A retrospective analysis of carbapenem-resistant Acinetobacter baumannii infections in critically ill patients: Experience at a tertiary-care teaching hospital ICU

Background

Acinetobacter baumannii is a clinically significant pathogen with a high incidence of multidrug resistance that is associated with life-threatening nosocomial infections. Here, we aimed to provide an insight into the clinical characteristics and outcomes of a unique group of A. baumannii infections in which the isolates were resistant to carbapenems and most other antibiotic groups in a tertiary-care intensive care unit (ICU).

Methods

We performed a retrospective observational study in which records of patients hospitalized in the ICU between June 1, 2021 and June 1, 2023 were reviewed. We checked the clinical, laboratory, and microbiological records of all adult patients who had carbapenem-resistant A. baumannii (CRAB) infections. Prior antibiotic treatments and definitive antibiotic treatments after culture positivity and susceptibility test results were recorded. C-reactive protein (CRP) and procalcitonin levels and leukocyte counts were noted. Length of ICU stay and 30-day mortality were defined as the outcome parameters.

Results

During the study period, 57 patients were diagnosed with CRAB infections. The respiratory tract was the leading infection site (80.7%). In non-survivors, bloodstream infections (21.9% vs. 4.0% P=0.05) and colistin-resistant (col-R) CRAB infections (43.8% vs. 24.0%, P=0.12) were more common than in survivors, but these parameters were not statistically significant. The length of ICU stay was not different between survivors and non-survivors. Overall, the rate of col-R among CRAB clinical isolates was 35.1%. The 30-day mortality in all patients with CRAB infection was 56.1%. Mortality in col-R CRAB and colistin-susceptible (col-S) CRAB infections was 70.0% and 48.6%, respectively (P=0.12). Prior carbapenem use was 56.1%. Prior colistin use before col-R and col-S CRAB infections was not significant (35.0% vs. 27.0%, P=0.53).

Conclusions

Our study provides real-world data on highly resistant A. baumannii infections and shares the characteristics of infections with such resistant strains. Unfortunately, carbapenem resistance in A. baumannii is a challenge for intensive care specialists who are faced with few treatment options, and colistin resistance further complicates the problem.

Refeeding Hypophosphatemia in Oldest Old Critically Ill Patients

BACKGROUND

Refeeding syndrome is characterized by metabolic and electrolyte alterations that result from the initiation of feeding after a period of inadequate caloric intake. Especially, in the elderly with acute and/or chronic illness, nutritional deficiencies are common, and diminished oral intake with effects of catabolic status yields malnutrition. This study was conducted to evaluate refeeding hypophosphatemia and its consequences on outcomes in the oldest old critically ill patients.

METHODS

This study was designed as a retrospective cohort study that included patients who were 80 years old or older admitted to ICU. Patients were grouped depending on whether hypophosphatemia occurred after 48 hours of admission who started feeding.

RESULTS

The median age of all patients was 87[82-90] years and 61(73%) of them were female. Refeeding hypophosphatemia was observed in 25(30%) patients. When patients were grouped depending on the occurrence of hypophosphatemia, groups were similar according to the severity scores, and comorbidities. Neither ICU mortality nor hospital mortality was different between groups (p=0.76 and p=0.19, respectively).

CONCLUSION

Refeeding hypophosphatemia incidence was similar to previous studies, although study patients were the highest risk group. Outcome parameters including mortality rate and length of ICU stay were not different between patients with or without refeeding hypophosphatemia.

Epidemiology and risk factors of 28-day mortality of hospital-acquired bloodstream infection in Turkish intensive care units: a prospective observational cohort study

OBJECTIVES

To uncover clinical epidemiology, microbiological characteristics and outcome determinants of hospital-acquired bloodstream infections (HA-BSIs) in Turkish ICU patients.

METHODS

The EUROBACT II was a prospective observational multicontinental cohort study. We performed a subanalysis of patients from 24 Turkish ICUs included in this study. Risk factors for mortality were identified using multivariable Cox frailty models.

RESULTS

Of 547 patients, 58.7% were male with a median [IQR] age of 68 [55-78]. Most frequent sources of HA-BSIs were intravascular catheter [182, (33.3%)] and lower respiratory tract [175, (32.0%)]. Among isolated pathogens (n = 599), 67.1% were Gram-negative, 21.5% Gram-positive and 11.2% due to fungi. Carbapenem resistance was present in 90.4% of Acinetobacter spp., 53.1% of Klebsiella spp. and 48.8% of Pseudomonas spp. In monobacterial Gram-negative HA-BSIs (n = 329), SOFA score (aHR 1.20, 95% CI 1.14-1.27), carbapenem resistance (aHR 2.46, 95% CI 1.58-3.84), previous myocardial infarction (aHR 1.86, 95% CI 1.12-3.08), COVID-19 admission diagnosis (aHR 2.95, 95% CI 1.25-6.95) and not achieving source control (aHR 2.02, 95% CI 1.15-3.54) were associated with mortality. However, availability of clinical pharmacists (aHR 0.23, 95% CI 0.06-0.90) and source control (aHR 0.46, 95% CI 0.28-0.77) were associated with survival. In monobacterial Gram-positive HA-BSIs (n = 93), SOFA score (aHR 1.29, 95% CI 1.17-1.43) and age (aHR 1.05, 95% CI 1.03-1.08) were associated with mortality, whereas source control (aHR 0.41, 95% CI 0.20-0.87) was associated with survival.

CONCLUSIONS

Considering high antimicrobial resistance rate, importance of source control and availability of clinical pharmacists, a multifaceted management programme should be adopted in Turkish ICUs.

EFFECTS OF DIABETES AND FIRST-WEEK HYPERGLYCEMIC EPISODE FREQUENCY ON THE MORTALITY AND INFLAMMATION IN CRITICALLY ILL COVID-19 PATIENTS: A CASE-CONTROL STUDY

Background

We know that mortality had increased in diabetic patients with COVID-19 pneumonia. The aim of this study was to compare the mortality and inflammation parameters difference in critically ill COVID-19 patients according to their admission HbA1c levels and diabetes mellitus status. Secondary aim was to evaluate the effect of the first week hyperglycemic episode frequency on mortality.

Methods

Critically ill COVID-19 patients who were tested for HbA1c levels on ICU admission were analyzed retrospectively.

Results

Of 218 COVID PCR(+) patients, 139 met the inclusion criteria in study period. The median age was 67 [57-76] years and 55(40%) of them were female. Seventy-six (55%) of the patients required invasive mechanical ventilation (IMV). The IMV requirement was higher in diabetic patients (p=0.01). When the groups were compared in terms of inflammatory parameters no significant difference was found except for admission and first week's highest fibrinogen levels (p=0.02 and p=0.03, respectively). In multivariate analysis, fibrinogen levels were not determined as a risk factor for mortality. Overall ICU mortality was 43% (60/139). In group-1 23 (37%), in group-2 27 (57%), and in group-3 10 (34%) patients had died. There was no statistically significant difference between groups in terms of mortality (p=0.05). Records of 96 (69%) patients revealed there were more than five glucose readings over 180mg/dL during the first week. Mortality was higher in patients with more frequently hyperglycemic recordings (p=0.03).

Conclusions

There was no significant mortality and inflammatory parameters difference in patients with and without diabetes. However, more than five glucose readings over 180mg/dL during the first week were found with increased mortality.