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de Mul N, Verlaan D, Ruurda JP, van Grevenstein WMU, Hagendoorn J, de Borst GJ, Vriens MR, de Bree R, Zweemer RP, Vogely C, Haitsma Mulier JLG, Vernooij LM, Reitsma JB, de Zoete MR, Top J, Kluijtmans JAJ, Hoefer IE, Noordzij P, Rettig T, Marsman M, de Smet AMGA, Derde L, van Waes J, Rijsdijk M, Schellekens WJM, Bonten MJM, Slooter AJC, Cremer OL. Cohort profile of PLUTO: a perioperative biobank focusing on prediction and early diagnosis of postoperative complications. BMJ Open 2023; 13:e068970. [PMID: 37076142 PMCID: PMC10124280 DOI: 10.1136/bmjopen-2022-068970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
PURPOSE Although elective surgery is generally safe, some procedures remain associated with an increased risk of complications. Improved preoperative risk stratification and earlier recognition of these complications may ameliorate postoperative recovery and improve long-term outcomes. The perioperative longitudinal study of complications and long-term outcomes (PLUTO) cohort aims to establish a comprehensive biorepository that will facilitate research in this field. In this profile paper, we will discuss its design rationale and opportunities for future studies. PARTICIPANTS Patients undergoing elective intermediate to high-risk non-cardiac surgery are eligible for enrolment. For the first seven postoperative days, participants are subjected to daily bedside visits by dedicated observers, who adjudicate clinical events and perform non-invasive physiological measurements (including handheld spirometry and single-channel electroencephalography). Blood samples and microbiome specimens are collected at preselected time points. Primary study outcomes are the postoperative occurrence of nosocomial infections, major adverse cardiac events, pulmonary complications, acute kidney injury and delirium/acute encephalopathy. Secondary outcomes include mortality and quality of life, as well as the long-term occurrence of psychopathology, cognitive dysfunction and chronic pain. FINDINGS TO DATE Enrolment of the first participant occurred early 2020. During the inception phase of the project (first 2 years), 431 patients were eligible of whom 297 patients consented to participate (69%). Observed event rate was 42% overall, with the most frequent complication being infection. FUTURE PLANS The main purpose of the PLUTO biorepository is to provide a framework for research in the field of perioperative medicine and anaesthesiology, by storing high-quality clinical data and biomaterials for future studies. In addition, PLUTO aims to establish a logistical platform for conducting embedded clinical trials. TRIAL REGISTRATION NUMBER NCT05331118.
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Affiliation(s)
- Nikki de Mul
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
- Julius Center, Department of Epidemiology, Program of Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Diede Verlaan
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
- Julius Center, Department of Epidemiology, Program of Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgical Oncology, Upper Gastro-Intestinal Surgery, UMC Utrecht, Utrecht, The Netherlands
| | | | - Jeroen Hagendoorn
- Department of Surgical Oncology, Hepatobilliary and Pancreatic Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Gert-Jan de Borst
- Department of Vascular Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Menno R Vriens
- Department of Endocrine and Surgical Oncology, Cancer Center, UMC Utrecht, Utrecht, The Netherlands
| | - Remco de Bree
- Department of Head and Neck Surgical Oncology, UMC Utrecht, Utrecht, The Netherlands
| | - Ronald P Zweemer
- Department of Gynaecological Oncology, UMC Utrecht, Utrecht, The Netherlands
| | - Charles Vogely
- Department of Orthopaedic Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Jelle L G Haitsma Mulier
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
- Julius Center, Department of Epidemiology, Program of Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
- Department of Anaesthesiology and Intensive Care, Antonius Ziekenhuis Nieuwegein, Nieuwegein, The Netherlands
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Marcel R de Zoete
- Department of Medical Microbiology, UMC Utrecht, Utrecht, The Netherlands
| | - Janetta Top
- Department of Medical Microbiology, UMC Utrecht, Utrecht, The Netherlands
| | - Jan A J Kluijtmans
- Department of Medical Microbiology, UMC Utrecht, Utrecht, The Netherlands
| | - Imo E Hoefer
- Central Diagnostic Laboratory, Universitair Medisch Centrum, Utrecht, The Netherlands
| | - Peter Noordzij
- Department of Anaesthesiology and Intensive Care, Antonius Ziekenhuis Nieuwegein, Nieuwegein, The Netherlands
| | - Thijs Rettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, Amphia Hospital site Molengracht, Breda, The Netherlands
| | - Marije Marsman
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
| | | | - Lennie Derde
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
| | - Judith van Waes
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
| | - Mienke Rijsdijk
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
| | - Willem Jan M Schellekens
- Department of Anaesthesiology, UMC Utrecht, Utrecht, The Netherlands
- Department of Anaesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Marc J M Bonten
- Julius Center, Department of Epidemiology, Program of Infectious Diseases, UMC Utrecht, Utrecht, The Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, UMC Utrecht, Utrecht, The Netherlands
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2
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Seinen J, Dieperink W, Mekonnen SA, Lisotto P, Harmsen HJM, Hiemstra B, Ott A, Schultz D, Lalk M, Oswald S, Hammerschmidt S, de Smet AMGA, van Dijl JM. Heterogeneous antimicrobial activity in broncho-alveolar aspirates from mechanically ventilated intensive care unit patients. Virulence 2020; 10:879-891. [PMID: 31662033 PMCID: PMC6844299 DOI: 10.1080/21505594.2019.1682797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Pneumonia is an infection of the lungs, where the alveoli in the affected area are filled with pus and fluid. Although ventilated patients are at risk, not all ventilated patients develop pneumonia. This suggests that the sputum environment may possess antimicrobial activities. Despite the generally acknowledged importance of antimicrobial activity in protecting the human lung against infections, this has not been systematically assessed to date. Therefore, the objective of the present study was to measure antimicrobial activity in broncho-alveolar aspirate (‘sputum”) samples from patients in an intensive care unit (ICU) and to correlate the detected antimicrobial activity with antibiotic levels, the sputum microbiome, and the respective patients’ characteristics. To this end, clinical metadata and sputum were collected from 53 mechanically ventilated ICU patients. The antimicrobial activity of sputum samples was tested against Streptococcus pneumoniae, Staphylococcus aureus and Streptococcus anginosus. Here we show that sputa collected from different patients presented a high degree of variation in antimicrobial activity, which can be partially attributed to antibiotic therapy. The sputum microbiome, although potentially capable of producing antimicrobial agents, seemed to contribute in a minor way, if any, to the antimicrobial activity of sputum. Remarkably, despite its potentially protective effect, the level of antimicrobial activity in the investigated sputa correlated inversely with patient outcome, most likely because disease severity outweighed the beneficial antimicrobial activities.
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Affiliation(s)
- Jolien Seinen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University of Greifswald, Greifswald, Germany
| | - Willem Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Solomon A Mekonnen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University Medicine of Greifswald, Greifswald, Germany
| | - Paola Lisotto
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hermie J M Harmsen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alewijn Ott
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Medical Microbiology, Certe, Groningen, The Netherlands
| | - Daniel Schultz
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Michael Lalk
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Stefan Oswald
- Department of Clinical Pharmacology, University Medicine of Greifswald, Greifswald, Germany
| | - Sven Hammerschmidt
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University of Greifswald, Greifswald, Germany
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Heuker M, Koser U, Ott A, Karrenbeld A, van Dijl JM, van Dam GM, de Smet AMGA, van Oosten M. Yeast Infections after Esophagectomy: A Retrospective Analysis. Sci Rep 2020; 10:4343. [PMID: 32152398 PMCID: PMC7062806 DOI: 10.1038/s41598-020-61113-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 02/06/2020] [Indexed: 12/03/2022] Open
Abstract
Esophageal malignancy is a disease with poor prognosis. Curative therapy incorporates surgery and is burdensome with high rates of infection morbidity and mortality. The role of yeast as causative organisms of post-esophagectomy infections is poorly defined. Consequently, the benefits of specific antifungal prophylactic therapy in improving patient outcome are unclear. Therefore, this study aimed at investigating the incidence of yeast infections at the University Medical Center Groningen among 565 post-esophagectomy patients between 1991 and 2017. The results show that 7.3% of the patients developed a yeast infection after esophageal resection with significantly increased incidence among patients suffering from diabetes mellitus. For patients with yeast infections, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, more frequent intensive care unit readmissions, prolonged hospital stays and higher mortality rates were observed. One-year survival was significantly lower for patients with a yeast infection, as well as diabetes mellitus and yeast-positive pleural effusion. We conclude that the incidence of yeast infections following esophagectomy is considerable, and that patients with diabetes mellitus are at increased risk. Furthermore, yeast infections are associated with higher complication rates and mortality. These observations encourage further prospective investigations on the possible benefits of antifungal prophylactic therapy for esophagectomy patients.
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Affiliation(s)
- Marjolein Heuker
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Usma Koser
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Alewijn Ott
- Department of Medical Microbiology, Certe, PO Box 909, 9700 AX, Groningen, The Netherlands
| | - Arend Karrenbeld
- Department of Pathology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Gooitzen M van Dam
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
- Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Marleen van Oosten
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, The Netherlands.
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4
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Aardema H, Lisotto P, Kurilshikov A, Diepeveen JRJ, Friedrich AW, Sinha B, de Smet AMGA, Harmsen HJM. Marked Changes in Gut Microbiota in Cardio-Surgical Intensive Care Patients: A Longitudinal Cohort Study. Front Cell Infect Microbiol 2020; 9:467. [PMID: 32010644 PMCID: PMC6974539 DOI: 10.3389/fcimb.2019.00467] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Virtually no studies on the dynamics of the intestinal microbiota in patients admitted to the intensive care unit (ICU) are published, despite the increasingly recognized important role of microbiota on human physiology. Critical care patients undergo treatments that are known to influence the microbiota. However, dynamics and extent of such changes are not yet fully understood. To address this topic, we analyzed the microbiota before, during and after planned major cardio surgery that, for the first time, allowed us to follow the microbial dynamics of critical care patients. In this prospective, observational, longitudinal, single center study, we analyzed the fecal microbiota using 16S rRNA gene sequencing. Results: Samples of 97 patients admitted between April 2015 and November 2016 were included. In 32 patients, data of all three time points (before, during and after admission) were available for analysis. We found a large intra-individual variation in composition of gut microbiota. During admission, a significant change in microbial composition occurred in most patients, with a significant increase in pathobionts combined with a decrease in strictly anaerobic gut bacteria, typically beneficial for health. A lower bacterial diversity during admission was associated with longer hospitalization. In most patients analyzed at all three time points, the change in microbiota during hospital stay reverted to the original composition post-discharge. Conclusions: Our study shows that, even with a short ICU stay, patients present a significant change in microbial composition shortly after admission. The unique longitudinal setup of this study displayed a restoration of the microbiota in most patients to baseline composition post-discharge, which demonstrated its great restorative capacity. A relative decrease in benign or even beneficial bacteria and increase of pathobionts shifts the microbial balance in the gut, which could have clinical relevance. In future studies, the microbiota of ICU patients should be considered a good target for optimisation.
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Affiliation(s)
- Heleen Aardema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Paola Lisotto
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Alexander Kurilshikov
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Janneke R J Diepeveen
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Alex W Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Hermie J M Harmsen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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5
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van Hout D, Plantinga NL, Bruijning-Verhagen PC, Oostdijk EAN, de Smet AMGA, de Wit GA, Bonten MJM, van Werkhoven CH. Cost-effectiveness of selective digestive decontamination (SDD) versus selective oropharyngeal decontamination (SOD) in intensive care units with low levels of antimicrobial resistance: an individual patient data meta-analysis. BMJ Open 2019; 9:e028876. [PMID: 31494605 PMCID: PMC6731916 DOI: 10.1136/bmjopen-2018-028876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of selective digestive decontamination (SDD) as compared to selective oropharyngeal decontamination (SOD) in intensive care units (ICUs) with low levels of antimicrobial resistance. DESIGN Post-hoc analysis of a previously performed individual patient data meta-analysis of two cluster-randomised cross-over trials. SETTING 24 ICUs in the Netherlands. PARTICIPANTS 12 952 ICU patients who were treated with ≥1 dose of SDD (n=6720) or SOD (n=6232). INTERVENTIONS SDD versus SOD. PRIMARY AND SECONDARY OUTCOME MEASURES The incremental cost-effectiveness ratio (ICER; ie, costs to prevent one in-hospital death) was calculated by comparing differences in direct healthcare costs and in-hospital mortality of patients treated with SDD versus SOD. A willingness-to-pay curve was plotted to reflect the probability of cost-effectiveness of SDD for a range of different values of maximum costs per prevented in-hospital death. RESULTS The ICER resulting from the fixed-effect meta-analysis, adjusted for clustering and differences in baseline characteristics, showed that SDD significantly reduced in-hospital mortality (adjusted absolute risk reduction 0.0195, 95% CI 0.0050 to 0.0338) with no difference in costs (adjusted cost difference €62 in favour of SDD, 95% CI -€1079 to €935). Thus, SDD yielded significantly lower in-hospital mortality and comparable costs as compared with SOD. At a willingness-to-pay value of €33 633 per one prevented in-hospital death, SDD had a probability of 90.0% to be cost-effective as compared with SOD. CONCLUSION In Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD. These data support the implementation of SDD in settings with low levels of antimicrobial resistance.
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Affiliation(s)
- Denise van Hout
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
| | - Nienke L Plantinga
- University Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Patricia C Bruijning-Verhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
- Center for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Evelien A N Oostdijk
- University Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Marie G A de Smet
- University Utrecht, Utrecht, The Netherlands
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Marc J M Bonten
- University Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Cornelis H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- University Utrecht, Utrecht, The Netherlands
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de Lange DW, Brinkman S, Flaatten H, Boumendil A, Morandi A, Andersen FH, Artigas A, Bertolini G, Cecconi M, Christensen S, Faraldi L, Fjølner J, Jung C, Marsh B, Moreno R, Oeyen S, Öhman CA, Bollen Pinto B, de Smet AMGA, Soliman IW, Szczeklik W, Valentin A, Watson X, Zafeiridis T, Guidet B. Cumulative Prognostic Score Predicting Mortality in Patients Older Than 80 Years Admitted to the ICU. J Am Geriatr Soc 2019; 67:1263-1267. [PMID: 30977911 PMCID: PMC6850576 DOI: 10.1111/jgs.15888] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To develop a scoring system model that predicts mortality within 30 days of admission of patients older than 80 years admitted to intensive care units (ICUs). DESIGN Prospective cohort study. SETTING A total of 306 ICUs from 24 European countries. PARTICIPANTS Older adults admitted to European ICUs (N = 3730; median age = 84 years [interquartile range = 81‐87 y]; 51.8% male). MEASUREMENTS Overall, 24 variables available during ICU admission were included as potential predictive variables. Multivariable logistic regression was used to identify independent predictors of 30‐day mortality. Model sensitivity, specificity, and accuracy were evaluated with receiver operating characteristic curves. RESULTS The 30‐day‐mortality was 1562 (41.9%). In multivariable analysis, these variables were selected as independent predictors of mortality: age, sex, ICU admission diagnosis, Clinical Frailty Scale, Sequential Organ Failure Score, invasive mechanical ventilation, and renal replacement therapy. The discrimination, accuracy, and calibration of the model were good: the area under the curve for a score of 10 or higher was .80, and the Brier score was .18. At a cut point of 10 or higher (75% of all patients), the model predicts 30‐day mortality in 91.1% of all patients who die. CONCLUSION A predictive model of cumulative events predicts 30‐day mortality in patients older than 80 years admitted to ICUs. Future studies should include other potential predictor variables including functional status, presence of advance care plans, and assessment of each patient's decision‐making capacity.
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Affiliation(s)
- Dylan W de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Sylvia Brinkman
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Ariane Boumendil
- Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France
| | - Alessandro Morandi
- Department of Rehabilitation, Hospital Ancelle di Cremona, Cremona, Italy.,Geriatric Research Group, Brescia, Italy
| | - Finn H Andersen
- Department of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway.,Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway
| | - Antonio Artigas
- Department of Intensive Care Medecine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - Guido Bertolini
- Laboratorio di Epidemiologia Clinica, Centro di Coordinamento GiViTI Dipartimento di Salute Pubblica, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Ranica (Bergamo), Italy
| | | | - Steffen Christensen
- Department of Anaesthesia and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | | | - Jesper Fjølner
- Department of Anaesthesia and Intensive Care Medicine, Aarhus University Hospital, Denmark
| | - Christian Jung
- Department of Cardiology, Pulmonology and Angiology, University Hospital, Düsseldorf, Germany
| | - Brian Marsh
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Rui Moreno
- Unidade de Cuidados Intensivos Neurocriticos e Trauma, Hospital de São José, Centro Hospitalar Universitário de Lisboa Central Nova Medical School, Lisbon, Portugal
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | | | | | - Anne Marie G A de Smet
- Department of Critical Care, University Medical Center Groningen, University Groningen, Groningen, The Netherlands
| | - Ivo W Soliman
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Wojciech Szczeklik
- Intensive Care and Perioperative Medicine Division, Jagiellonian University Medical College, Kraków, Poland
| | | | - Ximena Watson
- St George's University Hospital, London, United Kingdom
| | | | - Bertrand Guidet
- Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France.,ICU, hospital Saint Antoine, APHP, Paris, France
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7
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Mulder T, Kluytmans-van den Bergh MFQ, de Smet AMGA, van 't Veer NE, Roos D, Nikolakopoulos S, Bonten MJM, Kluytmans JAJW. Prevention of severe infectious complications after colorectal surgery using preoperative orally administered antibiotic prophylaxis (PreCaution): study protocol for a randomized controlled trial. Trials 2018; 19:51. [PMID: 29351789 PMCID: PMC5775605 DOI: 10.1186/s13063-018-2439-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 01/02/2018] [Indexed: 01/29/2023] Open
Abstract
Background Colorectal surgery is frequently complicated by surgical site infections (SSIs). The most important consequences of SSIs are prolonged hospitalization, an increased risk of surgical reintervention and an increase in mortality. Perioperative intravenously administered antibiotic prophylaxis is the standard of care to reduce the risk of SSIs. In the last few decades, preoperative orally administered antibiotics have been suggested as additional prophylaxis to further reduce the risk of infection, but are currently not part of routine practice in most hospitals. The objective of this study is to evaluate the efficacy of a preoperative orally administered antibiotic prophylaxis (Pre-OP) in addition to intravenously administered perioperative antibiotic prophylaxis to reduce the incidence of deep SSIs and/or mortality after elective colorectal surgery. Methods/design The PreCaution trial is designed as a multicenter, double-blind, randomized, placebo-controlled clinical trial that will be carried out in The Netherlands. Adult patients who are scheduled for elective colorectal surgery are eligible to participate. In total, 966 patients will be randomized to receive the study medication. This will either be Pre-OP, a solution that consists of tobramycin and colistin sulphate, or a placebo solution. The study medication will be administered four times daily during the 3 days prior to surgery. Perioperative intravenously administered antibiotic prophylaxis will be administered to all patients in accordance with national infection control guidelines. The primary endpoint of the study is the cumulative incidence of deep SSIs and/or mortality within 30 days after surgery. Secondary endpoints include both infectious and non-infectious complications of colorectal surgery, and will be evaluated 30 days and/or 6 months after surgery. Discussion To date, conclusive evidence on the added value of preoperative orally administered antibiotic prophylaxis in colorectal surgery is lacking. The PreCaution trial should determine the effects of orally administered antibiotics in preventing infectious complications in elective colorectal surgery. Trial registration Netherlands Trial Register, ID: NTR6113. Registered on 11 October 2016; EudraCT 2015-005736-17. Electronic supplementary material The online version of this article (doi:10.1186/s13063-018-2439-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tessa Mulder
- Division Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Marjolein F Q Kluytmans-van den Bergh
- Division Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Amphia Academy Infectious Disease Foundation, Amphia Hospital, Breda, The Netherlands.,Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nils E van 't Veer
- Department of Clinical Pharmacy, Amphia Hospital, Breda, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Stavros Nikolakopoulos
- Division Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marc J M Bonten
- Division Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan A J W Kluytmans
- Division Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands
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Hiemstra B, Eck RJ, Koster G, Wetterslev J, Perner A, Pettilä V, Snieder H, Hummel YM, Wiersema R, de Smet AMGA, Keus F, van der Horst ICC. Clinical examination, critical care ultrasonography and outcomes in the critically ill: cohort profile of the Simple Intensive Care Studies-I. BMJ Open 2017; 7:e017170. [PMID: 28963297 PMCID: PMC5623575 DOI: 10.1136/bmjopen-2017-017170] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE In the Simple Intensive Care Studies-I (SICS-I), we aim to unravel the value of clinical and haemodynamic variables obtained by physical examination and critical care ultrasound (CCUS) that currently guide daily practice in critically ill patients. We intend to (1) measure all available clinical and haemodynamic variables, (2) train novices in obtaining values for advanced variables based on CCUS in the intensive care unit (ICU) and (3) create an infrastructure for a registry with the flexibility of temporarily incorporating specific (haemodynamic) research questions and variables. The overall purpose is to investigate the diagnostic and prognostic value of clinical and haemodynamic variables. PARTICIPANTS The SICS-I includes all patients acutely admitted to the ICU of a tertiary teaching hospital in the Netherlands with an ICU stay expected to last beyond 24 hours. Inclusion started on 27 March 2015. FINDINGS TO DATE On 31 December 2016, 791 eligible patients fulfilled our inclusion criteria of whom 704 were included. So far 11 substudies with additional variables have been designed, of which six were feasible to implement in the basic study, and two are planned and awaiting initiation. All researchers received focused training for obtaining specific CCUS images. An independent Core laboratory judged that 632 patients had CCUS images of sufficient quality. FUTURE PLANS We intend to optimise the set of variables for assessment of the haemodynamic status of the critically ill patient used for guiding diagnostics, prognosis and interventions. Repeated evaluations of these sets of variables are needed for continuous improvement of the diagnostic and prognostic models. Future plans include: (1) more advanced imaging; (2) repeated clinical and haemodynamic measurements; (3) expansion of the registry to other departments or centres; and (4) exploring possibilities of integration of a randomised clinical trial superimposed on the registry. STUDY REGISTRATION NUMBER NCT02912624; Pre-results.
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Affiliation(s)
- Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yoran M Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Oostdijk EAN, Kesecioglu J, Schultz MJ, Visser CE, de Jonge E, van Essen EHR, Bernards AT, Purmer I, Brimicombe R, Bergmans D, van Tiel F, Bosch FH, Mascini E, van Griethuysen A, Bindels A, Jansz A, van Steveninck FAL, van der Zwet WC, Fijen JW, Thijsen S, de Jong R, Oudbier J, Raben A, van der Vorm E, Koeman M, Rothbarth P, Rijkeboer A, Gruteke P, Hart H, Peerbooms P, Winsser LJ, van Elsacker-Niele AMW, Demmendaal K, Brandenburg A, de Smet AMGA, Bonten MJM. Notice of Retraction and Replacement: Oostdijk et al. Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial. JAMA. 2014;312(14):1429-1437. JAMA 2017; 317:1583-1584. [PMID: 28418487 DOI: 10.1001/jama.2017.1282] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht2Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam
| | - Caroline E Visser
- Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden
| | - Einar H R van Essen
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden
| | | | - Ilse Purmer
- Department of Intensive Care, HagaZiekenhuis, The Hague
| | | | - Dennis Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht
| | - Frank van Tiel
- Department of Medical Microbiology, Maastricht University Medical Centre+, Maastricht
| | - Frank H Bosch
- Department of Intensive Care, Rijnstate Hospital, Arnhem
| | - Ellen Mascini
- Laboratory for Medical Microbiology and Immunology, Rijnstate Hospital, Arnhem
| | | | - Alexander Bindels
- Department of Intensive Care Medicine, Catharina Hospital, Eindhoven
| | - Arjan Jansz
- Laboratory for Medical Microbiology, Laboratories for Pathology and Medical Microbiology, Catharina Hospital, Eindhoven
| | | | - Wil C van der Zwet
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht16Department of Medical Microbiology, Deventer Hospital, Deventer
| | | | - Steven Thijsen
- Department of Medical Microbiology, Diakonessenhuis Utrecht, Utrecht
| | - Remko de Jong
- Department of Intensive Care, BovenIJ Hospital, Amsterdam
| | - Joke Oudbier
- Department of Medical Microbiology, Zaans Medical Center, Zaandam
| | - Adrienne Raben
- Department of Intensive Care, Groene Hart Hospital, Gouda
| | | | | | - Philip Rothbarth
- Department of Medical Microbiology, Rijnland Hospital, Leiderdorp
| | | | - Paul Gruteke
- Department of Medical Microbiology, Flevo Hospital, Almere
| | - Helga Hart
- Department of Intensive Care, Sint Lucas Andreas Hospital, Amsterdam
| | - Paul Peerbooms
- Department of Medical Microbiology, Sint Lucas Andreas Hospital, Amsterdam
| | - Lex J Winsser
- Department of Intensive Care, Antonius Hospital, Sneek
| | | | | | | | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht32Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Oude Lansink-Hartgring A, Hessels L, Weigel J, de Smet AMGA, Gommers D, Panday PVN, Hoorn EJ, Nijsten MW. Long-term changes in dysnatremia incidence in the ICU: a shift from hyponatremia to hypernatremia. Ann Intensive Care 2016; 6:22. [PMID: 26983857 PMCID: PMC4794471 DOI: 10.1186/s13613-016-0124-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 03/02/2016] [Indexed: 12/18/2022] Open
Abstract
Background Dysnatremia is associated with adverse outcome in critically ill patients. Changes in patients or treatment strategies may have affected the incidence of dysnatremia over time. We investigated long-term changes in the incidence of dysnatremia and analyzed its association with mortality. Methods Over a 21-year period (1992–2012), all serum sodium measurements were analyzed retrospectively in two university hospital ICUs, up to day 28 of ICU admission for the presence of dysnatremia. The study period was divided into five periods. All serum sodium measurements were collected from the electronic databases of both ICUs. Serum sodium was measured at the clinical chemistry departments using standard methods. All sodium measurements were categorized in the following categories: <120, 120–124, 125–129, 130–134, 135–139, 140–145, 146–150, 151–155, 156–160, >160 mmol/L. Mortality was determined at 90 days after ICU admission. Results In 80,571 ICU patients, 913,272 serum sodium measurements were analyzed. A striking shift in the pattern of ICU-acquired dysnatremias was observed: The incidence of hyponatremia almost halved (47–25 %, p < 0.001), whereas the incidence of hypernatremia nearly doubled (13–24 %, p < 0.001). Most hypernatremias developed after ICU admission, and the incidence of severe hypernatremia (sodium > 155 mmol/L) increased dramatically over the years. On ICU day 10 this incidence was 0.7 % in the 1992–1996 period, compared to 6.3 % in the 2009–2012 period (p < 0.001). More severe dysnatremia was associated with significantly higher mortality throughout the 21-year study period (p < 0.001). Conclusions In two large Dutch cohorts, we observed a marked shift in the incidence of dysnatremia from hyponatremia to hypernatremia over two decades. As hypernatremia was mostly ICU acquired, this strongly suggests changes in treatment as underlying causes. This shift may be related to the increased use of sodium-containing infusions, diuretics, and hydrocortisone. As ICU-acquired hypernatremia is largely iatrogenic, it should be—to an important extent—preventable, and its incidence may be considered as an indicator of quality of care. Strategies to prevent hypernatremia deserve more emphasis; therefore, we recommend that further study should be focused on interventions to prevent the occurrence of dysnatremias during ICU stay. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0124-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annemieke Oude Lansink-Hartgring
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Lara Hessels
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Joachim Weigel
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
| | - Prashant V Nannan Panday
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Maarten W Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
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de Jong E, van Oers JA, Beishuizen A, Vos P, Vermeijden WJ, Haas LE, Loef BG, Dormans T, van Melsen GC, Kluiters YC, Kemperman H, van den Elsen MJ, Schouten JA, Streefkerk JO, Krabbe HG, Kieft H, Kluge GH, van Dam VC, van Pelt J, Bormans L, Otten MB, Reidinga AC, Endeman H, Twisk JW, van de Garde EMW, de Smet AMGA, Kesecioglu J, Girbes AR, Nijsten MW, de Lange DW. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis 2016; 16:819-827. [PMID: 26947523 DOI: 10.1016/s1473-3099(16)00053-0] [Citation(s) in RCA: 509] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 01/15/2016] [Accepted: 01/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND In critically ill patients, antibiotic therapy is of great importance but long duration of treatment is associated with the development of antimicrobial resistance. Procalcitonin is a marker used to guide antibacterial therapy and reduce its duration, but data about safety of this reduction are scarce. We assessed the efficacy and safety of procalcitonin-guided antibiotic treatment in patients in intensive care units (ICUs) in a health-care system with a comparatively low use of antibiotics. METHODS We did a prospective, multicentre, randomised, controlled, open-label intervention trial in 15 hospitals in the Netherlands. Critically ill patients aged at least 18 years, admitted to the ICU, and who received their first dose of antibiotics no longer than 24 h before inclusion in the study for an assumed or proven infection were eligible to participate. Patients who received antibiotics for presumed infection were randomly assigned (1:1), using a computer-generated list, and stratified (according to treatment centre, whether infection was acquired before or during ICU stay, and dependent on severity of infection [ie, sepsis, severe sepsis, or septic shock]) to receive either procalcitonin-guided or standard-of-care antibiotic discontinuation. Both patients and investigators were aware of group assignment. In the procalcitonin-guided group, a non-binding advice to discontinue antibiotics was provided if procalcitonin concentration had decreased by 80% or more of its peak value or to 0·5 μg/L or lower. In the standard-of-care group, patients were treated according to local antibiotic protocols. Primary endpoints were antibiotic daily defined doses and duration of antibiotic treatment. All analyses were done by intention to treat. Mortality analyses were completed for all patients (intention to treat) and for patients in whom antibiotics were stopped while being on the ICU (per-protocol analysis). Safety endpoints were reinstitution of antibiotics and recurrent inflammation measured by C-reactive protein concentrations and they were measured in the population adhering to the stopping rules (per-protocol analysis). The study is registered with ClinicalTrials.gov, number NCT01139489, and was completed in August, 2014. FINDINGS Between Sept 18, 2009, and July 1, 2013, 1575 of the 4507 patients assessed for eligibility were randomly assigned to the procalcitonin-guided group (761) or to standard-of-care (785). In 538 patients (71%) in the procalcitonin-guided group antibiotics were discontinued in the ICU. Median consumption of antibiotics was 7·5 daily defined doses (IQR 4·0-12·7) in the procalcitonin-guided group versus 9·3 daily defined doses (5·0-16·6) in the standard-of-care group (between-group absolute difference 2·69, 95% CI 1·26-4·12, p<0·0001). Median duration of treatment was 5 days (3-9) in the procalcitonin-guided group and 7 days (4-11) in the standard-of-care group (between-group absolute difference 1·22, 0·65-1·78, p<0·0001). Mortality at 28 days was 149 (20%) of 761 patients in the procalcitonin-guided group and 196 (25%) of 785 patients in the standard-of-care group (between-group absolute difference 5·4%, 95% CI 1·2-9·5, p=0·0122) according to the intention-to-treat analysis, and 107 (20%) of 538 patients in the procalcitonin-guided group versus 121 (27%) of 457 patients in the standard-of-care group (between-group absolute difference 6·6%, 1·3-11·9, p=0·0154) in the per-protocol analysis. 1-year mortality in the per-protocol analysis was 191 (36%) of 538 patients in the procalcitonin-guided and 196 (43%) of 457 patients in the standard-of-care groups (between-group absolute difference 7·4, 1·3-13·8, p=0·0188). INTERPRETATION Procalcitonin guidance stimulates reduction of duration of treatment and daily defined doses in critically ill patients with a presumed bacterial infection. This reduction was associated with a significant decrease in mortality. Procalcitonin concentrations might help physicians in deciding whether or not the presumed infection is truly bacterial, leading to more adequate diagnosis and treatment, the cornerstones of antibiotic stewardship. FUNDING Thermo Fisher Scientific.
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Affiliation(s)
| | | | - Albertus Beishuizen
- VU University Medical Center, Amsterdam, Netherlands; Medisch Spectrum Twente, Enschede, Netherlands
| | - Piet Vos
- Elisabeth Tweesteden Hospital, Tilburg, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joost van Pelt
- University Medical Centre, University of Groningen, Groningen, Netherlands
| | | | | | | | | | - Jos W Twisk
- VU University Medical Center, Amsterdam, Netherlands
| | | | | | | | | | - Maarten W Nijsten
- University Medical Centre, University of Groningen, Groningen, Netherlands
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12
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Hoekstra M, Hessels L, Rienstra M, Yeh L, Lansink AO, Vogelzang M, van der Horst ICC, van der Maaten JMAA, Mariani MA, de Smet AMGA, Struys MMRF, Zijlstra F, Nijsten MW. Computer-guided normal-low versus normal-high potassium control after cardiac surgery: No impact on atrial fibrillation or atrial flutter. Am Heart J 2016; 172:45-52. [PMID: 26856215 DOI: 10.1016/j.ahj.2015.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 10/29/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study was designed to determine the effect of 2 different potassium regulation strategies with different targets (within the reference range) on atrial fibrillation (AF) or atrial flutter (AFL) in a cohort of intensive care unit patients after cardiac surgery. METHODS The GRIP-COMPASS study was a prospective double-blinded interventional study in 910 patients after cardiac surgery (coronary artery bypass grafting and/or valvular surgery). Patients were assigned to either the normal-low potassium target (nLP group, 4.0 mmol/L) or the normal-high potassium target (nHP group, 4.5 mmol/L) in alternating blocks of 50 patients. Potassium levels were regulated using a validated computer-assisted potassium replacement protocol (GRIP-II). The primary end point was the incidence of AF/AFL on a 12-lead electrocardiogram during the first postoperative week. RESULTS Of the 910 patients, 447 were assigned to the nLP group; and 463, to the nHP group, with no baseline differences between the 2 groups. The mean daily administered dose of potassium was 30 ± 23 mmol (nLP) versus 52 ± 27 mmol (nHP) (P < .001), which resulted in mean intensive care unit potassium concentration of 4.22 ± 0.36 mmol/L and 4.33 ± 0.34 mmol/L, respectively (P < .001). The incidence of AF/AFL after cardiac surgery did not differ: 38% in the nLP group and 41% in the nHP group. Also in several subgroups (eg, patients not known with prior AF/AFL or with valve surgery), there were no differences. CONCLUSIONS There were no differences in incidence of AF/AFL with 2 potassium regulation strategies with different potassium targets and different amounts of potassium administered in patients after cardiac surgery.
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Affiliation(s)
- Miriam Hoekstra
- Department of Anesthesiology of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Lara Hessels
- Department of Critical Care of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Michiel Rienstra
- Department of Cardiology of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Lu Yeh
- Department of Anesthesiology of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Annemieke Oude Lansink
- Department of Critical Care of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Mathijs Vogelzang
- Department of Critical Care of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Iwan C C van der Horst
- Department of Critical Care of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Joost M A A van der Maaten
- Department of Anesthesiology of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Critical Care of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Anne Marie G A de Smet
- Department of Critical Care of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Michel M R F Struys
- Department of Anesthesiology of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Felix Zijlstra
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Maarten W Nijsten
- Department of Critical Care of the University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Wittekamp BHJ, Oostdijk EAN, de Smet AMGA, Bonten MJM. Colistin and tobramycin resistance during long- term use of selective decontamination strategies in the intensive care unit: a post hoc analysis. Crit Care 2015; 19:113. [PMID: 25880968 PMCID: PMC4373110 DOI: 10.1186/s13054-015-0838-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 02/23/2015] [Indexed: 11/10/2022]
Abstract
Introduction Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) have been shown to improve intensive care unit (ICU) patients’ outcomes. The aim of this study was to determine the effects of long-term use of SDD and SOD on colistin and tobramycin resistance among gram-negative bacteria. Methods We performed a post hoc analysis of two consecutive multicentre cluster-randomised trials with crossover of interventions. SDD and SOD were alternately but continuously used during 7 years in five Dutch ICUs participating in two consecutive cluster-randomised trials. In both trials, to measure colistin and tobramycin resistance among gram-negative bacteria, rectal and respiratory samples were obtained monthly from all patients present in the ICU. Results The prevalence of tobramycin resistance in respiratory and rectal samples decreased significantly during long-term use of SOD and SDD. (rectal samples risk ratio (RR) 0.35 (0.23 to 0.53); respiratory samples RR 0.48 (0.32 to 0.73), SDD compared to standard care). Colistin resistance in rectal and respiratory samples did not change (rectal samples RR 0.63 (0.29 to 1.38); respiratory samples RR 1.26 (0.35 to 4.57), SDD compared to standard care). Conclusions In this study, in a setting with low antimicrobial resistance rates, the prevalence of resistance against colistin and tobramycin among gram-negative isolates did not increase during a mean of 7 years of SDD or SOD use. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0838-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bastiaan H J Wittekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Anne Marie G A de Smet
- CAPE, Critical Care, Anesthesiology, Peri-operative and Emergency Medicine Research Program, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. .,Department of Medical Microbiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Oostdijk EAN, Kesecioglu J, Schultz MJ, Visser CE, de Jonge E, van Essen EHR, Bernards AT, Purmer I, Brimicombe R, Bergmans D, van Tiel F, Bosch FH, Mascini E, van Griethuysen A, Bindels A, Jansz A, van Steveninck FAL, van der Zwet WC, Fijen JW, Thijsen S, de Jong R, Oudbier J, Raben A, van der Vorm E, Koeman M, Rothbarth P, Rijkeboer A, Gruteke P, Hart-Sweet H, Peerbooms P, Winsser LJ, van Elsacker-Niele AMW, Demmendaal K, Brandenburg A, de Smet AMGA, Bonten MJM. Effects of decontamination of the oropharynx and intestinal tract on antibiotic resistance in ICUs: a randomized clinical trial. JAMA 2014; 312:1429-1437. [PMID: 25271544 DOI: 10.1001/jama.2014.7247] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) are prophylactic antibiotic regimens used in intensive care units (ICUs) and associated with improved patient outcome. Controversy exists regarding the relative effects of both measures on patient outcome and antibiotic resistance. OBJECTIVE To compare the effects of SDD and SOD, applied as unit-wide interventions, on antibiotic resistance and patient outcome. DESIGN, SETTING, AND PARTICIPANTS Pragmatic, cluster randomized crossover trial comparing 12 months of SOD with 12 months of SDD in 16 Dutch ICUs between August 1, 2009, and February 1, 2013. Patients with an expected length of ICU stay longer than 48 hours were eligible to receive the regimens, and 5881 and 6116 patients were included in the clinical outcome analysis for SOD and SDD, respectively. INTERVENTIONS Intensive care units were randomized to administer either SDD or SOD. MAIN OUTCOMES AND MEASURES Unit-wide prevalence of antibiotic-resistant gram-negative bacteria. Secondary outcomes were day-28 mortality, ICU-acquired bacteremia, and length of ICU stay. RESULTS In point-prevalence surveys, prevalences of antibiotic-resistant gram-negative bacteria in perianal swabs were significantly lower during SDD compared with SOD; for aminoglycoside resistance, average prevalence was 5.6% (95% CI, 4.6%-6.7%) during SDD and 11.8% (95% CI, 10.3%-13.2%) during SOD (P < .001). During both interventions the prevalence of rectal carriage of aminoglycoside-resistant gram-negative bacteria increased 7% per month (95% CI, 1%-13%) during SDD (P = .02) and 4% per month (95% CI, 0%-8%) during SOD (P = .046; P = .40 for difference). Day 28-mortality was 25.4% and 24.1% during SOD and SDD, respectively (adjusted odds ratio, 0.96 [95% CI, 0.88-1.06]; P = .42), and there were no statistically significant differences in other outcome parameters or between surgical and nonsurgical patients. Intensive care unit-acquired bacteremia occurred in 5.9% and 4.6% of the patients during SOD and SDD, respectively (odds ratio, 0.77 [95% CI, 0.65-0.91]; P = .002; number needed to treat, 77). CONCLUSIONS AND RELEVANCE Unit-wide application of SDD and SOD was associated with low levels of antibiotic resistance and no differences in day-28 mortality. Compared with SOD, SDD was associated with lower rectal carriage of antibiotic-resistant gram-negative bacteria and ICU-acquired bacteremia but a more pronounced gradual increase in aminoglycoside-resistant gram-negative bacteria. TRIAL REGISTRATION trialregister.nlIdentifier: NTR1780.
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Affiliation(s)
- Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht2Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam
| | - Caroline E Visser
- Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden
| | - Einar H R van Essen
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden
| | | | - Ilse Purmer
- Department of Intensive Care, HagaZiekenhuis, The Hague
| | | | - Dennis Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht
| | - Frank van Tiel
- Department of Medical Microbiology, Maastricht University Medical Centre+, Maastricht
| | - Frank H Bosch
- Department of Intensive Care, Rijnstate Hospital, Arnhem
| | - Ellen Mascini
- Laboratory for Medical Microbiology and Immunology, Rijnstate Hospital, Arnhem
| | | | - Alexander Bindels
- Department of Intensive Care Medicine, Catharina Hospital, Eindhoven
| | - Arjan Jansz
- Laboratory for Medical Microbiology, Laboratories for Pathology and Medical Microbiology, Catharina Hospital, Eindhoven
| | | | | | | | - Steven Thijsen
- Department of Medical Microbiology, Diakonessenhuis Utrecht, Utrecht
| | - Remko de Jong
- Department of Intensive Care, BovenIJ Hospital, Amsterdam
| | - Joke Oudbier
- Department of Medical Microbiology, Zaans Medical Center, Zaandam
| | - Adrienne Raben
- Department of Intensive Care, Groene Hart Hospital, Gouda
| | | | | | - Philip Rothbarth
- Department of Medical Microbiology, Rijnland Hospital, Leiderdorp
| | | | - Paul Gruteke
- Department of Medical Microbiology, Flevo Hospital, Almere
| | - Helga Hart-Sweet
- Department of Intensive Care, Sint Lucas Andreas Hospital, Amsterdam
| | - Paul Peerbooms
- Department of Medical Microbiology, Sint Lucas Andreas Hospital, Amsterdam
| | - Lex J Winsser
- Department of Intensive Care, Antonius Hospital, Sneek
| | | | | | | | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht32Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Oostdijk EAN, de Smet AMGA, Bonten MJM. Effects of decontamination of the digestive tract and oropharynx in intensive care unit patients on 1-year survival. Am J Respir Crit Care Med 2013; 188:117-20. [PMID: 23815730 DOI: 10.1164/rccm.201209-1733le] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Oostdijk EAN, de Wit GA, Bakker M, de Smet AMGA, Bonten MJM. Selective decontamination of the digestive tract and selective oropharyngeal decontamination in intensive care unit patients: a cost-effectiveness analysis. BMJ Open 2013; 3:bmjopen-2012-002529. [PMID: 23468472 PMCID: PMC3612803 DOI: 10.1136/bmjopen-2012-002529] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To determine costs and effects of selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) as compared with standard care (ie, no SDD/SOD (SC)) from a healthcare perspective in Dutch Intensive Care Units (ICUs). DESIGN A post hoc analysis of a previously performed cluster-randomised trial (NEJM 2009;360:20). SETTING 13 Dutch ICUs. PARTICIPANTS Patients with ICU-stay of >48 h that received SDD (n=2045), SOD (n=1904) or SC (n=1990). INTERVENTIONS SDD or SOD. PRIMARY AND SECONDARY OUTCOME MEASURES Effects were based on hospital survival, expressed as crude Life Years Gained (cLYG). The incremental cost-effectiveness ratio (ICER) was calculated, with corresponding cost acceptability curves. Sensitivity analyses were performed for discount rates, costs of SDD, SOD and mechanical ventilation. RESULTS Total costs per patient were €41 941 for SC (95% CI €40 184 to €43 698), €40 433 for SOD (95% CI €38 838 to €42 029) and €41 183 for SOD (95% CI €39 408 to €42 958). SOD and SDD resulted in crude LYG of +0.04 and +0.25, respectively, as compared with SC, implying that both SDD and SOD are dominant (ie, cheaper and more beneficial) over SC. In cost-effectiveness acceptability curves probabilities for cost-effectiveness, compared with standard care, ranged from 89% to 93% for SOD and from 63% to 72% for SDD, for acceptable costs for 1 LYG ranging from €0 to €20 000. Sensitivity analysis for mechanical ventilation and discount rates did not change interpretation. Yet, if costs of the topical component of SDD and SOD would increase 40-fold to €400/day and €40/day (maximum values based on free market prices in 2012), the estimated ICER as compared with SC for SDD would be €21 590 per LYG. SOD would remain cost-saving. CONCLUSIONS SDD and SOD were both effective and cost-saving in Dutch ICUs.
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Affiliation(s)
- Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Oostdijk EAN, Smits L, de Smet AMGA, Leverstein-van Hall MA, Kesecioglu J, Bonten MJM. Colistin resistance in gram-negative bacteria during prophylactic topical colistin use in intensive care units. Intensive Care Med 2012. [PMID: 23203301 DOI: 10.1007/s00134-012-2761-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Topical use of colistin as part of selective digestive decontamination (SDD) and selective oropharyngeal decontamination (SOD) has been associated with improved patient outcome in intensive care units (ICU), yet little is known about the risks of colistin resistance. We quantified effects of selective decontamination on acquisition of colistin-resistant gram-negative bacteria (GNB) using data from a cluster-randomized study and a single-centre cohort. METHODS Acquisition of colistin-resistant GNB and conversion from susceptible to resistance in GNB was determined in respiratory samples [from patients receiving SDD (n = 455), SOD (n = 476), or standard care (SC) (n = 315)], and in rectal swabs from 1,840 SDD-patients. Genotyping of converting isolates was performed where possible. RESULTS The respiratory tract acquisition rates of colistin-resistant GNB were comparable during SDD, SOD, and SC and ranged from 0.7 to 1.1/1,000 patient-days at risk. Rectal acquisition rates during SDD were <3.3/1,000 days at risk. In patients with respiratory tract GNB carriage, conversion rates were 3.6 and 1.1/1,000 patient-days at risk during SDD and SC, respectively, (p > 0.05). In patients with rectal GNB carriage conversion rates during SDD were 5.4 and 3.2/1,000 days at risk and 15.5 and 12.6/1,000 days at risk when colonized with tobramycin-resistant GNB. CONCLUSIONS Acquisition rates with colistin-resistant GNB in the respiratory tract were low and comparable with and without topical use of colistin. Rates of acquisition of colistin-resistant GNB during SDD were--in ICUs with low endemicity of antibiotic resistance--<2.5/1,000 days at risk, but were fivefold higher during persistent GNB colonization and 15-fold higher during carriage with tobramycin-resistant GNB.
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Affiliation(s)
- Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, G04.614, PO box 85500, 3508 GA, Utrecht, The Netherlands.
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Oostdijk EAN, de Smet AMGA, Blok HEM, Thieme Groen ES, van Asselt GJ, Benus RFJ, Bernards SAT, Frénay IHME, Jansz AR, de Jongh BM, Kaan JA, Leverstein-van Hall MA, Mascini EM, Pauw W, Sturm PDJ, Thijsen SFT, Kluytmans JAJW, Bonten MJM. Ecological effects of selective decontamination on resistant gram-negative bacterial colonization. Am J Respir Crit Care Med 2009; 181:452-7. [PMID: 19965807 DOI: 10.1164/rccm.200908-1210oc] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) eradicate gram-negative bacteria (GNB) from the intestinal and respiratory tract in intensive care unit (ICU) patients, but their effect on antibiotic resistance remains controversial. OBJECTIVES We quantified the effects of SDD and SOD on bacterial ecology in 13 ICUs that participated in a study, in which SDD, SOD, or standard care was used during consecutive periods of 6 months (de Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, van der Hoeven JG, Pickkers P, Bogaers-Hofman D, van der Meer NJ, et al. N Engl J Med 2009;360:20-31). METHODS Point prevalence surveys of rectal and respiratory samples were performed once monthly in all ICU patients (receiving or not receiving SOD/SDD). Effects of SDD on rectal, and of SDD/SOD on respiratory tract, carriage of GNB were determined by comparing results from consecutive point prevalence surveys during intervention (6 mo for SDD and 12 mo for SDD/SOD) with consecutive point prevalence data in the pre- and postintervention periods. MEASUREMENTS AND MAIN RESULTS During SDD, average proportions of patients with intestinal colonization with GNB resistant to either ceftazidime, tobramycin, or ciprofloxacin were 5, 7, and 7%, and increased to 15, 13, and 13% postintervention (P < 0.05). During SDD/SOD resistance levels in the respiratory tract were not more than 6% for all three antibiotics but increased gradually (for ceftazidime; P < 0.05 for trend) during intervention and to levels of 10% or more for all three antibiotics postintervention (P < 0.05). CONCLUSIONS SOD and SDD have marked effects on the bacterial ecology in an ICU, with rising ceftazidime resistance prevalence rates in the respiratory tract during intervention and a considerable rebound effect of ceftazidime resistance in the intestinal tract after discontinuation of SDD.
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Affiliation(s)
- Evelien A N Oostdijk
- Department of Medical Microbiology, University Medical Center Utrecht, GA Utrecht, The Netherlands.
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de Smet AMGA, Hopmans TEM, Minderhoud ALC, Blok HEM, Gossink-Franssen A, Bernards AT, Bonten MJM. Decontamination of the digestive tract and oropharynx: hospital acquired infections after discharge from the intensive care unit. Intensive Care Med 2009; 35:1609-13. [PMID: 19551370 PMCID: PMC2726913 DOI: 10.1007/s00134-009-1554-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 06/01/2009] [Indexed: 12/02/2022]
Abstract
Objective To determine the incidence rates of hospital acquired infections (HAI) during the first 14 days after ICU discharge after treatment during ICU-stay with Selective Decontamination of the Digestive tract (SDD), Selective Oropharyngeal Decontamination (SOD) or Standard Care (SC). Design Prospective observational study. Setting ICUs in two tertiary care hospitals. Patients Patients discharged from the ICU to the ward. Interventions None. Measurements and results Post-ICU incidences of HAI per 1,000 days at risk were 11.2, 12.9 and 8.3 for patients that had received SDD (n = 296), SOD (n = 286) or SC (n = 289) respectively in ICU, yielding relative risks, as compared to SC, of 1.49 (CI95 0.9–2.47) for SOD and 1.44 (CI95 0.87–2.39) for SDD. Incidences of surgical site infections (per 100 surgical procedures) were 4 after SC and 11.8 and 8 after SOD and SDD (p = 0.04). Among patients that succumbed in the hospital after ICU-stay (n = 58) eight (14%) had developed HAI after ICU discharge; 3 of 21 after SDD, 3 of 15 after SOD and 2 of 22 after SC. Conclusions Incidences of HAI in general wards tended to be higher in patients that had received either SDD or SOD during ICU-stay, but it seems unlikely that these infections have an effect on hospital mortality rates.
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Affiliation(s)
- Anne Marie G A de Smet
- Division of Perioperative and Emergency Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Lo-Ten-Foe JR, de Smet AMGA, Diederen BMW, Kluytmans JAJW, van Keulen PHJ. Comparative evaluation of the VITEK 2, disk diffusion, etest, broth microdilution, and agar dilution susceptibility testing methods for colistin in clinical isolates, including heteroresistant Enterobacter cloacae and Acinetobacter baumannii strains. Antimicrob Agents Chemother 2007; 51:3726-30. [PMID: 17646414 PMCID: PMC2043258 DOI: 10.1128/aac.01406-06] [Citation(s) in RCA: 155] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Increasing antibiotic resistance in gram-negative bacteria has recently renewed interest in colistin as a therapeutic option. The increasing use of colistin necessitates the availability of rapid and reliable methods for colistin susceptibility testing. We compared seven methods of colistin susceptibility testing (disk diffusion, agar dilution on Mueller-Hinton [MH] and Isosensitest agar, Etest on MH and Isosensitest agar, broth microdilution, and VITEK 2) on 102 clinical isolates collected from patient materials during a selective digestive decontamination or selective oral decontamination trial in an intensive-care unit. Disk diffusion is an unreliable method to measure susceptibility to colistin. High error rates and low levels of reproducibility were observed in the disk diffusion test. The colistin Etest, agar dilution, and the VITEK 2 showed a high level of agreement with the broth microdilution reference method. Heteroresistance for colistin was observed in six Enterobacter cloacae isolates and in one Acinetobacter baumannii isolate. This is the first report of heteroresistance to colistin in E. cloacae isolates. Resistance to colistin in these isolates seemed to be induced upon exposure to colistin rather than being caused by stable mutations. Heteroresistant isolates could be detected in the broth microdilution, agar dilution, Etest, or disk diffusion test. The VITEK 2 displayed low sensitivity in the detection of heteroresistant subpopulations of E. cloacae. The VITEK 2 colistin susceptibility test can therefore be considered to be a reliable tool to determine susceptibility to colistin in isolates of genera that are known not to exhibit resistant subpopulations. In isolates of genera known to (occasionally) exhibit heteroresistance, an alternative susceptibility testing method capable of detecting heteroresistance should be used.
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Affiliation(s)
- Jerome R Lo-Ten-Foe
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands.
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Cremer OL, van Dijk GW, Amelink GJ, de Smet AMGA, Moons KGM, Kalkman CJ. Cerebral hemodynamic responses to blood pressure manipulation in severely head-injured patients in the presence or absence of intracranial hypertension. Anesth Analg 2004; 99:1211-1217. [PMID: 15385378 DOI: 10.1213/01.ane.0000133917.67728.2a] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The management of cerebral perfusion pressure (CPP) remains a controversial issue in the critical care of severely head-injured patients. Recently, it has been proposed that the state of cerebrovascular autoregulation should determine individual CPP targets. To find optimal perfusion pressure, we pharmacologically manipulated CPP in a range of 51 mm Hg (median; 25th-75th percentile, 48-53 mm Hg) to 108 mm Hg (102-112 mm Hg) on Days 0, 1, and 2 after severe head injury in 13 patients and studied the effects on intracranial pressure (ICP), autoregulation capacity, and brain tissue partial pressure of oxygen. Autoregulation was expressed as a static rate of regulation for 5-mm Hg CPP intervals based on middle cerebral artery flow velocity. When ICP was normal (26 occasions), there were no major changes in the measured variables when CPP was altered from a baseline level of 78 mm Hg (74-83 mm Hg), indicating that the brain was within autoregulation limits. Conversely, when intracranial hypertension was present (11 occasions), CPP reduction to less than 77 mm Hg (73-82 mm Hg) further increased ICP, decreased the static rate of regulation, and decreased brain tissue partial pressure of oxygen, whereas a CPP increase improved these variables, indicating that the brain was operating at the lower limit of autoregulation. We conclude that daily trial manipulation of arterial blood pressure over a wide range can provide information that may be used to optimize CPP management.
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Affiliation(s)
- Olaf L Cremer
- *Division of Perioperative Care and Emergency Medicine, Departments of †Neurology and ‡Neurosurgery, and the §Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
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Bonten MJM, Joore HCA, de Jongh BM, Kluytmans J, Kuijper EJ, van Leeuwen HJ, de Smet AMGA, Vandenbroucke-Grauls C. Selective decontamination of the digestive tract: all questions answered? Crit Care 2003; 7:203-5. [PMID: 12793864 PMCID: PMC270668 DOI: 10.1186/cc1881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Although many studies have shown beneficial effects of SDD on the incidence of respiratory tract infections, SDD did not become routine practice because mortality reduction was not demonstrated in individual trials, beneficial effects on duration of ventilation, ICU stay or hospital stay were not demonstrated, cost-efficacy had not been demonstrated, and selection of antibiotic resistance was considered a serious side-effect. A recent study has now shown improved patient survival and lower prevalence of antibiotic resistance in patients receiving SDD. Why could this study show mortality reduction, where all others studies had failed before? And do the microbiological data unequivocally prove protective effects of SDD on emergence of antibiotic resistance? Interestingly, the reported mortality reductions exceeds even the most optimistic predictions from previous meta-analyses, but a clear explanation is not yet evident. The data on antibiotic resistance, however, are rather superficial and do not allow to interpret the underlying epidemiological dynamics. Therefore, the recent findings are provocative and shed new light on the SDD issue, warranting studies confirming its beneficial effects but also addressing several important aspects related to study design.
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Affiliation(s)
- Marc J M Bonten
- Department of Internal Medicine & Dermatology, Division of Acute Internal Medicine & Infectious Diseases, University Medical Center Utrecht, The Netherlands.
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Liem MSL, Kallewaard JW, de Smet AMGA, van Vroonhoven TJMV. Does Hypercarbia Develop Faster During Laparoscopic Herniorrhaphy Than During Laparoscopic Cholecystectomy? Assessment with Continuous Blood Gas Monitoring. Anesth Analg 1995. [DOI: 10.1213/00000539-199512000-00021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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