Incidence and susceptibility of pathogenic bacteria vary between intensive care units within a single hospital: implications for empiric antibiotic strategies

A Single Hospital-Wide Antibiogram is Insufficient to Account for Differences in Antibiotic Resistance Patterns Across Multiple ICUs

BACKGROUND

Infection is a common cause of mortality within intensive care units (ICUs). Antibiotic resistance patterns and culture data are used to create antibiograms. Knowledge of antibiograms facilitates guiding empiric therapies and reduces mortality. Most major hospitals utilize data collection to create hospital-wide antibiograms. Previous studies have shown significant differences in susceptibility patterns between hospital wards and ICUs. We hypothesize that institutional or combined ICU antibiograms are inadequate to account for differences in susceptibility for patients in individual ICUs.

METHODS

Culture and susceptibility data were reviewed over a 1-year period for 13 bacteria in the following ICUs: Surgical/Trauma, Medical, Neuroscience, Burn, and Emergency department. Antibiotic management decisions are made by individual teams.

RESULTS

Nine species had sufficient data for inclusion into an All-ICU antibiogram. E coli and S aureus were the most common isolates. Seven species had significant differences in susceptibility patterns between ICUs. E cloacae showed higher rates of resistance to multiple antibiotics in the STICU than other ICUs. P aeruginosa susceptibility rates in the NSICU and BICU were 88% and 92%, respectively, compared to 60% and 55% in the STICU and MICU. Cephalosporins and Aztreonam had reduced efficacy against E coli in the NSICU, however remain effective in other ICUs.

CONCLUSIONS

The results of this study show that different ICUs do have variability in antibiotic susceptibility patterns within a single hospital. While this only represents a single institution, it shows that the use of hospital-wide antibiograms is inadequate for creating empiric antibiotic protocols within individual ICUs.

Is There a Community Microbial Community? A Comparison of Pathogens Between Two Hospital Surgical Intensive Care Units in a Single City

Background: Nosocomial and health-care-associated infections drive increased healthcare costs and negatively affect patient outcomes. The human microbiome has been heavily explored in recent years with incomplete data regarding hospital-specific and community-specific microbial communities. Although bacterial species differ between intensive care units in the same hospital, it is unclear if they differ between similar units in similar hospitals in the same community. Our hypothesis is that pathogens in surgical intensive care units (SICUs) are distinct between hospitals, even in the same community. Methods: From 2017 to 2021, data were collected prospectively from the SICUs of two 400-bed hospitals located three miles apart in the same city (Hospital A and Hospital B). Infections defined using U.S. Centers for Disease Control and Prevention (CDC) criteria were recorded for trauma and general surgery patients, as well as patient demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and causative organism. Results: Overall, Escherichia coli was the most commonly isolated pathogen in Hospital A, whereas Staphylococcus aureus was most commonly isolated at Hospital B. Enterococci were more common in Hospital A, and Haemophilus influenzae and Enterobacter spp. were more common in Hospital B. After stratification between trauma and non-trauma patients, however, these differences disappeared, with the exception of more overall gram-positive organisms and fewer gram-negative organisms among Hospital A trauma patients compared to Hospital B. There were no differences in rates of isolation of either fungi or resistant bacteria between hospitals. Conclusions: At a species level, admission diagnosis appears to be a greater determinant of pathogen isolation than hospital when comparing similar intensive care units (ICUs) in the same geographic area, but a larger body of data is needed to flesh out a distinct microbial map of the organisms occupying a certain geographic region. Further areas for investigation include comparison between hospital units, specific anatomic sites, and ICU versus floor patients.

Risk Factors and Algorithms for the Empirical Treatment of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) continue to be major concerns for morbidity and mortality, especially in patients treated in the intensive care unit. With the rise in multidrug-resistant organisms, HAP and VAP treatment is challenged by the need for early appropriate treatment, with broad-spectrum agents, while still being aware of the principles of antibiotic stewardship. The two major society guidelines proposed a series of risk factors in their most recent guidelines to help identify patients who can most benefit from narrow- or broad-spectrum initial empiric antibiotic therapy. The guidelines reveal differences in the proposed risk factors and treatment approaches, as well as major similarities.

Infection management processes in intensive care and their association with mortality

BACKGROUND

ICU-specific tables of antimicrobial susceptibility for key microbial species ('antibiograms'), antimicrobial stewardship (AMS) programmes and routine rounds by infectious diseases (ID) physicians are processes aimed at improving patient care. Their impact on patient-centred outcomes in Australian and New Zealand ICUs is uncertain.

OBJECTIVES

To measure the association of these processes in ICU with in-hospital mortality.

METHODS

The Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database and Critical Care Resources registry were used to extract patient-level factors, ICU-level factors and the year in which each process took place. Descriptive statistics and hierarchical logistic regression were used to determine the relationship between each process and in-hospital mortality.

RESULTS

The study included 799 901 adults admitted to 173 ICUs from July 2009 to June 2016. The proportion of patients exposed to each process of care was 38.7% (antibiograms), 77.5% (AMS programmes) and 74.0% (ID rounds). After adjusting for confounders, patients admitted to ICUs that used ICU-specific antibiograms had a lower risk of in-hospital mortality [OR 0.95 (99% CI 0.92-0.99), P = 0.001]. There was no association between the use of AMS programmes [OR 0.98 (99% CI 0.94-1.02), P = 0.16] or routine rounds with ID physicians [OR 0.96 (99% CI 0.09-1.02), P = 0.09] and in-hospital mortality.

CONCLUSIONS

Use of ICU-specific antibiograms was associated with lower in-hospital mortality for patients admitted to ICU. For hospitals that do not perform ICU-specific antibiograms, their implementation presents a low-risk infection management process that might improve patient outcomes.

Strategies for implementation of a multidisciplinary approach to the treatment of nosocomial infections in critically ill patients

INTRODUCTION

Intensive Care Units (ICU) are among the hospital wards exhibiting the highest prevalence of antimicrobial resistance (AMR), and resulting impact on patient outcomes. Antimicrobial resistance surveillance and antimicrobial stewardship (AMS) programs play a pivotal role in promoting interventions tailored to optimize infection diagnosis and treatment in the final attempt to limit unnecessary antimicrobial use and development of resistance.

AREAS COVERED

A narrative review of the literature was carried out to summarize the available evidence and develop a set of actions that should be considered for integration into the ICU stewardship framework. Four questions were addressed: how AMR surveillance can inform antibiotic policy in ICU; whether pharmacokinetic and pharmacodynamic (PK/PD) principles and the use of procalcitonin should be incorporated as a standard practice in ICU AMS programs to optimize antibiotic treatment and to drive antibiotic discontinuation; which criteria should drive treatment duration of ICU-associated infections.

EXPERT OPINION

In this review we aim to highlight that the ICU must be considered in its own right. Each ICU has its own characteristics depending on the country, on the local antibiotic resistance profile, on the patients feature and the severity of infection.

Dynamics of microbiota during mechanical ventilation in aspiration pneumonia

BACKGROUND

The emergence of multi-drug resistant pathogens is an urgent health-related problem, and the appropriate use of antibiotics is imperative. It is often difficult to identify the causative bacteria in patients with aspiration pneumonia because tracheal aspirate contains contaminants of oral bacteria. We investigated the dynamics of microbiota in mechanically ventilated patients with aspiration pneumonia to develop a treatment strategy.

METHODS

Twenty-two intubated patients with aspiration pneumonia were recruited. Saliva and tracheal aspirate of the subjects were collected at three time points: (A) within 2 h after intubation, (B) just before administration of antibiotics, and (C) 48-72 h after administration of antibiotics. The microbiota in each specimen was analyzed by using the 16S rRNA gene clone library sequencing method. Bacterial floras of the samples were analyzed by principal component analysis.

RESULTS

Principal component analysis based on the composition of genus revealed that although the changes of microbiota in the saliva from (A) to (B) were not clear, the composition of anaerobes in the tracheal aspirate (B) was lower than (A). In fact, the reduction of anaerobes, not in the saliva but in the tracheal aspirate from (A) to (B), was confirmed by incident rate ratios estimated by a multilevel Poisson regression model (p < 0.001). The extent of decrease in anaerobes was fully dependent on the time difference between the sampling of tracheal aspirate (A) and (B)-in particular, over 3 h of mechanical ventilation. This indicates that the alterations of microbiota (involving the reduction of anaerobes in the lower respiratory tract) occurred during mechanical ventilation prior to the administration of antibiotics. After the administration of antibiotics, Enterobacter spp., Corynebacterium spp., Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus, and Granulicatera adiacens were predominantly detected in the tracheal aspirate (C).

CONCLUSION

The microbiota of the lower respiratory tract changes dynamically during mechanical ventilation and during the administration of antibiotics in intubated patients with aspiration pneumonia. Antibiotics should be selected on the premise that dynamic changes in microbiota (involved in the reduction of anaerobes) may occur during the mechanical ventilation in these patients.

A 2000 patient retrospective assessment of a new strategy for burn wound management in view of infection prevention and treatment

Infections in burn patients are still the principal cause of complications in burn injuries. The aim of this study is to assess a new strategy for burn wound management in view of infection prevention and treatment in the experience of the Burn Treatment Center in Siemianowice Śląskie. The applied methodology involved the analysis of patient records describing the hospital's epidemiological situation between 2014 and 2016. The analysis also included the use and cost of antibiotics, silver-containing dressings, and other antiseptics relative to the number of sepsis cases, including those caused by Pseudomonas aeruginosa, as well as the mortality ratio. The total costs of prevention and treatment of infections were reduced, while the use of silver-containing dressings and antiseptics increased. The number of patients with sepsis decreased, including cases caused by P. aeruginosa, and the mortality ratio was reduced. Introducing a strategy for burn wound-oriented infection prevention and treatment in burn patients provides a number of benefits. It is also cost-effective. Using locally applied active dressings and antiseptics can be a welcome choice for often-unnecessary antibiotic therapy of a suspected or existing burn wound infection.

Feasibility and applicability of antimicrobial stewardship in immunocompromised patients

PURPOSE OF REVIEW

Antimicrobial stewardship is the primary intervention in the battle against antimicrobial resistance, but clinicians do not always apply many key antimicrobial stewardship principles to patients with significant immune defects due to lack of data and fear of bad outcomes. We review evidence regarding the application of stewardship principles to immunocompromised patients, with a focus on solid organ and hematopoietic stem cell transplant recipients.

RECENT FINDINGS

Antimicrobial stewardship programs (ASPs), targeting immunocompromised patient populations such as oncology and transplant, are gaining traction. Emerging literature suggests that several stewardship interventions can be adapted to immunocompromised hosts and improve antimicrobial utilization, but data supporting improved outcomes is very limited.

SUMMARY

The application of antimicrobial stewardship principles to immunocompromised patients is feasible, necessary, and urgent. As antimicrobial stewardship programs gain momentum across a diverse range of healthcare settings more immunocompromised patients will fall under their purview. It is imperative that centers applying antimicrobial stewardship principles share their experience and establish collaborative research efforts to advance our knowledge base in applying antimicrobial stewardship initiatives to immunocompromised host populations, both in terms of programmatic success and patient outcomes.

Pneumonia in Trauma Patients

Purpose of Review

This article reviews the new definitions of pneumonia, discusses risk factors for pneumonia among trauma patients, presents the latest evidence for prevention strategies, discusses the best ways to make the diagnosis, and reviews the microbiology and treatment for trauma patients with pneumonia.

Recent Findings

Pneumonia can be prevented by decreasing the duration of mechanical ventilation using daily paired spontaneous awakening and breathing trials, but not with early tracheostomy placement. Other useful prevention strategies include semirecumbent positioning and oral care. Mini-BAL is a sensitive and specific means of securing the diagnosis of pneumonia that does not require a physician to be present and is therefore especially useful in busy trauma centers.

Summary

Pneumonia is a frequent complication among trauma patients. Risk factors are largely unmodifiable. However, trauma centers can institute routine daily paired spontaneous awakening and breathing trials to decrease the duration of ventilation and incidence of pneumonia. Future research is needed to further characterize the microbiology of pneumonia among trauma patients.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

Solid organ transplant antibiograms: an opportunity for antimicrobial stewardship

OBJECTIVES

We aimed to compare the antimicrobial susceptibility percentages in blood and urine bacterial isolates recovered from solid organ transplant (SOT) recipients with those reported in the hospital-wide antibiogram.

METHODS

Retrospective review of the antimicrobial susceptibilities of bacterial isolates recovered from SOT recipients at a 1550-bed hospital over a 2-year period. Antibiograms were categorized by anatomic site (blood and urine). Percentage of bacterial susceptibilities to specific antibiotics were compared with the hospital-wide antibiogram.

RESULTS

A total of 1889 unique cultures were identified. Blood and urine isolates of Escherichia coli, Klebsiella pneumonia and Pseudomonas aeruginosa had significantly lower susceptibility to first and second line antibiotics compared to the hospital-wide antibiogram.

CONCLUSION

Significant differences in susceptibilities between isolates from blood and urine cultures from SOT recipients and the hospital-wide antibiogram were found. A population-based strategy for the development of antibiograms specific for this group of high-risk patients could better guide appropriate empiric antimicrobial selection.

Selection of an Empiric Antibiotic Regimen for Hospital-Acquired Pneumonia Using a Unit and Culture-Type Specific Antibiogram

The objective of this retrospective study was to determine the optimal initial antibiotic regimen for hospital-acquired pneumonia using the frequency and sensitivity of Gram negative microorganisms found in sputum cultures. An antibiogram was constructed and compared with the hospital intensive care unit (ICU) antibiogram. The results yielded 191 microorganisms. The study-generated antibiogram showed that the highest percent susceptible antibiotics for all Gram-negative microorganisms were imipenem (75%) and amikacin (84%). Considering only Pseudomonas aeruginosa, the study-generated antibiogram and the hospital ICU antibiogram showed similar results, piperacillin and amikacin (86% and 82%, respectively, vs 91% and 85%, P = nonsignificant for both). The optimal empiric antibiotic regimen in the surgical ICU is different if directed against all possible microorganisms as opposed to the most prevalent microorganism P aeruginosa. Determining initial empiric antibiotic therapy using an ICU and culture-type specific antibiogram would result in a g reater likelihood that more patients would receive adequate initial antibiotic therapy.

Comparison of Unit-Specific and Hospital-Wide Antibiograms Potential Implications for Selection of Empirical Antimicrobial Therapy

Objective.

To identify differences between unit-specific and hospital-wide antibiograms and to determine the potential impact of these differences on selection of empirical antimicrobial therapy.

Setting.

A 625-bed tertiary care medical center.

Methods.

Antimicrobial susceptibility results were collected for all inpatient clinical bacterial isolates recovered over a 3-year period; isolates were categorized by the hospital location of the patient at the time of sampling and by the anatomic site from which the isolate was recovered. Antibiograms from each unit were compiled for the most commonly isolated organisms and were compared to the hospital-wide antibiogram.

Results.

A total of 9,970 bacterial isolates were evaluated in this study, including 2,646 enterococcal isolates, 2,806 S. aureus isolates, 2,795 E. coli isolates, and 1,723 Pseudomonas aeruginosa isolates. The percentages of bacterial isolates resistant to antimicrobials were significantly higher in the medical ICU and surgical ICU than the hospital-wide antibiogram would have predicted, whereas the percentages of isolates susceptible to antimicrobials were significantly higher in the non-ICU units, compared with the hospital overall. However, on general medicine units, the prevalence of susceptibility to levofloxacin was significantly lower than that for the hospital overall.

Conclusions.

Unit-specific antibiograms are important for making informed decisions about empirical antimicrobial therapy, because the hospital-wide antibiogram may mask important differences in susceptibility rates across different units. These differences may have important implications for selecting the optimal empirical antimicrobial therapy.

Antimicrobial susceptibilities of respiratory pathogens in the surgical/trauma intensive care unit compared with the hospital-wide respiratory antibiogram in a level I trauma center

BACKGROUND

Unit-specific antibiograms have developed to guide clinicians to appropriate antibiotic choices for subsets of patients. The additional level of a unit- and respiratory-specific antibiogram for surgical and trauma patients defines key differences in susceptibility information for treating hospital-acquired pneumonia.

METHODS

This was a three-year, retrospective single-center study. A total of 729 positive respiratory specimens from 612 patients were analyzed using Quality Compass Pathfinder(®), the antibiotic-reporting software. Culture and susceptibility reports were compared for the surgical/trauma intensive care unit (S/TICU) and the general hospital (excluding the S/TICU but including the medical ICU [MICU]). Data were filtered to include those genera and organisms with a high association with hospital-acquired pneumonia: Acinetobacter, Citrobacter, Enterobacter, Escherichia coli, Haemophilus, Klebsiella, Neisseria, Pseudomonas, Staphylococcus, Stenotrophomonas, Streptococcus, and Serratia.

RESULTS

For gram-negative organisms, susceptibility differences were noted for Acinetobacter and Pseudomonas between the S/TICU and the rest of the hospital. In particular, Acinetobacter was significantly more susceptible to ciprofloxacin (86% vs. 43%; p<0.001), gentamicin (86% vs. 54%; p=0.001), imipenem-cilastatin (93% vs. 55%; p<0.001), trimethoprim-sulfamethoxazole (88% vs. 54%; p=0.001), and tobramycin (50% vs. 0; p=0.012). Pseudomonas isolates from the S/TICU were significantly more susceptible to aztreonam (83% vs. 68%; p=0.037), ciprofloxacin (86% vs. 69%; p=0.019), and imipenem-cilastatin (94% vs. 79%; p=0.01). For gram-positive organisms, Staphylococcus isolates from the S/TICU were significantly more susceptible to erythromycin (81% vs. 57%; p=0.007) and trimethoprim-sulfamethoxazole (98% vs. 91%; p=0.034) than were the hospital isolates.

CONCLUSIONS

For key respiratory pathogens, such as Pseudomonas, Acinetobacter, and Staphylococcus, surgical and trauma patients present greater susceptibility to several antibiotics. Although this information cannot be extrapolated to other institutions, it does provide a basis for comparable institutions to consider developing unit- and collection-site-specific antibiograms for infections that affect surgical/trauma patients commonly.

Comparison of Hospitalwide and Custom Antibiograms for Clinical Isolates of Pseudomonas aeruginosa

BACKGROUND

Hospital antibiograms, which are commonly used to determine empiric antibiotic therapy and as a tool in stewardship in a given institution, are open to bias when combining susceptibility results from various sources, hospital locations, and patient groups.

METHODS

We assessed such differences, using Pseudomonas aeruginosa as a test case, with susceptibility data from 2008 through 2010 in our institution. Each year's data were analyzed separately. A variety of specific or subcategorical antibiograms were compared with each other as well as with versions including all tested isolates and those with results from inpatients and outpatients only. Statistical significance was determined at the .01 level using either chi-square or Fisher exact test, and clinical significance was defined as ≥10 percentage points.

RESULTS

A variety of clinically significant differences were found that illustrated important differences within the intensive care unit environment and based on population, specifically adult versus pediatric. Concordance between statistically significant and clinically significant differences was poor.

CONCLUSION

These results corroborate and extend previous similar observations and point to the potential importance of subanalyses in preparing the annual hospital antibiogram.

Comparison of Hospitalwide and Custom Antibiograms for Clinical Isolates of Pseudomonas aeruginosa

BACKGROUND

Hospital antibiograms, which are commonly used to determine empiric antibiotic therapy and as a tool in stewardship in a given institution, are open to bias when combining susceptibility results from various sources, hospital locations, and patient groups.

METHODS

We assessed such differences, using Pseudomonas aeruginosa as a test case, with susceptibility data from 2008 through 2010 in our institution. Each year's data were analyzed separately. A variety of specific or subcategorical antibiograms were compared with each other as well as with versions including all tested isolates and those with results from inpatients and outpatients only. Statistical significance was determined at the .01 level using either chi-square or Fisher exact test, and clinical significance was defined as ≥10 percentage points.

RESULTS

A variety of clinically significant differences were found that illustrated important differences within the intensive care unit environment and based on population, specifically adult versus pediatric. Concordance between statistically significant and clinically significant differences was poor.

CONCLUSION

These results corroborate and extend previous similar observations and point to the potential importance of subanalyses in preparing the annual hospital antibiogram.

Locally derived versus guideline-based approach to treatment of hospital-acquired pneumonia in the trauma intensive care unit

BACKGROUND

Appropriate initial antibiotic therapy for presumed pneumonia in critically ill patients decreases the mortality rate. To achieve this goal, treatment guidelines developed by groups such as the American Thoracic Society (ATS) have been stressed. However, often overlooked is the importance of incorporating local microbiologic data into an empiric algorithm. Our hypothesis was that an empiric algorithm supported by our locally-driven analysis would predict more accurate coverage than one defined strictly by an unmodified guideline-driven approach.

METHODS

Retrospective review of all first hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) pathogens in consecutive trauma intensive care unit (TICU) patients over 18 months. Microbiologic data were analyzed to update our TICU-specific empiric algorithm. The ATS guidelines define patients at risk for multidrug-resistant (MDR) organisms on the basis of standardized criteria and time since admission (early <5 days; late ≥5 days).

RESULTS

A total of 164 pathogens caused 117 pneumonias. For early coverage, ATS guidelines stress identification of MDR risks; these criteria failed to identify 8 of 13 (62%) early MDR pneumonias. For early HAP/VAP with no MDR risks, the ATS guidelines recommend monotherapy; susceptibility differed (49% to ciprofloxacin, 68% to ampicillin-sulbactam, 83% to ceftriaxone). A total of 15% of early pathogens were MDR gram-positive, so addition of vancomycin resulted in adequate predicted coverage of 100%, 79%, and 95% for ciprofloxacin, ampicillin-sulbactam, and ceftriaxone, respectively. For late HAP/VAP, ATS recommends regimens based on broad-spectrum drugs. Vancomycin with ciprofloxacin, cefepime, or piperacillin-tazobactam had predicted coverage of 95%, 94%, and 93%, respectively.

CONCLUSIONS

The empiric algorithm derived from analysis of local microbiologic data predicted significantly better coverage than one defined by an unmodified guideline-driven approach for early HAP/VAP. Our locally-derived TICU algorithm of ceftriaxone+vancomycin for early pneumonia and piperacillin-tazobactam+vancomycin for late pneumonia optimizes the adequacy of initial therapy. Understanding local patterns of pneumonia ensures the creation and maintenance of empiric algorithms that achieve the best clinical outcomes.

Infections in Burns

Infections remain a leading cause of death in burn patients. This is as a result of loss of the environmental barrier function of the skin predisposing these patients to microbial colonization leading to invasion. Therefore, reconstitution of the environmental barrier by debriding the devitalized tissue and wound closure with application of allograft versus autograft is of optimal importance.

Potentially resistant microorganisms in intubated patients with hospital-acquired pneumonia: the interaction of ecology, shock and risk factors

PURPOSE

As per 2005 American Thoracic Society and Infectious Disease Society of America (ATS/IDSA) guidelines for managing hospital-acquired pneumonia, patients with early-onset pneumonia and without risk factors do not need to be treated for potentially resistant microorganisms (PRM).

METHODS

This was a secondary analysis of a prospective, observational, cohort, multicentre study conducted in 27 ICUs from nine European countries.

RESULTS

From a total of 689 patients with nosocomial pneumonia who required mechanical ventilation, 485 patients with confirmed etiology and antibiotic susceptibility were further analysed. Of these patients, 152 (31.3 %) were allocated to group 1 with early-onset pneumonia and no risk factors for PRM acquisition, and 333 (68.7 %) were classified into group 2 with early-onset pneumonia with risk factors for PRM or late-onset pneumonia. Group 2 patients were older and had more chronic renal failure and more severe illness (SAPS II score, 44.6 ± 16.5 vs. 47.4 ± 17.8, p = 0.04) than group 1 patients. Trauma patients were more frequent and surgical patients less frequent in group 1 than in group 2 (p < 0.01). In group 1, 77 patients (50.7 %) had PRM in spite of the absence of classic risk factors recognised by the current guidelines. A logistic regression analysis identified that presence of severe sepsis/septic shock (OR = 3.7, 95 % CI 1.5-8.9) and pneumonia developed in centres with greater than 25 % prevalence of PRM (OR = 11.3, 95 % CI 2.1-59.3) were independently associated with PRM in group 1 patients.

CONCLUSIONS

In patients admitted to ICUs with a prevalence of PRM greater than 25 % or with severe sepsis/septic shock, empiric therapy for group 1 nosocomial pneumonia requiring mechanical ventilation should also include agents likely to be effective for PRM pathogens.

Antibiotic resistance patterns in medical and surgical patients in a combined medical-surgical intensive care unit

PURPOSE

Studies have found different rates of antimicrobial resistance among patients in medical and surgical intensive care units (ICUs). We studied whether these differences were a function of geography or differences in the patient populations, by comparing resistance rates among bacteria isolated from a combined medical/surgical ICU.

MATERIALS AND METHODS

We retrospectively evaluated the results of bacterial cultures of each patient admitted to the ICU between February 2005 and September 2006. Data collection included patient demographics and culture and sensitivity results. Intensive care unit populations were compared using the Fisher exact test and the Student t test.

RESULTS

One hundred seventy-one medical and 94 surgical patients with positive cultures were studied. Organisms were grouped into 4 classes: Staphylococcus aureus, nonlactose fermenting gram-negative bacilli, Enterococcus species, and gram-negative enteric bacteria. In the 4 classes, no significant difference in antibiotic resistance was found between medical and surgical patients.

CONCLUSION

Reported differences in resistance patterns among bacteria cultured from medical and surgical patients may be due to geographic separation of the ICUs as opposed to differences in the patient characteristics. This study suggests that ICU-specific antibiograms remain a useful tool to guide the choice of antimicrobial therapy, even in medical/surgical ICUs.

Empiric antibiotic selection strategies for healthcare-associated pneumonia, intra-abdominal infections, and catheter-associated bacteremia

Initial selection and early deployment of appropriate/adequate empiric antimicrobial therapy is critical to minimize the significant morbidity and mortality associated with hospital- or healthcare-associated infections (HAIs). Initial empiric therapy that inadequately covers the pathogen(s) causing a serious HAI has been associated with increased mortality, longer hospital stay, and elevated healthcare costs. Moreover, subsequent modification of initial inadequate therapy, later in the disease process when culture results become available, may not remedy the impact of the initial choice. Because of this, it is important that initial empiric therapy covers the most likely pathogens associated with infection in a particular patient, even if this initial regimen turns out to be unnecessarily broad, based on subsequent culture results. The current paradigm for management of serious HAIs is to initiate empiric therapy with a broad-spectrum regimen covering likely pathogens, based on local surveillance and susceptibility data, and presence of risk factors for involvement of a resistant microorganism. Subsequent modification (de-escalation) of the initial regimen becomes possible later, when culture results are available and clinical status can be better assessed, 2 to 4 days after initiation of empiric therapy. When possible, de-escalation and other steps to modify antimicrobial exposure are important for minimizing risk of antimicrobial resistance development. This article examines the general process for selection of initial empiric antibiotic therapy for patients with HAIs, illustrated through 3 case studies dealing with healthcare-associated pneumonia, complicated intra-abdominal infection, and catheter-associated bacteremia, respectively.

Multidrug-resistant pathogens and pneumonia: comparing the trauma and surgical intensive care units

BACKGROUND

As acute care surgery evolves, more trauma surgeons are caring for critically ill general surgery as well as trauma patients. However, these two populations are unique, and infectious complications may need to be addressed differently, as the causative organisms may not be the same in the two groups. To study this, we evaluated ventilator-associated (VAP) and hospital-acquired (HAP) pneumonia in the trauma (TICU) and general surgical (SICU) intensive care units to investigate differences in the causative pathogens. Our hypothesis was that SICU patients would have a higher incidence of multi-drug-resistant (MDR) organisms causing VAP/HAP, possibly contributing to inadequate empiric antibiotic (IEA) coverage.

METHODS

Retrospective review of 116 patients admitted with VAP or HAP over a one-year period to the TICU (n = 72) or SICU (n = 44) at a tertiary medical center. Culture was followed by initiation of empiric antibiotics on the basis of an antibiotic algorithm derived from trauma patients. Demographics, illness, and pneumonia characteristics were assessed; MDR organisms were identified.

RESULTS

Multi-drug-resistant organisms caused 30.6% of first pneumonias in the TICU vs. 65.9% in the SICU (p = 0.0002). Subsequent pneumonias were seen in 31.8% of SICU patients and 16.7% of TICU patients (p = 0.0576). Inadequate empiric antibiotic coverage was documented in 38.6% of SICU pneumonias vs. 26.4% in the TICU (p = 0.12).

CONCLUSIONS

Multiply-resistant pathogens cause a significantly greater number of VAP/HAPs in the SICU than in the TICU. Associated with this, when using an antibiotic algorithm based on TICU bacterial pathogens, there is a trend toward a greater likelihood of subsequent pneumonias and toward more IEA coverage in the SICU population compared with TICU patients. Our results indicate that these distinct patient populations have different pathogens causing VAP/HAP and affirm the necessity for population-specific algorithms to tailor empiric coverage for presumed VAP/HAP.

A European care bundle for management of ventilator-associated pneumonia

BACKGROUND

Although there is a wealth of guidance concerning the management of patients with ventilator-associated pneumonia (VAP), compliance with recommendations concerning optimal treatment practices is highly variable.

METHODS

This document presents a comprehensive care bundle package addressing all aspects of VAP diagnosis and treatment in an attempt to promote guideline-compliant practices. Uniquely, the development of these care bundles used a formalized method to assess the supporting data, based on multicriteria decision analysis.

RESULTS

This system allowed the numerous VAP management parameters identified from recent European guidelines to be ranked according to defined criteria. The resulting VAP care bundles are (a) diagnosis: early chest x-rays within 1 hour, immediate reporting of respiratory secretions Gram staining, and (b) therapy: immediate treatment, empiric therapy based on local pathogens and risk factors, de-escalation, assessment of response within 72 hours, and short therapy duration if feasible.

CONCLUSION

Adoption of these care bundles should rationalize VAP management practices and facilitate the development of consistent and guideline-compliant care processes.

[Antibiotic multiresistance in critical care units]

The presence of microorganisms with acquired resistance to multiple antibiotics complicates the management and outcome of critically ill patients. The intensivist, in his/her daily activity, is responsible for the prevention and control of the multiresistance and the challenge of prescribing the appropriate treatment in case of an infection by these microorganisms. We have reviewed the literature regarding the definition, important concepts related to transmission, recommendations on general measures of control in the units and treatment options. We also present data on the situation in our country known primarily through the ENVIN-UCI register. Addressing the multiresistance not only requires training but also teamwork with other specialists and adaptation to the local environment.

Ventilator-associated pneumonia in trauma patients is associated with lower mortality: results from EU-VAP study

BACKGROUND

Differences in trauma patients developing ventilator-associated pneumonia (VAP) are described regarding etiology and risk factors associated. We aim to describe the differences in outcomes in trauma and nontrauma patients with VAP.

METHODS

A prospective, observational study conducted in 27 intensive care units from nine European countries. We included patients requiring invasive mechanical ventilation for >48 hours who developed VAP. Logistic regression model was used to assess the factors independently associated with mortality in trauma patients with VAP.

RESULTS

A total of 2,436 patients were evaluated; 465 developed VAP and of these 128 (27.5%) were trauma patients. Trauma patients were younger than nontrauma (45.3 ± 19.4 vs. 61.1 ± 16.7, p < 0.0001). Nontrauma had higher simplified acute physiology score II compared with trauma patients (45.5 ± 16.3 vs. 41.1 ± 15.2, p = 0.009). Most prevalent pathogens in trauma patients with early VAP were Enterobacteriaceae spp. (46.9% vs. 27.8%, p = 0.06) followed by methicillin-susceptible Staphylococcus aureus (30.6% vs. 13%, p = 0.03) and then Haemophilus influenzae (14.3% vs. 1.9%, p = 0.02), and the most prevalent pathogen in late VAP was Acinetobacter baumannii (12.2% vs. 44.4%, p < 0.0001). Mortality was higher in nontrauma patients than in trauma patients (42.6% vs. 17.2%, p < 0.001, odds ratio [OR] = 3.55, 95%CI = 2.14-5.88). A logistic regression model adjusted for sex, age, severity of illness at intensive care unit admission, and sepsis-related organ failure assessment score at the day of VAP diagnosis confirmed that trauma was associated with a lower mortality compared with nontrauma patients (odds ratio [OR] = 0.37, 95%CI = 0.21-0.65).

CONCLUSIONS

Trauma patients developing VAP had different demographic characteristics and episodes of etiology. After adjustment for potential confounders, VAP episodes in trauma patients are associated with lower mortality when compared with nontrauma patients.

Simulation training in central venous catheter insertion: improved performance in clinical practice

PURPOSE

To determine whether simulation training of ultrasound (US)-guided central venous catheter (CVC) insertion skills on a partial task trainer improves cannulation and insertion success rates in clinical practice.

METHOD

This prospective, randomized, controlled, single-blind study of first- and second-year residents occurred at a tertiary care teaching hospital from January 2007 to September 2008. The intervention group (n = 90) received a didactic and hands-on, competency-based simulation training course in US-guided CVC insertion, whereas the control group (n = 95) received training through a traditional, bedside apprenticeship model. Success at first cannulation and successful CVC insertion served as the primary outcomes. Secondary outcomes included reduction in technical errors and decreased mechanical complications.

RESULTS

Blinded independent raters observed 495 CVC insertions by 115 residents over a 21-month period. Successful first cannulation occurred in 51% of the intervention group versus 37% of the control group (P = .03). CVC insertion success occurred for 78% of the intervention group versus 67% of the control group (P = .02). Simulation training was independently and significantly associated with success at first cannulation (odds ratio: 1.7; 95% confidence interval: 1.1-2.8) and with successful CVC insertion (odds ratio: 1.7; 95% confidence interval: 1.1-2.8)--both independent of US use, patient comorbidities, or resident specialty. No significant differences related to technical errors or mechanical complications existed between the two groups.

CONCLUSIONS

Simulation training was associated with improved in-hospital performance of CVC insertion. Procedural simulation was associated with improved residents' skills and was more effective than traditional training.

Recognition and prevention of nosocomial pneumonia in the intensive care unit and infection control in mechanical ventilation

Nosocomial pneumonia (NP) is a difficult diagnosis to establish in the critically ill patient due to the presence of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with this infection. Additionally, the classification of NP in the intensive care unit setting has become increasingly complex, as the types of patients who develop NP become more diverse. The occurrence of NP is especially problematic as it is associated with a greater risk of hospital mortality, longer lengths of stay on mechanical ventilation and in the intensive care unit, a greater need for tracheostomy, and significantly increased medical care costs. The adverse effects of NP on healthcare outcomes has increased pressure on clinicians and healthcare systems to prevent this infection, as well as other nosocomial infections that complicate the hospital course of patients with respiratory failure. This manuscript will provide a brief overview of the current approaches for the diagnosis of NP and focus on strategies for prevention. Finally, we will provide some guidance on how standardized or protocolized care of mechanically ventilated patients can reduce the occurrence of and morbidity associated with complications like NP.

Current Concepts in the Prevention and Treatment of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is one of the most common causes of infection in intensive care unit (ICU) patients. Efforts to prevent VAP have focused on both pharmacologic and nonpharmacologic strategies. Two of the more controversial pharmacologic approaches included selective decontamination of the digestive tract (SDD) and decontamination of the oropharynx using topical antimicrobials or antiseptics including chlorhexidine (CHX). Additionally, avoidance of pharmacotherapy-related risk factors is hypothesized to reduce VAP rates. Successful treatment of VAP is becoming increasingly difficult in the era of antibiotic resistance. Utilization of local antibiograms, implementation of standardized treatment pathways, and optimization of pharmacodynamic-based dosing offer methods to improve empiric therapy selections. De-escalation of therapy should be a constant focus in an attempt to reduce overall antibiotic consumption and the selection pressure on ICU flora, thus minimizing the development and spread of antimicrobial resistance in the ICU.

Delay of adequate empiric antibiotic therapy is associated with increased mortality among solid-organ transplant patients

Empiric antibiotic therapy is often prescribed prior to the availability of bacterial culture results. In some cases, the organism isolated may not be susceptible to initial empiric therapy (inadequate empiric therapy or IET). In solid-organ transplant recipients, the overall incidence and clinical importance of IET is unknown. We performed a retrospective cohort study of patients admitted from 2002 to 2004. Multiple logistic regression analyses were conducted to determine associations between potential determinants and mortality. IET was administered in 169/312 (54%) patients, with a hospital mortality rate that was significantly greater than those receiving adequate therapy (24.9% vs. 7.0%; relative risk [RR] 3.55; 95% confidence interval [CI], 1.85-6.83; p < 0.001). Regression analysis demonstrated that an increasing duration of IET (adjusted odds ratio [OR] at 24 h: 1.33; 95% CI: 1.15-1.53; p < 0.001), ICU-associated infections (adjusted OR: 6.27; 95% CI: 2.79-14.09; p < 0.001), prior antibiotic use (adjusted OR: 3.56; 95% CI: 1.51-8.41; p = 0.004) and increasing APACHE-II scores (adjusted OR: 1.26; 95% CI: 1.16-1.34; p < 0.001) were independently correlated with hospital mortality. IET is common and appears to be associated with an increased hospital mortality rate in the solid-organ transplant population.

National trends in emergency department antibiotic prescribing for elders with urinary tract infection, 1996-2005

OBJECTIVES

Given reported increases in antibiotic resistance among elders with urinary tract infection (UTI) and pyelonephritis, the authors identified national rates and trends in emergency department (ED) trimethoprim-sulfamethoxazole (TMP-SMX) and fluoroquinolone prescribing for older adults from 1996 to 2005.

METHODS

This was a retrospective analysis utilizing the ED component of the 1996-2005 National Hospital Ambulatory Medical Care Survey (NHAMCS). The authors included NHAMCS ED entries aged >or=18 years with a diagnosis of UTI or pyelonephritis; pregnancy was excluded. Records were divided into 18-64 years ("adults") and >or=65 years ("elders"). Primary outcome measures were prescription of TMP-SMX monotherapy, fluoroquinolone monotherapy, and combination therapy with two or more antibiotics. Estimated visit totals and rates were calculated and trends analyzed.

RESULTS

From 1996 to 2005, there were 5 million elder ED visits for UTI or pyelonephritis. Approximately 9.4% (95% confidence interval [CI] = 7.9% to 11%) of elders received TMP-SMX monotherapy with rates decreasing over time (p-value for trend = 0.031). Overall, 35% (95% CI = 32% to 38%) of elders received fluoroquinolone monotherapy, which increased from 21% (95% CI = 14% to 27%) in 1996 to 45% (95% CI = 39% to 50%) in 2005 (p-value for trend < 0.001). Therapy with a fluoroquinolone plus a second antibiotic was used in only 4.2% (95% CI = 3.1% to 5.3%) of older patients.

CONCLUSIONS

From 1996 to 2005, TMP-SMX monotherapy in elder ED patients decreased while fluoroquinolone therapy increased. The majority of older patients receiving fluoroquinolone therapy received a single agent. Given the continued prevalence of monotherapy for elder ED patients with UTI or pyelonephritis, antibiotic resistance patterns in these patients should be better characterized to ensure institution of appropriate empiric therapy.

[Infection associated with the use of assisted-ventilation devices]

The second most important infectious complication in hospitalised patients is pneumonia, and it hits first place in the Intensive Care Unit (ICU). Almost 80% of the episodes of health-care pneumonia happens when patient is under mechanical ventilation, causing ventilator-associated pneumonia (VAP). VAP is associated with the highest rates of mortality in ICU infections, mainly if due to Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). It also increases days under mechanical ventilation and the length of stay in ICU and hospital. Although all the diagnostic procedures, the diagnosis of VAP is based basically in the clinics: X-ray infiltrates and purulent endotracheal secretions are the cornerstone of the diagnosis. We should evaluate and screen any risk factor for multiresistant pathogens. If we have an early VAP and no risk factors, the majority of empiric antibiotic strategies are useful, but if we have a patient with more than one week under mechanical ventilation, previous antibiotic use, and risk factors for multiresistant pathogens, we should then individualize empiric antibiotic treatment.

Analysis of two- and three-year trends in antimicrobial resistance in intensive care units using unit-specific antibiograms

Unit-specific antibiograms serve as useful guides to clinicians and infection control personnel. We compared trends in antimicrobial resistance in intensive care units using traditional 2-y unit-specific antibiogram data and 3 y of data. Three-y unit-specific antibiogram data may provide increased statistical power to detect changes in antimicrobial resistance.

Acinetobacter infections: a growing threat for critically ill patients

There has been increasing concern regarding the rise of Acinetobacter infections in critically ill patients. We extracted information regarding the relative frequency of Acinetobacter pneumonia and bacteraemia in intensive-care-unit (ICU) patients and the antimicrobial resistance of Acinetobacter isolates from studies identified in electronic databases. Acinetobacter infections most frequently involve the respiratory tract of intubated patients and Acinetobacter pneumonia has been more common in critically ill patients in Asian (range 4-44%) and European (0-35%) hospitals than in United States hospitals (6-11%). There is also a gradient in Europe regarding the proportion of ICU-acquired pneumonias caused by Acinetobacter with low numbers in Scandinavia, and gradually rising in Central and Southern Europe. A higher proportion of Acinetobacter isolates were resistant to aminoglycosides and piperacillin/tazobactam in Asian and European countries than in the United States. The data suggest that Acinetobacter infections are a growing threat affecting a considerable proportion of critically ill patients, especially in Asia and Europe.

The use of systemic antibiotics in the treatment of chronic wounds

The role of microorganisms in the etiology and persistence of chronic wounds remains poorly understood. The chronic wound bed houses a complex microenvironment that typically includes more than one bacterial species. Difficulty lies in determining when the presence of bacteria impedes wound healing, thereby warranting intervention. Indications for antibiotic therapy and optimal treatment regimens are ill defined. The goal of this article is to describe the appropriate role of systemic antibiotics in the management of chronic wounds. A common sense approach will be offered based on six clinically pertinent questions: Is infection present? Are systemic antibiotics necessary? Should treatment be enteral or parenteral? What antibiotic or combination of antibiotics should be used? What should be the duration of therapy? What special circumstances are present (i.e., concomitant illnesses, potential drug-drug interactions) that can impact therapy?

Ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is a significant clinical infection affecting up to one-third of patients requiring mechanical ventilation, and is associated with significant attributable morbidity and mortality. Clinicians should have a heightened clinical suspicion for VAP with diagnostic goals focusing on accuracy; gathering of lower respiratory tract culture; and appropriate and timely initial antibiotic therapy. Early and adequate antibiotic therapy is important to optimize the management of patients with VAP. The incidence and etiologic patterns of the major pathogens causing VAP must be taken into account when making empiric antibiotic therapy choices. Subsequent de-escalation and prescription of an appropriate duration of therapy guided by clinical response and culture results may lead to decreased morbidity and future antibiotic resistance.

De-escalation therapy in ventilator-associated pneumonia

PURPOSE OF REVIEW

To describe the use of a 'de-escalation' strategy to deliver appropriate empiric therapy for ventilator-associated pneumonia, without the overuse of antibiotics.

RECENT FINDINGS

Initial empiric therapy can be appropriate in 80-90% of ventilator-associated pneumonia patients, if it is selected on the basis of local microbiologic data or individual patient surveillance cultures. Following initial empiric therapy, de-escalation means using microbiologic and clinical data to change from an initial broad-spectrum, multidrug empiric therapy regimen to a therapy with fewer antibiotics and agents of narrower spectrum. In spite of early success with this approach there is an opportunity to de-escalate more often, particularly in patients with negative pretherapy cultures, and in those whose cultures show multidrug-resistant organisms, including Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. In addition, it is possible to reduce the total duration of therapy, particularly when the initial therapy is accurate. When de-escalation has been employed, it has led to less antibiotic usage, shorter durations of therapy, fewer episodes of secondary pneumonia and reduced mortality, without increasing the frequency of antibiotic resistance.

SUMMARY

De-escalation is a promising strategy for optimizing the responsible use of antibiotics while allowing the delivery of prompt and appropriate empiric therapy of ventilator-associated pneumonia.

Perceptions of safety culture vary across the intensive care units of a single institution*

OBJECTIVE

To determine whether safety culture factors varied across the intensive care units (ICUs) of a single hospital, between nurses and physicians, and to explore ICU nursing directors' perceptions of their personnel's attitudes.

DESIGN

Cross-sectional surveys using the Safety Attitudes Questionnaire-ICU version, a validated, aviation industry-based safety culture survey instrument. It assesses culture across six factors: teamwork climate, perceptions of management, safety climate, stress recognition, job satisfaction, and work environment.

SETTING

Four ICUs in one tertiary care hospital.

SUBJECTS

All ICU personnel.

MEASUREMENTS AND MAIN RESULTS

We conducted the survey from January 1 to April 1, 2003, and achieved a 70.2% response rate (318 of 453). We calculated safety culture factor mean and percent-positive scores (percentage of respondents with a mean score of > or =75 on a 0-100 scale for which 100 is best) for each ICU. We compared mean ICU scores by ANOVA and percent-positive scores by chi-square. Mean and percent-positive scores by job category were modeled using a generalized estimating equations approach and compared using Wald statistics. We asked ICU nursing directors to estimate their personnel's mean scores and generated ratios of their estimates to the actual scores.Overall, factor scores were low to moderate across all factors (range across ICUs: 43.4-74.9 mean scores, 8.6-69.4 percent positive). Mean and percent-positive scores differed significantly (p < .0083, Bonferroni correction) across ICUs, except for stress recognition, which was uniformly low. Compared with physicians, nurses had significantly lower mean working conditions and perceptions of management scores. ICU nursing directors tended to overestimate their personnel's attitudes. This was greatest for teamwork, for which all director estimates exceeded actual scores, with a mean overestimate of 16%.

CONCLUSIONS

Significant safety culture variation exists across ICUs of a single hospital. ICU nursing directors tend to overestimate their personnel's attitudes, particularly for teamwork. Culture assessments based on institutional level analysis or director opinion may be flawed.

Hospital-acquired pneumonia in the 21st century: a review of existing treatment options and their impact on patient care

Hospital-acquired pneumonia is a common nosocomial infection, with significant morbidity and mortality, and represents a major therapeutic challenge to clinicians. The therapeutic approach must be patient-oriented and institution-specific. The specific risk factors of each patient, such as previous antibiotic exposure, underlying diseases, length of hospital stay and the local patterns of antimicrobial resistance, should guide physicians in their decision of the initial optimal empirical therapy. Delays in the initiation or inappropriate/inadequate initial therapy are related to increased mortality and worse outcomes. In responding patients, as soon as culture data are available, efforts should be made to change the initial broad spectrum antibiotic regimen to a more targeted one (de-escalation). The optimal duration of treatment is a matter of debate, but courses longer than 1 week are rarely justified.

Adverse drug event reporting in intensive care units: a survey of current practices

BACKGROUND

With the incidence of adverse drug events (ADEs) and adverse drug reactions (ADRs) higher in the intensive care unit (ICU) than other areas of the hospital, it is suspected that ADE/ADR surveillance systems differ between ICU and non-ICU areas. However, there is a lack of information about ADE/ADR identification, reporting, and evaluation strategies in the ICU. Understanding the frequency with which institutions incorporate standardized operational ADE/ADR definitions, triggers, and evaluation tools in this population will facilitate benchmarking between hospitals.

OBJECTIVE

To determine whether ADE/ADR identification, reporting, and evaluation strategies differ between ICU and non-ICU populations and to characterize ADE/ADR reporting strategies in the ICU.

METHODS

A validated survey was mailed to pharmacy directors at 590 randomly selected hospitals in the US having at least one ICU. A reminder was sent one week after the surveys were mailed. Five weeks later, a second survey was mailed to hospitals that did not respond.

RESULTS

The response rate was 22% (132/590); institutions were predominantly community (68.2%), with 199 or fewer (54.5%) operational beds and 19 or fewer (60.6%) ICU beds. ICU types included mixed medical/surgical (62.1%), medical (48.5%), surgical (31.8%), coronary (29.5%), neonatal (22.7%), and cardiothoracic (15.2%). Operational definitions for ADEs and ADRs varied little between ICU and non-ICU areas, as 92.4% of institutions used the same term for both settings. Triggers were used to identify ADE/ADRs hospital-wide (75%) and were usually the same between ICU and non-ICU areas (88.6%). ADE reporting was nearly always voluntary (94.7%), using paper reports (88.6%), phone calls (22.7%), e-mail (12.1%), Intranet (12.1%), Web-based/Internet (10.6%), or PDA (1.5%). Only 22% of hospitals tracked ICU-specific data.

CONCLUSIONS

ADE identification, reporting, and evaluation strategies are similar between ICU and non-ICU areas. Few institutions currently track ICU-specific ADE/ADR data. The institution of ICU-specific ADE detection and prevention strategies may improve the safety of critically ill patients.

Optimizing antibiotic treatment for ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is the most common infectious complication in patients receiving mechanical ventilation and accounts for exorbitant use of resources in the intensive care unit. Antimicrobial management of VAP incorporates an initial broad-spectrum, empiric regimen to ensure appropriate coverage with deescalation of therapy after 48-72 hours based on culture results and sensitivities. When VAP clinically responds to treatment, antimicrobials should be discontinued after 7-8 days to reduce overall antibiotic consumption and the selection pressure on flora observed in the intensive care unit and thus minimize the development and spread of antimicrobial resistance.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.