO) support in children postcardiac surgery are failure to wean from cardiopulmonary bypass (CPB), postcardiotomy cardiogenic shock (PCCS), refractory pulmonary arterial hypertension, and as a bridge to recovery or transplant. The survival rate of children on VA-ECMO support is 45%. The most frequently encountered complications during VA-ECMO are bleeding, thrombosis, acute kidney injury, and infections. Among those, infections acquired during VA-ECMO lead to high morbidity and mortality. Hence, this study aimed to determine infection rates, causal microorganisms, and mortality risk factors in children developing an infection during VA-ECMO therapy.
Methods This retrospective observational study was conducted on 106 children under 14 years of age who underwent elective or emergent cardiac surgery (between 2016 and 2020) and required VA-ECMO support. Medical records were reviewed to collect the targeted variables and analyzed.
Results Out of 106 children, 49 (46.23%) acquired infections representing a prevalence of 46.23% and an infection rate of 186.4 episodes per 1,000 ECMO days. Prevalence and acquired infection rate/1,000 ECMO days were higher in the nonsurvivor group than in the survivor group (26.42 vs.19.81%) and (215.07 vs. 157.49), respectively. The bloodstream infection (BSI) and catheter-associated urinary tract infection (CAUTI) episodes were 53.04 and 68.19 per 1,000 ECMO days, and the ventilator-associated pneumonia (VAP) rate was 44.50 per 1,000 ventilator days. The mean preoperative admission duration, aortic cross-clamping duration, CPB duration (minutes), and vasoactive-inotropic score were higher in the nonsurviving children (p < 0.001). Similarly, prolonged mean ECMO duration was also found in the nonsurvivor group compared with the survivor group (p = 0.03).
Conclusion In our study, the prevalence of acquired infection during VA-ECMO was 46.23%. The incidence of BSI, CAUTI, and VAP per 1,000 ECMO days was higher in the nonsurvivor group than in survivors. Acinetobacter baumannii was the most common cultured gram-negative organism in VAP and BSI, with 67.65% Acinetobacter spp. resistant to carbapenems. CAUTI was predominately due to Candida species during VA-ECMO.
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Affiliation(s)
- Seshagiribabu Yagani
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
| | - Sarvesh Pal Singh
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
| | - Manoj Kumar Sahu
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
| | - Shiv Kumar Choudhary
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
| | - Ujjwal Kumar Chowdhury
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
| | - Milind Padmakar Hote
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
| | - Ummed Singh
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
| | - Pradeep Ramakrishna Reddy
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Science, New Delhi, India
| | - Shivam Panday
- Department of Biostatistics, All India Institute of Medical Science, New Delhi, India
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Pasqueron J, Dureau P, Arcile G, Duceau B, Hariri G, Lepère V, Lebreton G, Rouby JJ, Bouglé A. Usefulness of lung ultrasound for early detection of hospital-acquired pneumonia in cardiac critically ill patients on venoarterial extracorporeal membrane oxygenation. Ann Intensive Care 2022; 12:43. [PMID: 35596817 PMCID: PMC9124275 DOI: 10.1186/s13613-022-01013-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/21/2022] [Indexed: 12/20/2022] Open
Abstract
Background Hospital-acquired pneumonia (HAP) is the most common and severe complication in patients treated with venoarterial extracorporeal membrane oxygenation (VA ECMO) and its diagnosis remains challenging. Nothing is known about the usefulness of lung ultrasound (LUS) in early detection of HAP in patients treated with VA ECMO. Also, LUS and chest radiography were performed when HAP was suspected in cardiac critically ill adult VA ECMO presenting with acute respiratory failure. The sonographic features of HAP in VA ECMO patients were determined and we assessed the performance of the lung ultrasound simplified clinical pulmonary score (LUS-sCPIS), the sCPIS and bioclinical parameters or chest radiography alone for early diagnosis of HAP. Results We included 70 patients, of which 44 (63%) were independently diagnosed with HAP. LUS examination revealed that color Doppler intrapulmonary flow (P = 0.0000043) and dynamic air bronchogram (P = 0.00024) were the most frequent HAP-related signs. The LUS-sCPIS (area under the curve = 0.77) yielded significantly better results than the sCPIS (area under the curve = 0.65; P = 0.004), while leukocyte count, temperature and chest radiography were not discriminating for HAP diagnosis. Discussion Diagnosis of HAP is a daily challenge for the clinician managing patients on venoarterial ECMO. Lung ultrasound can be a valuable tool as the initial imaging modality for the diagnosis of pneumonia. Color Doppler intrapulmonary flow and dynamic air bronchogram appear to be particularly insightful for the diagnosis of HAP. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01013-9.
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Affiliation(s)
- Jean Pasqueron
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Pauline Dureau
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Gauthier Arcile
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Baptiste Duceau
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Geoffroy Hariri
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Victoria Lepère
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Lebreton
- Sorbonne Université, Department of Cardiac Surgery, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Jean-Jacques Rouby
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Multidisciplinary Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Adrien Bouglé
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Institute of Cardiology, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
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Winiszewski H, Boyadjian C, Besch G, Soumagne T, Jeanney M, Pili-Floury S, Fournier D, Belon F, Chocron S, Capellier G, Perrotti A, Piton G. Extracorporeal Membrane Oxygenation Cannula-Related Infections: Epidemiology and Risk Factors. ASAIO J 2022; 68:571-576. [PMID: 34074852 DOI: 10.1097/mat.0000000000001505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although being a potential major source of infection in extracorporeal membrane oxygenation (ECMO) patients, data regarding cannula-related infections (CRI) remain scarce. We therefore aimed at describing the epidemiology of CRI among critically ill patients supported by ECMO. Between October 2017 and November 2019, adult patients supported by either venoarterial (VA), venopulmonary arterial, or venovenous (VV) ECMO for more than 24 hours were prospectively enrolled. When CRI was suspected, cannula swab and subcutaneous needle aspirate samples were obtained for microbiological culture. Cannula tips were systematically sent for culture at the time of ECMO removal. Primary end-point was CRI, which was defined by sepsis or local sign of cannula infection and at least one positive culture among swab, subcutaneous needle aspirate or tip. Multivariate analysis was performed to identify risk factors of CRI. Hundred patients were included, including 77 VA, 12 venopulmonary arterial, and 11 VV ECMO. Cannula-related infections were diagnosed after a median duration of ECMO of 10 [7-13] days. Rate of CRI was 24%, including 10% with bacteremia. Most frequent involved pathogens were Enterobacteriaceae (n = 14), Enterococci (n = 8), and coagulase-negative Staphylococci (n = 7). By multivariate analysis, diabetes and ECMO duration were independently associated with CRI.
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Affiliation(s)
| | - Charles Boyadjian
- From the Medical Intensive Care Unit, University Hospital, Besancon, France
| | - Guillaume Besch
- Research Unit EA 3920, University of Franche Comte, Besancon, France
| | - Thibaud Soumagne
- From the Medical Intensive Care Unit, University Hospital, Besancon, France
| | - Martin Jeanney
- From the Medical Intensive Care Unit, University Hospital, Besancon, France
| | | | - Damien Fournier
- Bacteriology Department, University Hospital, Besancon, France
| | - François Belon
- Anaesthesia and Surgical Intensive Care Unit, University Hospital, Besancon, France
| | - Sidney Chocron
- Research Unit EA 3920, University of Franche Comte, Besancon, France
- Cardiac Surgery Unit, University Hospital, Besancon, France
| | - Gilles Capellier
- From the Medical Intensive Care Unit, University Hospital, Besancon, France
- Research Unit EA 3920, University of Franche Comte, Besancon, France
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Clayton, Australia
| | - Andrea Perrotti
- Research Unit EA 3920, University of Franche Comte, Besancon, France
- Cardiac Surgery Unit, University Hospital, Besancon, France
| | - Gaël Piton
- Research Unit EA 3920, University of Franche Comte, Besancon, France
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37
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Impact of Invasive Fungal Diseases on Survival under Veno-Venous Extracorporeal Membrane Oxygenation for ARDS. J Clin Med 2022; 11:jcm11071940. [PMID: 35407548 PMCID: PMC8999842 DOI: 10.3390/jcm11071940] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To assess the incidence and significance of invasive fungal diseases (IFD) during veno-venous (VV) ECMO support for acute respiratory distress syndrome (ARDS). METHODS Retrospective analysis from January 2013 to April 2021 of all ECMO cases for ARDS at a German University Hospital. In patients with IFD (IFD patients), type of IFD, time of IFD, choice of antifungal agent, duration, and success of therapy were investigated. For comparison, patients without IFD (non-IFD patients) were selected by propensity score matching using treatment-independent variables (age, gender, height, weight, and the Sequential Organ Failure Assessment (SOFA) score at ICU admission). Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, prognostic scores (Charlson Comorbidity Index (CCI), Therapeutic Intervention Scoring System (TISS), and length of survival were assessed. RESULTS A total of 646 patients received ECMO, 368 patients received VV ECMO. The incidence of IFD on VV ECMO was 5.98%, with 5.43% for Candida bloodstream infections (CBSI) and 0.54% for invasive aspergillosis (IA). In IFD patients, in-hospital mortality was 81.8% versus 40.9% in non-IFD patients. The hazard ratio for death was 2.5 (CI 1.1-5.4; p: 0.023) with IFD. CONCLUSIONS In patients on VV ECMO for ARDS, about one in 17 contracts an IFD, with a detrimental impact on prognosis. Further studies are needed to address challenges in the diagnosis and treatment of IFD in this population.
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Solla-Buceta M, González-Vílchez F, Almenar-Bonet L, Lambert-Rodríguez JL, Segovia-Cubero J, González-Costello J, Delgado JF, Pérez-Villa F, Crespo-Leiro MG, Rangel-Sousa D, Martínez-Sellés M, Rábago-Juan-Aracil G, De-la-Fuente-Galán L, Blasco-Peiró T, Hervás-Sotomayor D, Garrido-Bravo IP, Mirabet-Pérez S, Muñiz J, Barge-Caballero E. Complicaciones infecciosas relacionadas con la asistencia circulatoria mecánica de corta duración en candidatos a trasplante cardiaco urgente. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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39
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Wicky PH, Martin-Loeches I, Timsit JF. "HAP and VAP after Guidelines". Semin Respir Crit Care Med 2022; 43:248-254. [PMID: 35042265 DOI: 10.1055/s-0041-1740246] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Nosocomial pneumonia is associated with worsened prognosis when diagnosed in intensive care unit (ICU), ranging from 12 to 48% mortality. The incidence rate of ventilation-acquired pneumonia tends to decrease below 15/1,000 intubation-day. Still, international guidelines are heterogeneous about diagnostic criteria because of inaccuracy of available methods. New entities have thus emerged concerning lower respiratory tract infection, namely ventilation-acquired tracheobronchitis (VAT), or ICU-acquired pneumonia (ICUAP), eventually requiring invasive ventilation (v-ICUAP), according to the type of ventilation support. The potential discrepancy with non-invasive methods could finally lead to underdiagnosis in almost two-thirds of non-intubated patients. Delayed diagnostic could explain in part the 2-fold increase in mortality of penumonia when invasive ventilation is initiated. Here we discuss the rationale underlying this new classification.Many situations can lead to misdiagnosis, even more when the invasive mechanical ventilation is initiated. The chest radiography lacks sntivity and specificity for diagnosing pneumonia. The place of chest computed tomography and lung ultrasonography for routine diagnostic of new plumonary infiltrate remain to be evaluated.Microbiological methods used to confirm the diagnostic can be heterogeneous. The development of molecular diagnostic tools may improve the adequacy of antimicrobial therapies of ventilated patients with pneumonia, but we need to further assess its impact in non-ventilated pneumonia.In this review we introduce distinction between hospital-acquired pneumonia according to the localization in the hospital and the oxygenation/ventilation mode. A clarification of definition is the first step to develop more accurate diagnostic strategies and to improve the patients' prognosis.
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Affiliation(s)
- Paul-Henri Wicky
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France
| | - Ignacio Martin-Loeches
- Department of Anaesthesia and Critical Care Medicine, St. James's Hospital, Dublin, Ireland.,Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland
| | - Jean-François Timsit
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France.,UMR 1137, IAME, Université Paris Diderot, Paris, France
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40
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Girard L, Djemili F, Devineau M, Gonzalez C, Puech B, Valance D, Renou A, Dubois G, Braunberger E, Allou N, Allyn J, Vidal C. Effect of Body Mass Index on the Clinical Outcomes of Adult Patients Treated With Venoarterial ECMO for Cardiogenic Shock. J Cardiothorac Vasc Anesth 2021; 36:2376-2384. [PMID: 34903457 DOI: 10.1053/j.jvca.2021.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Current guidelines consider obesity to be a relative contraindication to venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. The authors investigated the effect of body mass index (BMI) on clinical outcomes in patients treated with VA-ECMO for cardiogenic shock. DESIGN This was a retrospective and observational study. SETTING University hospital. PARTICIPANTS The study comprised 150 adult patients who underwent VA-ECMO for cardiogenic shock. MEASUREMENTS AND MAIN RESULTS The primary outcome was intensive care unit (ICU) mortality. Of the 150 included patients, 10 were underweight (BMI < 18.5 kg/m²), 62 were normal weight (BMI = 18.5-24.9 kg/m²), 34 were overweight (BMI = 25.0-29.9 kg/m²), 34 were obese class I (BMI = 30.0-34.9 kg/m²), and 10 were obese class II (BMI = 35.0-39.9 kg/m²). All-cause ICU mortality was 62% (underweight, 70%; normal weight, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariate logistic regression, BMI was not associated with ICU mortality (adjusted odds ratio [aOR] 0.99 [0.92-1.07], p = 0.8). Analysis by BMI category showed unfavorable mortality trends in underweight patients (aOR 3.58 [0.82-19.6], p = 0.11) and class I obese patients (aOR 2.39 [0.95-6.38], p = 0.07). No statistically significant differences were found among BMI categories in the incidences of complications. CONCLUSION The results suggested that BMI alone should not be considered an exclusion criterion for VA-ECMO. The unfavorable trend observed in underweight patients could be the result of malnutrition.
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Affiliation(s)
- Léandre Girard
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France.
| | - Fares Djemili
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Marjolaine Devineau
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Céline Gonzalez
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Bérénice Puech
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Dorothée Valance
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Amélie Renou
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Gilbert Dubois
- Service de Chirurgie Thoracique et Cardiovasculaire, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Eric Braunberger
- Service de Chirurgie Thoracique et Cardiovasculaire, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Nicolas Allou
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Jérôme Allyn
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Charles Vidal
- Réanimation Polyvalente, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
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Population Pharmacokinetics of Meropenem in Critically Ill Korean Patients and Effects of Extracorporeal Membrane Oxygenation. Pharmaceutics 2021; 13:pharmaceutics13111861. [PMID: 34834278 PMCID: PMC8625191 DOI: 10.3390/pharmaceutics13111861] [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: 09/30/2021] [Revised: 10/22/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Limited studies have investigated population pharmacokinetic (PK) models and optimal dosage regimens of meropenem for critically ill adult patients using the probability of target attainment, including patients receiving extracorporeal membrane oxygenation (ECMO). A population PK analysis was conducted using non-linear mixed-effect modeling. Monte Carlo simulation was used to determine for how long the free drug concentration was above the minimum inhibitory concentration (MIC) at steady state conditions in patients with various degrees of renal function. Meropenem PK in critically ill patients was described using a two-compartment model, in which glomerular filtration rate was identified as a covariate for clearance. ECMO did not affect meropenem PK. The simulation results showed that the current meropenem dosing regimen would be sufficient for attaining 40%fT>MIC for Pseudomonas aeruginosa at MIC ≤ 4 mg/L. Prolonged infusion over 3 h or a high-dosage regimen of 2 g/8 h was needed for MIC > 2 mg/L or in patients with augmented renal clearance, for a target of 100%fT>MIC or 100%fT>4XMIC. Our study suggests that clinicians should consider prolonged infusion or a high-dosage regimen of meropenem, particularly when treating critically ill patients with augmented renal clearance or those infected with pathogens with decreased in vitro susceptibility, regardless of ECMO support.
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Monk EJM, Rautemaa-Richardson R, Felton T, Montalti A, Parkes M, Templeton R, Ashworth A, Garcia M, Barker J, Thomas S. Candidaemia incidence in prolonged veno-venous extracorporeal membrane oxygenation. J Hosp Infect 2021; 119:49-53. [PMID: 34562545 DOI: 10.1016/j.jhin.2021.09.014] [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: 07/21/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 11/25/2022]
Abstract
This single-centre retrospective study reports the dynamics of candida bloodstream infection (CBSI) incidence in 145 patients receiving venovenous ECMO for respiratory support, between January 2014 and December 2018. Incidence rate and odds ratio (OR) of CBSI were calculated, stratified by week of ECMO exposure. Weekly incidence increased throughout the ECMO run, with a rising trend in OR (P = 0.005), and a window of continued risk after decannulation was observed. Of the 13 patients that developed CBSI, five (38%) received empirical micafungin treatment before positive culture due to clinical suspicion. Prospective studies, aiming to improve ECMO diagnostic stewardship practices and discourage antifungal prophylaxis or empiric management where unnecessary, are needed.
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Affiliation(s)
- Edward J M Monk
- Department of Microbiology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Infectious Diseases Service, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom.
| | - Riina Rautemaa-Richardson
- Infectious Diseases Service, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Mycology Reference Centre Manchester (ECMM Centre of Excellence), Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Timothy Felton
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom; Acute Intensive Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom; Department of Respiratory Medicine, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Alice Montalti
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Matthew Parkes
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Richard Templeton
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Alan Ashworth
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Miguel Garcia
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Julian Barker
- Cardiothoracic Critical Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Stephanie Thomas
- Department of Microbiology, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
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Mihu MR, Mageka D, Swant LV, El Banayosy A, Maybauer MO, Harper MD, Koerner MM, El Banayosy A. Veno-arteriovenous extracorporeal membrane oxygenation-A single center experience. Artif Organs 2021; 45:1554-1561. [PMID: 34519067 DOI: 10.1111/aor.14070] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/07/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with combined circulatory shock and respiratory failure may benefit from veno-arteriovenous (V-AV) extracorporeal membrane oxygenation support (ECMO). We report our center's experience with V-AV ECMO and propose an algorithm to help identify patients that may benefit from early V-AV ECMO support. METHODS Clinical data were extracted from electronic medical records between November 1, 2016 and November 1, 2019. RESULTS Out of a total of 369 patients placed on extracorporeal life support (ECLS), we identified a total of 26 patients who underwent hybrid ECMO placement. Three patients were excluded from our analysis due to veno-venoarterial extracorporeal membrane oxygenation (V-VA ECMO) configuration, therefore 23 patients were included in our analysis. The median age was 53 (range 25-73) years. Hybrid ECMO support was instituted most commonly for differential hypoxemia in patients on venoarterial (V-A) ECMO support, and cardiogenic shock in patients who were initially started on venovenous (V-V) ECMO. The initial ECMO cannulation was V-A in 12 patients, V-V in 8 patients, and directly V-AV in 3 patients. Nine out of 23 patients were successfully decannulated (39.1%) and survived until hospital discharge. The main ECMO-related complications included bleeding (n = 10), circuit exchange either due to hemolysis or oxygenator failure (n = 4), ECMO cannula site infection (n = 2), deep venous thrombosis (n = 2), and death during ECMO cannula exchange (n = 1). CONCLUSIONS V-AV ECMO represents a rescue strategy in critically ill patients with combined respiratory failure and cardio-circulatory shock.
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Affiliation(s)
- Mircea R Mihu
- Advanced Critical Care, Nazih Zuhdi Transplant Institute, Advanced Cardiac Care and 24/7 Shock Service, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA.,Department of Medicine/Cardiology, Oklahoma State University Health Science Center, Tulsa, Oklahoma, USA
| | - Dennis Mageka
- Advanced Critical Care, Nazih Zuhdi Transplant Institute, Advanced Cardiac Care and 24/7 Shock Service, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Laura V Swant
- Advanced Critical Care, Nazih Zuhdi Transplant Institute, Advanced Cardiac Care and 24/7 Shock Service, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Ahmed El Banayosy
- Advanced Critical Care, Nazih Zuhdi Transplant Institute, Advanced Cardiac Care and 24/7 Shock Service, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Marc O Maybauer
- Advanced Critical Care, Nazih Zuhdi Transplant Institute, Advanced Cardiac Care and 24/7 Shock Service, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA.,Department of Medicine/Cardiology, Oklahoma State University Health Science Center, Tulsa, Oklahoma, USA.,Department of Anesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany.,Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Brisbane, Queensland, Australia.,Department of Anaesthesia, Manchester University NHS Foundation Trust, University of Manchester, Manchester Health Science Center, Manchester, UK
| | - Michael D Harper
- Advanced Critical Care, Nazih Zuhdi Transplant Institute, Advanced Cardiac Care and 24/7 Shock Service, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA.,Department of Medicine/Cardiology, Oklahoma State University Health Science Center, Tulsa, Oklahoma, USA
| | - Michael M Koerner
- Department of Medicine/Cardiology, Oklahoma State University Health Science Center, Tulsa, Oklahoma, USA.,Faculty of Medicine, Ruhr-University, Bochum, Germany.,Department of Medicine/Cardiology, Baylor, Scott & White Health and College of Medicine, Texas A&M, Temple, Texas, USA
| | - Aly El Banayosy
- Advanced Critical Care, Nazih Zuhdi Transplant Institute, Advanced Cardiac Care and 24/7 Shock Service, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA
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Tsangaris A, Alexy T, Kalra R, Kosmopoulos M, Elliott A, Bartos JA, Yannopoulos D. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med 2021; 8:686558. [PMID: 34307500 PMCID: PMC8292640 DOI: 10.3389/fcvm.2021.686558] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
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Affiliation(s)
- Adamantios Tsangaris
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jason A. Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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45
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Duceppe MA, Kanji S, Do AT, Ruo N, Cavayas YA, Albert M, Robert-Halabi M, Zavalkoff S, Dupont P, Samoukovic G, Williamson DR. Pharmacokinetics of Commonly Used Antimicrobials in Critically Ill Adults During Extracorporeal Membrane Oxygenation: A Systematic Review. Drugs 2021; 81:1307-1329. [PMID: 34224115 DOI: 10.1007/s40265-021-01557-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Adequate dosing of antimicrobials is critical to properly treat infections and limit development of resistance and adverse effects. Limited guidance exists for antimicrobial dosing adjustments in patients requiring extracorporporeal membrane oxygenation (ECMO) therapy. A systematic review was conducted to delineate the pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobials in critically ill adult patients requiring ECMO. METHODS Medline, EMBASE, Global Health, and All EBM Reviews databases were searched. Grey literature was examined. All studies reporting PK/PD parameters of antimicrobials in critically ill adults treated with ECMO were included, except for case reports and congress abstracts. Ex vivo studies were included. Two independent reviewers applied the inclusion and exclusion criteria. Reviewers were then paired to independently abstract data and evaluate methodological quality of studies using the ROBINS-I tool and the compliance with ClinPK guidelines. Patients' and studies' characteristics, key PK/PD findings, details of ECMO circuits and co-treatments were summarized qualitatively. Dosing recommendations were formulated based on data from controlled studies. RESULTS Thirty-two clinical studies were included; most were observational and uncontrolled. Fourteen ex vivo studies were analysed. Information on patient characteristics and co-treatments was often missing. The effect of ECMO on PK/PD parameters of antimicrobials varied depending on the studied drugs. Few dosing recommendations could be formulated given the lack of good quality data. CONCLUSION Limited data exist on the PK/PD of antimicrobials during ECMO therapy. Rigorously designed and well powered populational PK studies are required to establish empiric dosing guidelines for antimicrobials in patients requiring ECMO support. PROSPERO REGISTRATION NUMBER CRD42018099992 (Registered: July 24th 2018).
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Affiliation(s)
- Marc-Alexandre Duceppe
- Department of Pharmacy, McGill University Health Centre, 1001 Boul. Décarie, Local C-RC 6004, Montreal, QC, H4A 3J1, Canada.
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Faculté de Pharmacie, Université de Montréal, Montreal, Canada
| | - Anh Thu Do
- Department of Pharmacy, McGill University Health Centre, 1001 Boul. Décarie, Local C-RC 6004, Montreal, QC, H4A 3J1, Canada
| | - Ni Ruo
- Department of Pharmacy, McGill University Health Centre, 1001 Boul. Décarie, Local C-RC 6004, Montreal, QC, H4A 3J1, Canada
| | - Yiorgos Alexandros Cavayas
- Department of Medicine, Division of Critical Care, Hôpital du Sacré-Coeur de Montréal Research Centre, Montreal, Canada.,Department of Surgery, Division of Critical Care, Montreal Heart Institute, Montreal, Canada.,Département de Médecine, Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Martin Albert
- Department of Medicine, Division of Critical Care, Hôpital du Sacré-Coeur de Montréal Research Centre, Montreal, Canada.,Department of Surgery, Division of Critical Care, Montreal Heart Institute, Montreal, Canada.,Département de Médecine, Faculté de Médecine, Université de Montréal, Montreal, Canada
| | - Maxime Robert-Halabi
- Department of Medicine, Division of Cardiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Samara Zavalkoff
- Department of Pediatrics, Division of Pediatric Critical Care, McGill University Health Centre, Montreal, Canada.,Faculty of Medicine, McGill University, Montreal, Canada
| | - Patrice Dupont
- Bibliothèque de la santé, Université de Montréal, Montreal, Canada
| | - Gordan Samoukovic
- Faculty of Medicine, McGill University, Montreal, Canada.,Department of Surgery, Division of Critical Care, McGill University Health Centre, Montreal, Canada
| | - David R Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, Canada.,Department of Pharmacy, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
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Lin JC, Barron LM, Vogel AM, Colvin RM, Baltagi SA, Doctor A, Gazit AZ, Mehegan M, O'Connor N, Said AS, Shepard M, Wallendorf M, Spinella PC. Context-Responsive Anticoagulation Reduces Complications in Pediatric Extracorporeal Membrane Oxygenation. Front Cardiovasc Med 2021; 8:637106. [PMID: 34179125 PMCID: PMC8224528 DOI: 10.3389/fcvm.2021.637106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/21/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO). Design: Single-center, observational pre- and post-implementation cohort study. Setting: Academic pediatric hospital. Patients: Patients in the PICU, CICU, and NICU receiving ECMO support. Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline. Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications. Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg. Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.
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Affiliation(s)
- John C Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Lauren M Barron
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Ryan M Colvin
- Pediatric Computing Facilities, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Sirine A Baltagi
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Avihu Z Gazit
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Mary Mehegan
- St. Louis Children's Hospital, St. Louis, MO, United States
| | | | - Ahmed S Said
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Mark Shepard
- St. Louis Children's Hospital, St. Louis, MO, United States
| | - Michael Wallendorf
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
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47
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Selçuk ÜN, Sargın M, Baştopçu M, Mete EMT, Erdoğan SB, Öcalmaz Ş, Orhan G, Aka SA. Microbiological Spectrum of Nosocomial ECMO Infections in a Tertiary Care Center. Braz J Cardiovasc Surg 2021; 36:338-345. [PMID: 33355788 PMCID: PMC8357375 DOI: 10.21470/1678-9741-2020-0077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a life-saving treatment in cardiogenic and respiratory shock. It is prone to various complications, infection being among the most frequent. This study aims to define the prevalence and characteristics of infections in ECMO patients in a tertiary care center for cardiac diseases. METHODS All ECMO patients between 2012 and 2016 in a single cardiac center were retrospectively included. Demographic data, ECMO indications, type, site, duration, and infection-related data were recorded. Data were analyzed among all patients and separately between pediatric and adult patient groups. RESULTS One hundred and twenty-six patients, 66 (53.4%) pediatric and 60 (47.6%) adult, received ECMO within the study period. Mean age was 3.54±4.27 years in the pediatric group and 54.92±15.57 years in the adult group. The main indication for ECMO was postcardiotomy shock (77.8%). Forty-six (36.5%) of all cases developed a culture-proven nosocomial infection with a rate of 49/1000 ECMO days. Infection was associated with > 5 days of ECMO duration and hemodialysis requirement in all patients and lower age in the pediatric group. The most frequent infection site was the lower respiratory tract (14.3%), while the most common isolated organisms were Klebsiella (8.7%) and Streptococcus (4.8%) species. CONCLUSION The respiratory tract is the most common site of infection, however, all sites impose a threat to recovery, with longer treatment durations required for patients with culture-proven infections. A better understanding of the infectious spectrum and its effect on the mortality and morbidity is required for more successful treatment of ECMO patients.
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Affiliation(s)
- Ümmühan Nehir Selçuk
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Sargın
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Baştopçu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Evren Müge Taşdemir Mete
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinç Bayer Erdoğan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Şeyda Öcalmaz
- Department of Infectious Diseases and Clinical Microbiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gökçen Orhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serap Aykut Aka
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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48
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Cies JJ, Nikolos P, Moore WS, Giliam N, Low T, Marino D, Deacon J, Enache A, Chopra A. Oxygenator impact on meropenem/vaborbactam in extracorporeal membrane oxygenation circuits. Perfusion 2021; 37:729-737. [PMID: 34034594 DOI: 10.1177/02676591211018985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION To determine the oxygenator impact on alterations of meropenem (MEM)/vaborbactam (VBR) in a contemporary neonatal/pediatric (1/4-inch) and adolescent/adult (3/8-inch) extra corporeal membrane oxygenation (ECMO) circuit including the Quadrox-i® oxygenator. METHODS 1/4-inch and 3/8-inch, simulated closed-loop ECMO circuits were prepared with a Quadrox-i pediatric and Quadrox-i adult oxygenator and blood primed. Additionally, 1/4-inch and 3/8-inch circuits were also prepared without an oxygenator in series. A one-time dose of MEM/VBR was administered into the circuits and serial pre- and post-oxygenator concentrations were obtained at 5 minutes, 1, 2, 3, 4, 5, 6, 8, 12, and 24-hour time points. MEM/VBR was also maintained in a glass vial and samples were taken from the vial at the same time periods for control purposes to assess for spontaneous drug degradation. RESULTS For the 1/4-inch circuit, there was an approximate mean 55% MEM loss with the oxygenator in series and a mean 33%-40% MEM loss without an oxygenator in series at 24 hours. For the 3/8-inch circuit, there was an approximate mean 70% MEM loss with the oxygenator in series and a mean 30%-38% MEM loss without an oxygenator in series at 24 hours. For both the 1/4-inch circuit and 3/8-inch circuits with and without an oxygenator, there was <10% VBR loss for the duration of the experiment. CONCLUSIONS This ex-vivo investigation demonstrated substantial MEM loss within an ECMO circuit with an oxygenator in series with both sizes of the Quadrox-i oxygenator at 24 hours and no significant VBR loss. Further evaluations with multiple dose in-vitro and in-vivo investigations are needed before specific MEM/VBR dosing recommendations can be made for clinical application with ECMO.
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Affiliation(s)
- Jeffrey J Cies
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, PA, USA.,St. Christopher's Hospital for Children, Philadelphia, PA, USA.,Drexel University College of Medicine, Philadelphia, PA, USA
| | - Peter Nikolos
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Brooklyn, NY, USA.,New York Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Wayne S Moore
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, PA, USA
| | - Nadji Giliam
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Tracy Low
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Daniel Marino
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Jillian Deacon
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Adela Enache
- Atlantic Diagnostic Laboratories, Bensalem, PA, USA
| | - Arun Chopra
- The Center for Pediatric Pharmacotherapy LLC, Pottstown, PA, USA.,NYU Langone Medical Center, New York, NY, USA.,NYU School of Medicine, New York, NY, USA
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49
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Wang J, Huang J, Hu W, Cai X, Hu W, Zhu Y. Risk factors and prognosis of nosocomial pneumonia in patients undergoing extracorporeal membrane oxygenation: a retrospective study. J Int Med Res 2021; 48:300060520964701. [PMID: 33086927 PMCID: PMC7585896 DOI: 10.1177/0300060520964701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective We aimed to examine the risk factors and prognosis of nosocomial pneumonia (NP) during extracorporeal membrane oxygenation (ECMO). Methods We retrospectively analyzed data of patients who received ECMO at the Affiliated Hangzhou Hospital of Nanjing Medical University between January 2013 and August 2019. The primary outcome was the survival-to-discharge rate. Results Sixty-nine patients who received ECMO were enrolled, median age 42 years and 26 (37.7%) women; 14 (20.3%) patients developed NP. The NP incidence was 24.7/1000 ECMO days. Patients with NP had a higher proportion receiving veno-venous (VV) ECMO (50% vs. 7.3%); longer ECMO support duration (276 vs. 140 hours), longer ventilator support duration before ECMO weaning (14.5 vs. 6 days), lower ECMO weaning success rate (50.0% vs. 81.8%), and lower survival-to-discharge rate (28.6% vs. 72.7%) than patients without NP. Multivariable analysis showed independent risk factors that predicted NP during ECMO were ventilator support duration before ECMO weaning (odds ratio [OR] = 1.288; 95% confidence interval [CI]: 1.111–1.494) and VV ECMO mode (OR = 10.970; 95% CI: 1.758–68.467). Conclusion NP during ECMO was associated with ventilator support duration before ECMO weaning and VV ECMO mode. Clinicians should shorten the respiratory support duration for patients undergoing ECMO to prevent NP.
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Affiliation(s)
- Jianrong Wang
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Jinyu Huang
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Wei Hu
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Xueying Cai
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
| | - Weihang Hu
- Department of Critical Care Medicine, Zhejiang Hospital, Zhejiang, China
| | - Ying Zhu
- Department of Critical Care Medicine, The Affiliated Hangzhou Hospital of Nanjing Medical University, Zhejiang, China
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50
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Pearse I, Corley A, Qu Y, Fraser J. Tissue adhesives for bacterial inhibition in extracorporeal membrane oxygenation cannulae. Intensive Care Med Exp 2021; 9:25. [PMID: 33969444 PMCID: PMC8107059 DOI: 10.1186/s40635-021-00388-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/21/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND One of the most serious complications of extracorporeal membrane oxygenation (ECMO) therapy is ECMO cannulae infection, which can occur at quadruple the rate of central venous catheter infections, and significantly impact morbidity and paediatric mortality. The objective of this in vitro observational study was to assess antimicrobial properties of two n-butyl-2-octyl cyanoacrylate tissue adhesive (TA) formulations for bacterial inhibition at peripheral ECMO cannulae insertion sites. METHODS Antimicrobial properties were assessed using modified agar disk-diffusion (n = 3) and simulated agar cannulation insertion site (n = 20) models. Both assays used Staphylococcus epidermidis which was seeded at the edge of the TA or dressing. Microorganism inhibition was visually inspected and evidenced by the presence or absence of a TA bacterial inhibition zone at 24 and 72 h. RESULTS Both TAs provided effective barriers to bacterial migration under cannula dressings, to cannula insertion sites and down cannula tunnels. Additionally, both TAs demonstrated distinct zones of inhibition produced when left to polymerise onto agar plates seeded with S. epidermidis. CONCLUSIONS N-Butyl-2-octyl cyanoacrylate TA appears to inhibit bacterial growth and migration of S. epidermidis. Application of TA to cannulae insertion sites may therefore be a potential bedside strategy for infection prevention in ECMO cannulae, but requires further testing before being used clinically for this purpose.
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Affiliation(s)
- India Pearse
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, QLD, Australia. .,Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD, Australia.
| | - Amanda Corley
- School of Nursing and Midwifery, Griffith University, Queensland, Australia
| | - Yue Qu
- Biomedicine Discovery Institute, Department of Microbiology, School of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.,Department of Infectious Diseases, The Alfred Hospital and Central Clinical School,, Monash University, Melbourne, VIC, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Chermside, QLD, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD, Australia
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