[Bacterial coinfection in the critically-ill COVID-19 patient: incidence, impact and need for antimicrobial therapy]

OBJECTIVE

To assess the frequency of bacterial coinfection upon ICU admission in SARS-CoV-2 pneumonia patients, its microbiology, and impact on prognosis.The secondary objective was to identify risk factors for coinfection on admission.

METHODS

Retrospective study, including patients with SARS-CoV-2 pneumonia admitted to the ICU.We defined bacterial coinfection by respiratory symptoms, radiological data, positive and clinically significant microbiological results in samples obtained in the first 48 h of admission and/or a determination of procalcitonin ≥ 0.5 ng/mL in the first 48 h.We evaluated demographic variables, comorbidities, SARS-CoV-2 infection data, severity scores, treatments received, need for respiratory support and outcomes (ICU and hospital mortality).

RESULTS

A total of 182 patients were analyzed, 62 (34.1%) with bacterial coinfection.The most frequent microbiology was S. pneumoniae and M. pneumoniae. 96.1% of the patients received antibiotic therapy on admission, 98.9% corticosteroids, 27.5% tocilizumab, and 7.7% remdesivir.85.7% required invasive mechanical ventilation.The SOFA score (OR: 1.315, 95% CI1.116-1.548) and the delay in ICU admission (OR: 0.899, 95% CI 0.831-0.972) were related to the risk of coinfection. Bacterial coinfection increases the risk of death in hospital (OR 2.283; 95% CI 1.011.5.151; p=0.047).

CONCLUSIONS

Bacterial coinfection is common in COVID patients admitted to the ICU and increases the risk of death. It is not possible to identify with certainty, at the time of admission, which patients do not benefit from antibiotic treatment.

Treatment of severe multi-drug resistant Pseudomonas aeruginosa infections

Pseudomonas aeruginosa is the microorganism most frequently involved in the main ICU-acquired infections, with special importance in ventilator associated pneumonia. Its importance lies, in addition to its high incidence in critically ill patients, in the severity of the infections it causes and in the difficulty of its antimicrobial treatment, directly related to the high percentage of resistance to antibiotics classically considered first-line. New active antibiotics have recently been developed against Pseudomonas aeruginosa, even against multi-drug resistant strains. This review analyzes both the differential characteristics of Pseudomonas aeruginosa infections and the new therapeutic options, focusing on multi-drug resistant Pseudomonas aeruginosa.

Impact of one year of pandemic on Spanish Intensive Care Units

Objective

To measure the impact of the pandemic in Spanish ICUs.

Material and methods

On-line survey, conducted in April 2021, among SEMICYUC members. Participants were asked about number of patients admitted, increase in the number of beds and staff, structures created in the hospital and self-assessment of the work performed.

Results

We received 246 answers from 157 hospitals. 67.7% of the ICUs were expanded during the pandemic, overall increase in beds of 58.6%. The ICU medical staff increased by 6.1% and there has been a nursing shortage in 93.7% of units. Patients exceeded 200% the pre-pandemic ICU capacity. In 88% of the hospitals the collaboration of other specialists was necessary. The predominant collaboration model consisted of the intensive care medicine specialist being responsible for triage and coordinating patient management. Despite that 53.2% centres offered training for critical care, a deterioration in the quality of care was perceived. 84.2% hospitals drew up a Contingency Plan and in 77.8% of the hospitals a multidisciplinary committee was set up to agree on decision-making.

Self-evaluation of the work performed was outstanding and 91.9% felt proud of what they had achieved, however, up to 15% considered leaving their job.

Conclusions

The Spanish ICUs assumed an unprecedented increase in the number of patients. They achieved it without hardly increasing their staff and, while intensive care medicine training was carried out for other specialists who collaborated. The degree of job satisfaction was consistent with pre-pandemic levels.

[Resuscitation strategy for patients with sepsis and septic shock]

Fluid and vasopressor resuscitation is, along with antimicrobial therapy and control of the focus of infection, a basic issue of the treatment of sepsis and septic shock. There is currently no accepted protocol that we can follow for the resuscitation of these patients and the Surviving Sepsis Campaign proposes controversial measures and without sufficient evidence support to establish firm recommendations. We propose a resuscitation strategy adapted to the situation of each patient: in the patient in whom community sepsis is suspected, we consider that the early administration of 30mL/kg of crystalloids is effective and safe; in the patient with nosocomial sepsis, we must carry out a more in-depth evaluation before initiating aggressive resuscitation. In patients who do not respond to initial resuscitation, it is necessary to increase monitoring level and, depending on the hemodynamic profile, administer more fluids, a second vasopressor or inotropes.

Enhancing sepsis management through machine learning techniques: A review

Sepsis is a major public health problem and a leading cause of death in the world, where delay in the beginning of treatment, along with clinical guidelines non-adherence have been proved to be associated with higher mortality. Machine Learning is increasingly being adopted in developing innovative Clinical Decision Support Systems in many areas of medicine, showing a great potential for automatic prediction of diverse patient conditions, as well as assistance in clinical decision making. In this context, this work conducts a narrative review to provide an overview of how specific Machine Learning techniques can be used to improve sepsis management, discussing the main tasks addressed, the most popular methods and techniques, as well as the obtained results, in terms of both intelligent system accuracy and clinical outcomes improvement.

Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

[Management of infectious complications associated with coronavirus infection in severe patients admitted to ICU]

Infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia admitted in ICU. Poor immune status, frequent development of organic failure requiring invasive supportive treatments, and prolonged ICU length of stay in saturated structural areas of patients are risk factors for infection development. The Working Group on Infectious Diseases and Sepsis GTEIS of the Spanish Society of Intensive Medicine and Coronary Units SEMICYUC emphasizes the importance of infection prevention measures related to health care, the detection and early treatment of major infections in the patient with SARS-CoV-2 infections. Bacterial co-infection, respiratory infections related to mechanical ventilation, catheter-related bacteremia, device-associated urinary tract infection and opportunistic infections are review in the document.

Management of infectious complications associated with coronavirus infection in severe patients admitted to ICU

Infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia admitted in ICU. Poor immune status, frequent development of organic failure requiring invasive supportive treatments, and prolonged ICU length of stay in saturated structural areas of patients are risk factors for infection development. The Working Group on Infectious Diseases and Sepsis GTEIS of the Spanish Society of Intensive Medicine and Coronary Units SEMICYUC emphasizes the importance of infection prevention measures related to health care, the detection and early treatment of major infections in the patient with SARS-CoV-2 infections. Bacterial co-infection, respiratory infections related to mechanical ventilation, catheter-related bacteremia, device-associated urinary tract infection and opportunistic infections are review in the document.

COVID-19 and Acute Respiratory Distress Syndrome. Impact of corticosteroid treatment and predictors of poor outcome

OBJECTIVE

To assess the impact of corticosteroids on inflammatory and respiratory parameters of patients with COVID-19 and acute respiratory distress syndrome (ARDS).

METHODS

Longitudinal, retrospective, observational study conducted in an ICU of a second level hospital. Adult patients with COVID-19 were included. Baseline characteristics, data on SARS-CoV-2 infection, treatment received, evolution of respiratory and inflammatory parameters, and ICU and hospital stay and mortality were analyzed.

RESULTS

A total of 27 patients were included, 63% men, median age: 68.4 (51.8, 72.2) years. All patients met ARDS criteria and received MV and corticosteroids. After corticosteroids treatment we observed a reduction in the O2 A-a gradient [day 0: 322 (249, 425); day 3: 169 (129.5, 239.5) p<0.001; day 5: 144 (127.5, 228.0) p<0.001; day 7: 192 (120, 261) p=0.002] and an increase in the pO2/FiO2 ratio on days 3 and 5, but not on day 7 [day 0: 129 (100, 168); day 3: 193 (140, 236) p=0.002; day 5: 183 (141, 255) p=0.004; day 7: 170 (116, 251) p=0.057]. CRP also decreased on days 3 and 5 and increased again on day 7 [day 0: 16 (8.6, 24); day 3: 3.4 (1.7, 10.2) p<0.001; day 5: 4.1 (1.4, 10.2) p<0.001; day 7: 13.5 (6.8, 17.3) p=0.063]. Persistence of moderate ARDS on day 7 was related to a greater risk of poor outcome (OR 6.417 [1.091-37.735], p=0.040).

CONCLUSIONS

Corticosteroids appears to reduce the inflammation and temporarily improve the oxygenation in COVID-19 and ARDS patients. Persistence of ARDS after 7 days treatment is a predictor of poor outcome.

Enhancing sepsis management through machine learning techniques: A review

Sepsis is a major public health problem and a leading cause of death in the world, where delay in the beginning of treatment, along with clinical guidelines non-adherence have been proved to be associated with higher mortality. Machine Learning is increasingly being adopted in developing innovative Clinical Decision Support Systems in many areas of medicine, showing a great potential for automatic prediction of diverse patient conditions, as well as assistance in clinical decision making. In this context, this work conducts a narrative review to provide an overview of how specific Machine Learning techniques can be used to improve sepsis management, discussing the main tasks addressed, the most popular methods and techniques, as well as the obtained results, in terms of both intelligent system accuracy and clinical outcomes improvement.

Epidemiology and outcome of HIV-infected patients admitted to the ICU in the current highly active antiretroviral therapy era

PURPOSE

To describe the epidemiology of critical disease in HIV-infected patients during the current highly active antiretroviral therapy (HAART) era and to identify hospital mortality predictors.

METHODS

A longitudinal, retrospective observational study was made of HIV-infected adults admitted to the ICU in two Spanish hospitals between 1 January 2000 and 31 December 2014. Demographic and HIV-related variables were analyzed, together with comorbidities, severity scores, reasons for admission and need for organ support. The chi-squared test was used to compare categorical variables, while continuous variables were contrasted with the Student's t-test, Mann-Whitney U-test or Kruskal-Wallis test, assuming an alpha level=0.05. Multivariate logistic regression analysis was used to calculate odds ratios for assessing correlations to mortality during hospital stay. Joinpoint regression analysis was used to study mortality trends over time.

RESULTS

A total of 283 episodes were included for analyses. Hospital mortality was 32.9% (95%CI: 21.2-38.5). Only admission from a site other than the Emergency Care Department (OR 3.64, 95%CI: 1.30-10.20; p=0.01), moderate-severe liver disease (OR 5.65, 95%CI: 1.11-28.87; p=0.04) and the APACHE II score (OR 1.14, 95%CI: 1.04-1.26; p<0.01) and SOFA score at 72h (OR 1.19, 95%CI: 1.02-1.40; p=0.03) maintained a statistically significant relationship with hospital mortality.

CONCLUSIONS

Delayed ICU admission, comorbidities and the severity of critical illness determine the prognosis of HIV-infected patients admitted to the ICU. Based on these data, HIV-infected patients should receive the same level of care as non-HIV-infected patients, regardless of their immunological or nutritional condition.

Types of antiseptics, presentations and rules of use

Antiseptics are chemical substances that when applied topically onto intact skin, mucous membranes or wounds partially or completely reduces the population of living microorganisms in those tissues. Different types of antiseptics are available - those most commonly used in clinical practice being alcohols, iodinated compounds and chlorhexidine. When using an antiseptic, consideration is required of its spectrum of antimicrobial activity, latency, residual effects, possible interferences of the presence of organic material with the activity of the antiseptic, its side effects, compatibility with other antiseptics, and cost. This article is part of a supplement entitled "Antisepsis in the critical patient", which is sponsored by Becton Dickinson.

Ventilator-associated pneumonia by methicillin-susceptible Staphylococcus aureus: do minimum inhibitory concentrations to vancomycin and daptomycin matter?

The use of vancomycin minimum inhibitory concentration (MIC) as an outcome predictor in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia has become an important topic for debate in the last few years. Given these previous results, we decided to investigate whether MICs to vancomycin or daptomycin had any effect on the evolution of patients with ventilator-associated pneumonia (VAP) due to MSSA. An observational, retrospective, multicenter study was conducted among patients with MSSA VAP. We analyzed the relationship between vancomycin and daptomycin MICs and early clinical response (72 h), 30-day mortality, intensive care unit (ICU) length of stay (LOS), and duration on mechanical ventilation. Univariate and multivariate analyses were performed. Sixty-six patients from 12 centers were included. Twenty-six patients (39%) had an infection due to MSSA strains with a vancomycin MIC ≥1.5 μg/mL. Daptomycin MIC was determined in 58 patients, of whom 17 (29%) had an MIC ≥1.0 μg/mL. Ten patients (15%) did not respond to first-line treatment. Only daptomycin MIC ≥1.0 μg/mL had a significant association [odds ratio (OR): 30.00; 95% confidence interval (CI): 2.91-60.41] with early treatment failure. The 30-day mortality was 12% (n = 8). Any variable was associated with mortality in the multivariate analysis. None of the variables studied were associated with ICU LOS or duration on mechanical ventilation. In patients with MSSA VAP, vancomycin MIC does not influence the response to antibiotic treatment or the 30-day mortality. Daptomycin MIC was directly related to early treatment failure.