Clindamycin but not Intravenous Immunoglobulins reduces mortality in a retrospective cohort of critically ill patients with bacteremic Group A Streptococcal infections

Objectives

Mortality of patients requiring Intensive Care Unit (ICU) admission for an invasive group A streptococcal (GAS) infection continues being high. In critically ill patients with bacteremic GAS infection we aimed at determining risk factors for mortality.

Patients and methods

Retrospective multicentre study carried out in nine ICU in Southern Spain. All adult patients admitted to the participant ICUs from January 2014 to June 2019 with one positive blood culture for S. pyogenes were included in this study. Patient characteristics, infection-related variables, therapeutic interventions, failure of organs, and outcomes were registered. Risk factors independently associated with ICU and in-hospital mortalities were determined by multivariate regression analyses.

Results

Fifty-seven patients were included: median age was 63 (45-73) years, median SOFA score at admission was 11 (7-13). The most frequent source was skin and soft tissue infection (n=32) followed by unknown origin of bacteremia (n=12). In the multivariate analysis, age (OR 1.079; 95% CI 1.016-1.145), SOFA score (OR 2.129; 95% CI 1.339-3.383) were the risk factors for ICU mortality and the use of clindamycin was identified as a protective factor (OR 0.049; 95% CI 0.003-0.737). Age and SOFA were the independent factors associated with hospital mortality however the use of clindamycin showed a strong trend but without reaching statistical significance (OR 0.085; 95% CI 0.007-1.095).

Conclusion

In this cohort of critically ill patients the use of intravenous immunoglobulin was not identified as a protective factor for ICU or hospital mortality treatment with clindamycin significantly reduced mortality after controlling for confounders.

Expanded Criteria Donors for Kidney Transplantation: Quality Control and Results

Although the number of kidneys from expanded criteria deceased donors (ECDs) is growing in most transplant centers, the limits for acceptance of these kidneys and the safety standards have still not been fully established. We evaluated 342 kidney transplants performed between January 1999 and December 2004. In 77 (22.5%) of these, the kidneys were from ECDs, that is, donors age >60 years and with one of the following characteristics: hypertension, death due to cerebrovascular accident (CVA) or glomerular filtration rate (GFR) <70 mL/min. The results of the ECD transplants were compared with 265 transplants during the same period from standard donors (SDs), that is, donors age <60 years and GFR > 70 mL/min. All the ECD kidneys underwent biopsy and were accepted for transplantation only if the score was <7. The ECDs (66.5 +/- 4.3 years) in comparison with the SDs (48.0 +/- 16.0 years) had a greater frequency of death due to CVA (94.8% vs 49.8%) and a lower GFR (80.4 +/- 25.0 vs 111 +/- 41.6 mL/min; P < .05). Of the ECDs, 97.4% had a history of hypertension versus 24.3% of the SDs. Kidney biopsies were performed in 116 SD kidneys because the donor age was >55 years or there was a history of hypertension. The median score for the kidney biopsies of the ECD kidneys was 3 versus 2 for the SD kidneys. Graft survival was not significantly different until the fifth year. The GFR at 12 months was significantly different (SDs, 58.0 +/- 22.7 vs ECDs, 48.9 +/- 16.5 mL/min; P < .05). Although the GFR in the ECD kidneys was lower than that of the SD kidneys, it could still be adequate for recipients older than 50 years of age. Accordingly, the acceptance criteria for ECD kidneys based mainly on the kidney biopsy score and donor GFR benefit the recipients.

Multifactorial snowball effect in the reduction of refusals for organ procurement

Interviewing the family of a possible organ donor is a legal requirement in Spain, but it is the stage at which most potential donors are lost. Multiple factors influence the family's acceptance or rejection of this option, including awareness of the wishes of the deceased, personal preconceived attitudes of family members, as well as issues related to the hospital and its health care personnel, whose attitudes are a key factor in obtaining permission. We examined all 651 donation situations in a single hospital that included a family interview over the last 15 years. Among these 651 cases, 191 families refused donation (29.3%). The rate of donation refusal has fallen from 46.3% to 12.5% over these 15 years. To better understand the evolution of donor characteristics, interviewees, and the setting, we divided the sample into three 5-year periods to analyze key variables collected from the family interviews. The results showed that at the same time as the donor profile has changed, namely, fewer brain trauma cases and more victims of stroke as well as older mean age and more coexistent diseases, these has been an improvement in the factors related to the information and opinion of both the families and the donor about this process. The main reasons for refusal of donation have changed from negation of brain death, religious factors, and the desire to maintain the body intact during the 1990s, to sociocultural reasons in minority ethnic groups, to presumed refusal during life, and to family disagreements during the more recent years.

Endogenous endotoxemia of intestinal origin during cardiopulmonary bypass. Role of type of flow and protective effect of selective digestive decontamination

OBJECTIVE

To evaluate the possible related factors to endotoxemia and cytokine activation during the ischemic phase of extracorporeal surgery, and the effect of selective digestive decontamination (SDD) as a preventive measure.

DESIGN

Prospective, open, randomized trial.

SETTING

Two multidisciplinary ICUs (tertiary care hospitals).

PATIENTS

One hundred consecutive patients undergoing cardiopulmonary bypass (CPB), randomly allocated to two groups; gut decontamination (group I = 50 cases) and controls (group II = 50 cases).

INTERVENTIONS

Preoperative administration of oral non-absorbable antibiotics (polymyxin E, tobramycin and amphotericin B) versus no administration.

MEASUREMENTS AND RESULTS

The assessment of decontamination by means of the bacteriologic control of rectal swabs. Determinations of gastric intramucosal pH (gastric pHi) and plasma endotoxin, tumor necrosis factor (TNF) aNd interleukin-6 (IL-6) before surgery and during the ischemic and reperfusion phases of bypass. Rectal aerobic Gram-negative bacilli (AGNB) were significantly reduced in the treated patients and in 56% total eradication was achieved. Endotoxin, TNF and IL-6 plasma levels were significantly lower in this group. By contrast, both endotoxin and TNF/IL-6 levels and gastric pHi correlated with the type of surgical flow (pulsatile versus non-pulsatile).

CONCLUSIONS

SDD reduces the gut content of enterobacteria. This may explain the lower endotoxin and cytokine levels detected in decontaminated patients. In addition to SDD, the type of flow employed during bypass seems to influence endotoxemia and cytokine levels.

Can selective digestive decontamination avoid the endotoxemia and cytokine activation promoted by cardiopulmonary bypass?

OBJECTIVE

To evaluate the effect of selective digestive decontamination on endotoxemia and cytokine activation during the ischemic phase of cardiopulmonary bypass surgery.

DESIGN

Prospective, open, randomized, controlled trial.

SETTING

Two multidisciplinary intensive care units in tertiary care hospitals.

PATIENTS

Eighty consecutive patients randomly allocated to two groups: selective digestive decontamination (group 1, n = 40) and controls (group 2, n = 40).

INTERVENTIONS

Preoperative administration of oral antibiotics (polymyxin E, tobramycin, and amphotericin B) vs. untreated controls.

MEASUREMENTS AND MAIN RESULTS

Assessment of decontamination by bacteriologic evaluation of rectal swabs (colony-forming units [cfu]/mL) were made in each group, along with circulating endotoxin, tumor necrosis factor and interleukin-6 (IL-6) determinations before surgery, during ischemic and reperfusion phases of bypass, and at 4 hrs and at 24 hrs after surgery. Group 1 patients showed that rectal bacteria decreased ten-fold after treatment for 24 hrs, thousand-fold after 48 hrs, and registered 0 cfu/mL after digestive decontamination was administered for > 72 hrs. Endotoxin and IL-6 assays showed significantly lower values in this latter group vs. those circulating concentrations of control patients. On the other hand, both endotoxin and IL-6 concentrations correlated positively with the duration of surgical ischemia.

CONCLUSIONS

Selective digestive decontamination reduces the gut content of enterobacteria, with complete elimination after 3 days of treatment. This fact could explain the lower endotoxin and cytokine concentrations found in the blood samples of patients who had been fully decontaminated. Duration of aortic cross-clamping is an important factor in generating endotoxemia and in the activation of cytokines.

Role of selective digestive decontamination (SDD) in the prevention of nosocomial pneumonia (NP): is gastric decontamination necessary?

In the course of a prospective selective digestive decontamination (SDD) trial to prevent nosocomial pneumonia (NP) during mechanical ventilation (MV), we carried out serial cultures of gastric aspirate to assess the importance of gastric colonization for potential respiratory pathogens and its relationship to the simultaneous gastric pH, to whether the patients were receiving Sucralfate or Ranitidine and to the nutritional biochemical parameters. If NP developed, a bronchial sample was taken by fibreoptic bronchoscopy to determine the causal organisms and its relationship to the previous gastric isolated. Results show: 1) Increase in aerobic Gram negative bacilli colonization during hospitalization. 2) Direct relationship between colonization level and gastric pH. 3) Greater pH in ranitidine vs sucralfate group. 4) Low incidence of NP (11%), the majority of these (66%) being early. 5) No bacteriological correlation between gastric colonization and aetiological agents of NP. 6) Close relationship between pharyngeal colonization and causative germs of pulmonary infection (40%).