Increased risk of bloodstream and urinary infections in intensive care unit (ICU) patients compared with patients fitting ICU admission criteria treated in regular wards

UK consultants' experiences of the decision-making process around referral to intensive care: an interview study

OBJECTIVE

The decision whether to initiate intensive care for the critically ill patient involves ethical questions regarding what is good and right for the patient. It is not clear how referring doctors negotiate these issues in practice. The aim of this study was to describe and understand consultants' experiences of the decision-making process around referral to intensive care.

DESIGN

Qualitative interviews were analysed according to a phenomenological hermeneutical method.

SETTING AND PARTICIPANTS

Consultant doctors (n=27) from departments regularly referring patients to intensive care in six UK hospitals.

RESULTS

In the precarious and uncertain situation of critical illness, trust in the decision-making process is needed and can be enhanced through the way in which the process unfolds. When there are no obvious right or wrong answers as to what ought to be done, how the decision is made and how the process unfolds is morally important. Through acknowledging the burdensome doubts in the process, contributing to an emerging, joint understanding of the patient's situation, and responding to mutual moral duties of the doctors involved, trust in the decision-making process can be enhanced and a shared moral responsibility between the stake holding doctors can be assumed.

CONCLUSION

The findings highlight the importance of trust in the decision-making process and how the relationships between the stakeholding doctors are crucial to support their moral responsibility for the patient. Poor interpersonal relationships can damage trust and negatively impact decisions made on behalf of a critically ill patient. For this reason, active attempts must be made to foster good relationships between doctors. This is not only important to create a positive working environment, but a mechanism to improve patient outcomes.

Antibiotic Resistant Bacterial Pathogens Associated with Blood Stream Infections and Urinary Tract Infections among Intensive Care Unit Patients

Blood Stream Infection (BSI) and Urinary Tract Infection (UTI) being leading causes of morbidity and mortality represent a common complication among critically ill patients. During the last decade, clinicians have observed a rising occurrence of BSIs due to bacterial resistance. Likewise, catheter-associated UTI is a main cause of morbidity and mortality affecting all age groups. Coliforms happen to be the prominent pathogens among our ICU admitted patients. It was alarming to notice 42.9% resistance to tigecycline among K. pneumoniae isolated from blood. K. pneumoniae isolates cultured from urine of ICU patients uniformly displayed 75% resistance to ciprofloxacin, ceftriaxone, cefoxitin and cefepime. Interestingly, it is of respite to observe 85.7% K. pneumoniae isolated from blood and 75% K. pneumoniae isolated from urine being susceptible to a conventional antibiotic, gentamicin. Escherichia coli isolated from urine were 100% susceptible to carbapenems and 91.75% were susceptible to tigecycline. Overall, 90% of Pseudomonas aeruginosa were susceptible to nitrofurantoin. The rapid spread of these MDR pathogens demands for national and regional guidelines. Policies to treat ICU related infections in UAE should be designed based on local microbiological data and resistance profiles of pathogens.

Implementing an intervention to improve decision making around referral and admission to intensive care: Results of feasibility testing in three NHS hospitals

RATIONALE, AIMS, AND OBJECTIVES

Decisions about whether to refer or admit a patient to an intensive care unit (ICU) are clinically, organizationally, and ethically challenging. Many explicit and implicit factors influence these decisions, and there is substantial variability in how they are made, leading to concerns about access to appropriate treatment for critically ill patients. There is currently no guidance to support doctors making these decisions. We developed an intervention with the aim of supporting doctors to make more transparent, consistent, patient-centred, and ethically justified decisions. This paper reports on the implementation of the intervention at three NHS hospitals in England and evaluates its feasibility in terms of usage, acceptability, and perceived impact on decision making.

METHODS

A mixed method study including quantitative assessment of usage and qualitative interviews.

RESULTS

There was moderate uptake of the framework (28.2% of referrals to ICU across all sites during the 3-month study period). Organizational structure and culture affected implementation. Concerns about increased workload in the context of limited resources were obstacles to its use. Doctors who used it reported a positive impact on decision making, with better articulation and communication of reasons for decisions, and greater attention to patient wishes. The intervention made explicit the uncertainty inherent in these decisions, and this was sometimes challenging. The patient and family information leaflets were not used.

CONCLUSIONS

While it is feasible to implement an intervention to improve decision making around referral and admission to ICU, embedding the intervention into existing organizational culture and practice would likely increase adoption. The doctor-facing elements of the intervention were generally acceptable and were perceived as making ICU decision making more transparent and patient-centred. While there remained difficulties in articulating the clinical reasoning behind some decisions, the intervention offers an important step towards establishing a more clinically and ethically sound approach to ICU admission.

The experiences of health care professionals, patients, and families of the process of referral and admission to intensive care: A systematic literature review

Treatment in an intensive care unit can be life-saving but it can be distressing and not every patient can benefit. Decisions to admit a patient to an intensive care unit are complex. We wished to explore how the decision to refer or admit is experienced by those involved, and undertook a systematic review of the literature to answer the research question: What are the experiences of health care professionals, patients, and families, of the process of referral and admission to an intensive care unit? Twelve relevant studies were identified, and a thematic analysis was conducted. Most studies involved health care professionals, with only two considering patients' or families' experiences. Four themes were identified which influenced experiences of intensive care unit referral and review: the professional environment; communication; the allocation of limited resources; and acknowledging uncertainty. Patients' and families' experiences have been under-researched in this area.

Socioeconomic gradients in admission to coronary or intensive care units among Australians presenting with non-traumatic chest pain in emergency departments

BACKGROUND

Socioeconomic inequalities in cardiovascular morbidity have been previously reported showing direct associations between socioeconomic disadvantage and worse health outcomes. However, disagreement remains regarding the strength of the direct associations. The main objective of this panel design was to inspect socioeconomic gradients in admission to a coronary care unit (CCU) or an intensive care unit (ICU) among adult patients presenting with non-traumatic chest pain in three acute-care public hospitals in Victoria, Australia, during 2009-2013.

METHODS

Consecutive adults aged 18 or over presenting with chest pain in three emergency departments (ED) in Victoria, Australia during the five-year study period were eligible to participate. A relative index of inequality of socioeconomic status (SES) was estimated based on residential postcode socioeconomic index for areas (SEIFA) disadvantage scores. Admission to specialised care units over repeated presentations was modelled using a multivariable Generalized Estimating Equations approach that accounted for various socio-demographic and clinical variables.

RESULTS

Non-traumatic chest pain accounted for 10% of all presentations in the emergency departments (ED). A total of 53,177 individuals presented during the study period, with 22.5% presenting more than once. Of all patients, 17,579 (33.1%) were hospitalised over time, of whom 8584 (48.8%) were treated in a specialised care unit. Female sex was independently associated with fewer admissions to CCU / ICU, whereas, a dose-response effect of socioeconomic disadvantage and admission to CCU / ICU was found, with risk of admission increasing incrementally as SES declined. Patients coming from the lowest SES locations were 27% more likely to be admitted to these units compared with those coming from the least disadvantaged locations, p <  0.001. Men were significantly more likely to be admitted to such units than similarly affected and aged women among those diagnosed with angina pectoris, arrhythmia, myocardial infarction, heart failure, chest pain, and general signs and symptoms.

CONCLUSIONS

This study is the first to report socioeconomic gradients in admission to CCU / ICU in patients presenting with chest pain showing a dose-response effect. Our findings suggest increased cardiovascular morbidity as socioeconomic disadvantage increases.

Characterization of Portuguese honey from Castelo Branco region according to their pollen spectrum, physicochemical characteristics and mineral contents

The aim of this work was to evaluate the quality of 16 honey samples from Castelo Branco region (Portugal). Twelve are monofloral from Calluna vulgaris, Erica, Lavandula, Echium and Campanula. The mean values obtained for physicochemical parameters were: 3.82 pH; 16.80% moisture; 81.6°Brix; 0.21% ash; 357.6 μS cm^-1 electrical conductivity; 33.7 meq/kg free acidity; 5.7 meq/kg lactonic acidity; 39.3 meq/kg total acidity; 9.11 mg/kg HMF; 21.3 IN invertase and 9.0° Gothe for diastase activities. The results indicate a good quality, adequate processing, good maturity and freshness of honey. Additionally, the determination of mineral contents revealed that the K was the major element. Mean values obtained were (mg/kg): Ca, 28.36; K, 701.87; Mg, 74.00; Na, 31.04; Fe, 097; Cu, 0.65; Zn, 1.23; Mn, 2.78 and P, 48.80. Among the overall determined parameters, CB2 stands out by its high values in minerals, pH, moisture, ash, electrical conductivity and enzyme activity.

Nonparametric estimation in the illness-death model using prevalent data

We study nonparametric estimation of the illness-death model using left-truncated and right-censored data. The general aim is to estimate the multivariate distribution of a progressive multi-state process. Maximum likelihood estimation under censoring suffers from problems of uniqueness and consistency, so instead we review and extend methods that are based on inverse probability weighting. For univariate left-truncated and right-censored data, nonparametric maximum likelihood estimation can be considerably improved when exploiting knowledge on the truncation distribution. We aim to examine the gain in using such knowledge for inverse probability weighting estimators in the illness-death framework. Additionally, we compare the weights that use truncation variables with the weights that integrate them out, showing, by simulation, that the latter performs more stably and efficiently. We apply the methods to intensive care units data collected in a cross-sectional design, and discuss how the estimators can be easily modified to more general multi-state models.

Procalcitonin to guide taking blood cultures in the intensive care unit; a cluster-randomized controlled trial

OBJECTIVES

We aimed to study the safety and efficacy of procalcitonin in guiding blood cultures taking in critically ill patients with suspected infection.

METHODS

We performed a cluster-randomized, multi-centre, single-blinded, cross-over trial. Patients suspected of infection in whom taking blood for culture was indicated were included. The participating intensive care units were stratified and randomized by treatment regimen into a control group and a procalcitonin-guided group. All patients included in this trial followed the regimen that was allocated to the intensive care unit for that period. In both groups, blood was drawn at the same moment for a procalcitonin measurement and blood cultures. In the procalcitonin-guided group, blood cultures were sent to the department of medical microbiology when the procalcitonin was >0.25 ng/mL. The main outcome was safety, expressed as mortality at day 28 and day 90.

RESULTS

The control group included 288 patients and the procalcitonin-guided group included 276 patients. The 28- and 90-day mortality rates in the procalcitonin-guided group were 29% (80/276) and 38% (105/276), respectively. The mortality rates in the control group were 32% (92/288) at day 28 and 40% (115/288) at day 90. The intention-to-treat analysis showed hazard ratios of 0.85 (95% CI 0.62-1.17) and 0.89 (95% CI 0.67-1.17) for 28-day and 90-day mortality, respectively. The results were deemed non-inferior because the upper limit of the 95% CI was below the margin of 1.20.

CONCLUSION

Applying procalcitonin to guide blood cultures in critically ill patients with suspected infection seems to be safe, but the benefits may be limited.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: ID NCT01847079. Registered on 24 April 2013, retrospectively registered.

Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting

BACKGROUND

Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated.

METHODS

Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.

RESULTS

Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %.

CONCLUSIONS

Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

Comparing estimation approaches for the illness-death model under left truncation and right censoring

Left-truncated data arise when lifetimes are observed only if they are larger than independent truncation times. For example, in a cross-sectional sampling, only individuals who live long enough to be present on the sampling day are observed. There are several ways to perform statistical inference under this setting. One can do the following: (i) use an unconditional approach, (ii) condition on the value of the truncation variable, or (iii) condition on all the history up to the time of truncation. The latter two approaches are equivalent when analyzing univariate survival outcomes but differ under the multi-state framework. In this paper, we consider the illness-death model and compare between the three estimation approaches in a parametric regression framework. We show that approach (ii) is more efficient than the standard approach (iii), although it requires more computational effort. Approach (i) is the most efficient approach, but it requires knowledge on the distribution of the truncation variable and hence is less robust. The methods are compared using a theoretical example and simulations and are applied to intensive care units data collected in a cross-sectional design, where the illness state corresponds to a bloodstream infection.

Does Catheter-Associated Urinary Tract Infection Increase Mortality in Critically Ill Patients?

Objective.

To produce an accurate estimate of the association between catheter-associated urinary tract infection (UTI) and intensive care unit (ICU) and hospital mortality, controlling for major confounding factors.

Design.

Nested case-control study in a multicenter cohort (the OutcomeRea database).

Setting.

Twelve French medical or surgical ICUs.

Methods.

All patients admitted between January 1997 and August 2005 who required the insertion of an indwelling urinary catheter. Patients who developed catheter-associated UTI (ie, case patients) were matched to control patients on the basis of the following criteria: sex, age ( ± 10 years), SAPS (Simplified Acute Physiology Score) II score ( ± 10 points), duration of urinary tract catheterization, and presence or absence of diabetes mellitus. The association of catheter-associated UTI with ICU and hospital mortality was assessed by use of conditional logistic regression.

Results.

Of the 3,281 patients who had an indwelling urinary catheter, 298 (9%) developed at least 1 episode of catheter-associated UTI. The incidence density of catheter-associated UTI was 12.9 infections per 1,000 catheterization-days. Crude ICU mortality rates were higher among patients with catheter-associated UTI, compared with those without catheter-associated UTI (32% vs 25%, P = .02); the same was true for crude hospital mortality rates (43% vs 30%, P>.01). After matching and adjustment, catheter-associated UTI was no longer associated with increased mortality (ICU mortality: odds ratio [OR], 0.846 [95% confidence interval {CI}, 0.659-1.086]; P = .19 and hospital mortality: OR, 0.949 [95% CI, 0.763-1.181]; P = .64).

Conclusion.

After carefully controlling for confounding factors, catheter-associated UTI was not found to be associated with excess mortality among our population of critically ill patients in either the ICU or the hospital.

Catheter-Associated Bloodstream Infections in General Medical Patients Outside the Intensive Care Unit: A Surveillance Study

Objective.

To determine the incidence of central venous catheter (CVC)-associated bloodstream infection (CA-BSI) among patients admitted to general medical wards outside the intensive care unit (ICU).

Design.

Prospective cohort study performed over a 13-month period, from April 1, 2002, through April 30, 2003.

Setting.

Four selected general medical wards at Barnes-Jewish Hospital, a 1,250-bed teaching hospital in Saint Louis, Missouri.

Patients.

All patients admitted to 4 general medical wards.

Results.

A total of 7,337 catheter-days were observed during 33,174 patient-days. The device utilization ratio (defined as the number of catheter-days divided by the number of patient-days) was 0.22 overall and was similar among the 4 wards (0.21, 0.25, 0.19, and 0.24). Forty-two episodes of CA-BSI were identified (rate, 5.7 infections per 1,000 catheter-days). Twenty-four (57%) of the 42 cases of CA-BSI were caused by gram-positive bacteria: 10 isolates (24%) were coagulase-negative staphylococci, 10 (24%) were Enterococcus species, and 3 (7%) were Staphylococcus aureus. Gram-negative bacteria caused 7 infections (17%). Five CA-BSIs (12%) were caused by Candida albicans, and 5 infections (12%) had a polymicrobial etiology. Thirty-five patients (83%) with CA-BSI had nontunneled CVCs in place.

Conclusions.

Non-ICU medical wards in the study hospital had device utilization rates that were considerably lower than those of medical ICUs, but CA-BSI rates were similar to CA-BSI rates in medical ICUs in the United States. Studies of catheter utilization and on CVC insertion and care should be performed on medical wards. CA-BSI prevention strategies that have been used in ICUs should be studied on medical wards.

Urinary tract infections in the critical care unit: A brief review

The use of indwelling catheters in the Critical Care Units (CCUs) has a major role in determining the incidence and the morbidity as well as mortality from hospital-acquired urinary tract infections (UTIs). Instituting evidence-based protocols can significantly reduce both the prevalence of indwelling catheterization as well as the incidence of hospital-acquired UTIs. The prevalence of catheter-associated urinary tract infections (CAUTIs) in the CCUs is directly linked to the widespread use of indwelling catheters in these settings. CAUTIs result in significant cost escalation for individual hospitals as well as the healthcare system as a whole. A UTI is an inflammatory response to colonization of the urinary tract, most commonly by bacteria or fungi. A UTI should be differentiated from the mere detection of bacteria in the urinary tract. This condition, referred to as asymptomatic bacteriuria, is common and does not require treatment, especially in the patient with an indwelling urinary catheter. A CAUTI occurs when a patient with an indwelling urinary catheter develops 2 or more signs or symptoms of a UTI such as hematuria, fever, suprapubic or flank pain, change in urine character, and altered mental status. CAUTI is classified as a complicated UTI. The current review highlights the important management issues in critical care patients having CAUTI. We performed a MEDLINE search using combinations of keywords such as urinary tract infection, critical care unit and indwelling urinary catheter. We reviewed the relevant publications with regard to CAUTI in patients in CCU.

Analysis of infections in the first 3-month after living donor liver transplantation

AIM: To identify factors related to serious postoperative bacterial and fungal infections in the first 3 mo after living donor liver transplantation (LDLT).

METHODS: In the present study, the data of 207 patients from 2004 to 2011 were reviewed. The pre-, intra- and post-operative factors were statistically analyzed. All transplantations were approved by the ethics committee of West China Hospital, Sichuan University. Patients with definitely preoperative infections and infections within 48 h after transplantation were excluded from current study. All potential risk factors were analyzed using univariate analyses. Factors significant at a P < 0.10 in the univariate analyses were involved in the multivariate analyses. The diagnostic accuracy of the identified risk factors was evaluated using receiver operating curve.

RESULTS: The serious bacterial and fungal infection rates were 14.01% and 4.35% respectively. Enterococcus faecium was the predominant bacterial pathogen, whereas Candida albicans was the most common fungal pathogen. Lung was the most common infection site for both bacterial and fungal infections. Recipient age older than 45 years, preoperative hyponatremia, intensive care unit stay longer than 9 d, postoperative bile leak and severe hyperglycemia were independent risk factors for postoperative bacterial infection. Massive red blood cells transfusion and postoperative bacterial infection may be related to postoperative fungal infection.

CONCLUSION: Predictive risk factors for bacterial and fungal infections were indentified in current study. Pre-, intra- and post-operative factors can cause postoperative bacterial and fungal infections after LDLT.

Incidence of bacteremia at the time of ICU admission and its impact on outcome

CONTEXT

Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome.

METHODS

Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score.

STATISTICAL ANALYSIS

Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality.

RESULTS

Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6-100).

CONCLUSIONS

Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.

Incidence of bacteremia at the time of ICU admission and its impact on outcome

CONTEXT

Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome.

METHODS

Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score.

STATISTICAL ANALYSIS

Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t-test. Primary outcome measure was ICU mortality.

RESULTS

Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P=0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality (P=0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6-100).

CONCLUSIONS

Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.

Hospital-wide reduction in central line-associated bloodstream infections: a tale of two small community hospitals

Despite increasing awareness of central line-associated bloodstream infections (CLABSIs) in general wards, published strategies come from intensive care units (ICUs) of large tertiary care centers. After implementing a central line insertion checklist, two community hospitals experienced an 86% reduction in CLABSI rates in ICUs and a 57% reduction in non-ICU settings over 36 months.

Infecção de corrente sanguínea relacionada a cateter venoso central (ICSRC) em enfermarias: estudo prospectivo comparativo entre veia subclávia e veia jugular interna

CONTEXTO: Hemocultura positiva associada a cateter venoso central tem sido estudada em unidades de terapia intensiva (UTI), mas ainda é controverso se o acesso jugular tem maior incidência de complicações infecciosas que o acesso na veia subclávia. OBJETIVO: Comparar índice de infecção entre os acessos na jugular interna e os na veia subclávia em pacientes internados nas enfermarias de cirurgia. MÉTODOS: Estudo prospectivo, descritivo e comparativo com 114 cateteres em 96 pacientes admitidos nas enfermarias de cirurgia de um Hospital Quaternário, tendo como variáveis o local de inserção, número de lumens, tempo de uso, comparando-os com o índice de complicações infecciosas. RESULTADOS: O índice de infecção foi de 9,64% (11 cateteres), sem significância estatística quando comparados o número de lumens (mono versus duplo) e infecção (p=0,274); também sem significância estatística a comparação entre o tempo de uso (>14 dias) e infecção (p=0,156). Comparando os acessos jugular e subclávia, encontramos significância estatística tendo infecção em 17,2% na subclávia e 1,8% na jugular, com p=0,005. Índice de Hemocultura positivo associado a cateter venoso central foi maior no acesso subclávia quando comparado com jugular interna, com OR 11,2, IC95% (1,4-90,9; p=0,023). CONCLUSÕES: O acesso venoso central na jugular interna tem menor risco de infecção se comparado com subclávia em enfermarias.

[Urinary tract colonization and infection in critically ill patients]

Urinary tract infections (UTIs) account for 20-50% of all hospital-acquired infections occurring in the intensive care unit (ICU). In some reports UTI was found to be more frequent than hospital-acquired pneumonia and intravascular device bacteremia, with a greater incidence in developing countries. The risk factors associated with the appearance of UTI include the severity of illness at the time of admission to the ICU, female status, prolonged urinary catheterization or a longer ICU stay and poor urinary catheter management - mainly disconnection of the closed system. about the present study offers data on the epidemiology of UTI in the ICU, the identified risk factors, etiology, diagnosis, impact upon morbidity and mortality, and the measures to prevent its appearance.

A systematic review of failures in handoff communication during intrahospital transfers

BACKGROUND

Handoffs serve a critical function in ensuring patient care continuity during transitions of care. Studies to date have predominantly focused on intershift handoffs, with relatively little attention given to intrahospital transfers. A systematic literature review was conducted to characterize the nature of handoff failures during intrahospital transfers and to examine factors affecting handoff communication and the effectiveness of current interventions.

METHODS

Primary studies investigating handoff communication between care providers during intrahospital transfers were sought in the English-language literature between 1980 and February 2011. Data for study design, population characteristics, sample size, setting, intervention specifics, and relevant outcome measures were extracted.

DATA SYNTHESIS

Study results were summarized by the impact of communication breakdown during intrahospital transfer of patients, and the current deficiencies in the process. Results of interventions were summarized by their effect on the quality of handoff communication and patient safety.

FINDINGS

The initial search identified 516 individual articles, 24 of which satisfied the inclusion criteria. Some 19 were primary studies on handoff practices and deficiencies, and the remaining 5 were interventional studies. The studies were categorized according to the clinical settings involved in the intrahospital patient transfers.

CONCLUSIONS

There is consistent evidence on the perceived impact of communication breakdown on patient safety during intrahospital transfers. Exposure of handoffs at patient transfers presents challenges that are not experienced in intershift handoffs. The distinct needs of the specific clinical settings involved in the intrahospital patient transfer must be considered when deciding on suitable interventions.

Postoperative surgical site infection following acetabular fracture fixation

Postoperative surgical site infection (SSI) in orthopaedic trauma surgery is uncommon, but can present serious complications. This study was designed to assess the prevalence of, and to identify the risk factors for, SSI following acetabular fracture open reduction and internal fixation. A total of 326 consecutive patients who underwent acetabular fracture surgery were retrospectively reviewed. There were 17 patients (5.2%) who developed a SSI, including 10 deep infections and 7 superficial infections. Staphylococcus aureus was the most common causative pathogens in 9 patients, and was Methicillin-resistant in 3 patients. Enterococcus faecalis was found in 6 patients, Staphylococcus epidermidis in 3 patients, and Pseudomonas aeruginosa and enterbacter cloacae in 2 patients each. Fourteen of 17 patients developed their infection within 4 weeks after the fixation. Univariate analysis demonstrated that the SSI group had statistically significant higher Injury Severity Score, longer intensive care unit (ICU) stays, larger amount of packed red blood cells transfused, longer operative time, larger estimated operative blood loss, higher body mass index (BMI), more frequent performance of combined approach, embolisation of internal iliac arteries, association of urinary tract injury, and Morel-Lavallée lesion compared to the no SSI group. Multivariate analysis using these 10 parameters showed that BMI, ICU stay, and Morel-Lavallée lesion were independently significant risk factors for SSI. To reduce the incidence of SSI following acetabular fracture surgery, special attention should be directed at the care of obese patients, patients requiring ICU care, and patients with associated Morel-Lavallée lesions.

Epidemiology and outcome of nosocomial bloodstream infection in elderly critically ill patients: a comparison between middle-aged, old, and very old patients

BACKGROUND

We investigated the epidemiology of nosocomial bloodstream infection in elderly intensive care unit (ICU) patients.

METHODS

In a single-center, historical cohort study (1992-2006), we compared middle-aged (45-64 years; n = 524), old(65-74 years; n = 326), and very old ICU patients (> 75 years; n = 134) who developed a nosocomial bloodstream infection during their ICU stay.

RESULTS

Although the total number of ICU admissions (patients aged > or = 45 years) decreased by approximately 10%, the number of very old patients increased by 33% between the periods 1992-1996 and 2002-2006. The prevalence of bloodstream infection (per 1,000 ICU admissions) increased significantly over time among old (p = 0.001) and very old patients (p = 0.002), but not among middle-aged patients (p = 0.232). Yet, this trend could not be confirmed with the incidence data expressed per 1,000 patient days (p > 0.05). Among patients with bloodstream infection, the proportion of very old patients increased significantly with time from 7.2% (1992-1996) to 13.5% (1997-2001) and 17.4% (2002-2006) (p <0.001). The incidence of bloodstream infection (per 1000 patient days) decreased with age: 8.4 per thousand in middle-aged, 5.5 per thousand in old, and 4.6 per thousand in very old patients (p < 0.001). Mortality rates increased with age: 42.9%, 49.1%, and 56.0% for middle-aged, old, and very old patients, respectively (p = 0.015). Regression analysis revealed that the adjusted relationship with mortality was borderline significant for old age (hazard ratio, 1.2; 95% confidence interval, 1.0 -1.5) and significant for very old age (hazard ratio,1.8; 95% confidence interval, 1.4 -2.4).

CONCLUSION

Over the past 15 years, an increasing number of elderly patients were admitted to our ICU. The incidence of nosocomial bloodstream infection is lower among very old ICU patients when compared to middle-aged and old patients. Yet, the adverse impact of this infection is higher in very old patients.

Catheter-associated bloodstream infections: looking outside of the ICU

BACKGROUND

Current recommendations for the prevention of central venous catheter-associated bloodstream infections (CA-BSIs) are mostly based on data from intensive care units (ICUs). The rates of CA-BSIs appear to be higher in non-ICU wards. Until this year, no published data were available on non-ICU CA-BSIs in the United States. This article is a summary of a talk given at an industry-sponsored conference on CA-BSIs. It summarizes an original article of ours previously published in a peer-reviewed journal.

OBJECTIVE

The objective of this study was to determine the rate of CA-BSIs in non-ICU medical patients by developing a prospective surveillance program in a major tertiary care hospital. All positive blood cultures electronically detected from April 1, 2002, to April 30, 2003, were reviewed and clinical data collected by chart review.

DEFINITIONS

Catheter utilization ratio = total number of days with a central venous catheter (CVC)/total number of patient-days; catheter-associated BSIs = defined by Centers for Disease Control and Prevention criteria, eg, a patient had to have a catheter at least 48 hours before detection of infection; CA-BSI rate = CA-BSIs/1000 catheter-days.

RESULTS

The 13-month study included 7337 catheter-days and 33,174 patient-days. The overall catheter-utilization ratio was 0.22 (range, 0.19-0.25). Of 42 cases of CA-BSIs, gram-positive organisms were recovered in 24 (57%); gram-negative bacteria in 7 (17%); and Candida spp in 6 (14%). The CA-BSI rate was 5.7 (95% confidence interval: 3.4-8.0) and varied from 4.3 to 8.0. There were no significant differences in CA-BSI rates among the wards (chi(2) for linear trend, 0.42; P = .52). The overall rate of CA-BSIs decreased steadily during the study period, from 7.8 during the first 6 months to 3.9 during the following 7 months, representing a rate ratio of 0.5 (95% confidence interval: 0.27-0.93).

CONCLUSION

Benchmark data for hospital infections in the non-ICU setting are starting to become available and efforts to improve care may have greater impact here than in the ICU. Upon patient transfer out of the ICU, it should be determined whether the catheter can be removed. Educational measures targeted at non-ICU wards are warranted. First results of computer-assisted methods to facilitate surveillance of larger number of patients are promising. The Healthcare Infection Control Practices Advisory Committee recommends that CA-BSIs be publicly reported. CA-BSIs in non-ICU patients could soon be part of a mandatory reporting.

Evolving pathogens in the surgical intensive care unit: a 6-year experience

BACKGROUND

Nosocomial infections in the intensive care unit (ICU) are well-known causes of morbidity and mortality in critically ill patients. Further complicating this issue is the ever-increasing number of multidrug-resistant pathogens. This study was designed to investigate and document changing microbial trends within the Los Angeles County/University of Southern California Medical Center surgical ICU (SICU), including drug-resistant pathogens.

METHODS

A 6-year retrospective cohort study of all patients 18 to 85 years old with positive blood, urine, or sputum cultures admitted to an urban, level 1 trauma/SICU. Patients were identified through the Los Angeles County/University of Southern California Medical Center epidemiological records and computerized ICU database. The entire data set was analyzed according to pathogen classification schemes, culture date, type of infection, and with some patient characteristics including sex, average age, and Acute Physiology and Chronic Health Evaluation II score. Two groups were created to analyze changing trends: a past group (2000-2002 cultures) and a present group (2003-2005 cultures). Any repeated cultures were excluded, as was coagulase-negative Staphylococcus, which was considered a contaminant.

RESULTS

Over the past 6 years, there were 1164 SICU patients who developed 2260 positive cultures (346 blood, 1,685 respiratory, 229 urine). The average age of patients was 43 +/- 19 years, and their average Acute Physiology and Chronic Health Evaluation II score was 22 +/- 12. Of the 1164 patients, 76% were male, and 64% suffered trauma injuries. Although there was no difference in the rate of positive blood cultures caused by Gram-positive (GP) or Gram-negative (GN) organisms in the past and present groups (P = .32), GPs became more common in the present group for both respiratory (P < .0001) and urine (P = .004) cultures. In both blood and respiratory cultures, oxacillin-resistant Staphylococcus aureus was a more common GP pathogen (22% vs 7%, P = .004 and 20% vs 11%, P = .004) and represented a larger proportion of staphylococcal species in the present group (50% vs 21%, P = .01 and 30% vs. 21%, P = .04).

CONCLUSIONS

Our study found that within the SICU, GP organisms play an increasing pathogenic role in critical patients. Staphylococcal species have become more common pathogens in the last 6 years, with an increase in the proportion of drug-resistant strains (oxacillin-resistant S aureus). These findings illustrate the need to keep constant surveillance on microbial trends within the SICU, especially those among drug-resistant pathogens.

Hydrocortisone therapy for patients with septic shock

BACKGROUND

Hydrocortisone is widely used in patients with septic shock even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after the administration of corticotropin.

METHODS

In this multicenter, randomized, double-blind, placebo-controlled trial, we assigned 251 patients to receive 50 mg of intravenous hydrocortisone and 248 patients to receive placebo every 6 hours for 5 days; the dose was then tapered during a 6-day period. At 28 days, the primary outcome was death among patients who did not have a response to a corticotropin test.

RESULTS

Of the 499 patients in the study, 233 (46.7%) did not have a response to corticotropin (125 in the hydrocortisone group and 108 in the placebo group). At 28 days, there was no significant difference in mortality between patients in the two study groups who did not have a response to corticotropin (39.2% in the hydrocortisone group and 36.1% in the placebo group, P=0.69) or between those who had a response to corticotropin (28.8% in the hydrocortisone group and 28.7% in the placebo group, P=1.00). At 28 days, 86 of 251 patients in the hydrocortisone group (34.3%) and 78 of 248 patients in the placebo group (31.5%) had died (P=0.51). In the hydrocortisone group, shock was reversed more quickly than in the placebo group. However, there were more episodes of superinfection, including new sepsis and septic shock.

CONCLUSIONS

Hydrocortisone did not improve survival or reversal of shock in patients with septic shock, either overall or in patients who did not have a response to corticotropin, although hydrocortisone hastened reversal of shock in patients in whom shock was reversed. (ClinicalTrials.gov number, NCT00147004.)

Survival of critically ill patients hospitalized in and out of intensive care

OBJECTIVE

A lack of intensive care units beds in Israel results in critically ill patients being treated outside of the intensive care unit. The survival of such patients is largely unknown. The present study's objective was to screen entire hospitals for newly deteriorated patients and compare their survival in and out of the intensive care unit.

DESIGN

A priori developed intensive care unit admission criteria were used to screen, during 2 wks, the patient population for eligible incident patients. A screening team visited every hospital ward of five acute care hospitals daily. Eligible patients were identified among new admissions in the emergency department and among hospitalized patients who acutely deteriorated. Patients were followed for 30 days for mortality regardless of discharge.

SETTING

Five acute care hospitals.

PATIENTS

A total of 749 newly deteriorated patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Crude survival of patients in and out of the intensive care unit was compared by Kaplan-Meier curves, and Cox models were constructed to adjust the survival comparisons for residual case-mix differences. A total of 749 newly deteriorated patients were identified among 44,000 patients screened (1.7%). Of these, 13% were admitted to intensive care unit, 32% to special care units, and 55% to regular departments. Intensive care unit patients had better early survival (0-3 days) relative to regular departments (p=.0001) in a Cox multivariate model. Early advantage of intensive care was most pronounced among patients who acutely deteriorated while on hospital wards rather than among newly admitted patients.

CONCLUSIONS

Only a small proportion of eligible patients reach the intensive care unit, and early admission is imperative for their survival advantage. As intensive care unit benefit was most pronounced among those deteriorating on hospital wards, intensive care unit triage decisions should be targeted at maximizing intensive care unit benefit by early admitting patients deteriorating on hospital wards.

Epidemiology of intensive care unit (ICU)-acquired infections in a 14-month prospective cohort study in a single mixed Scandinavian university hospital ICU

BACKGROUND

Our aim was to evaluate the epidemiology of intensive care unit (ICU)-acquired infections in a prospective cohort study.

METHODS

Patients with longer than a 48-h stay in an adult mixed medical-surgical ICU in a tertiary level teaching hospital were included. The incidence (per cent) and incidence density (per 1000 patient days) of ICU-acquired infections and the device-associated infection rates per 1000 device days were analysed prospectively in a 14-month study.

RESULTS

Eighty (23.9%) of 335 patients, whose ICU stay was longer than 48 h, acquired a total of 107 infections (1.3 per patient) during their ICU stay, with an infection rate of 48 per 1000 patient days. The most common infections were ventilator-associated pneumonia (VAP) [33.8% (18.8 per 1000 respiratory days)], other lower respiratory tract infections (LRTIs) (20%) and sinusitis (13.8%). The rate of central catheter-related (CRI) or primary bloodstream infections was 6.3% (2.2 per 1000 central venous catheter days), and the rate of urinary tract infections was 1.3% (0.5 per 1000 urinary catheter days). The first ICU infection was observed in 58.8% (47/80) of cases within 6 days after admission. The median time from admission to the diagnosis of an ICU-acquired infection was 4 days (25th-75th percentiles, 4.0-6.0) for VAP, 6.0 days (4.5-7.0) for LRTIs and 9.5 days (6.5-13.0) for CRIs.

CONCLUSIONS

The rates of urinary tract infections and bloodstream infections were lower than reported previously, differentiating our results from the classic pattern of ICU-acquired infections, with the exception of the predominance of VAP.

Prevention of infection in the intensive care unit

PURPOSE OF REVIEW

To review tactics used to prevent intensive care unit infections, particularly ventilator-associated pneumonia and catheter-related bloodstream infections.

RECENT FINDINGS

Health-care-associated infections in the intensive care unit are associated with elevated mortality, morbidity, and hospital costs, and increasing antibiotic resistance. The US Centers for Disease Control and Prevention recently published guidelines for the prevention of ventilator-associated pneumonia and catheter-related bloodstream infections. Though not generally recommended, selective decontamination of the digestive tract, an antibiotic prophylaxis strategy, consistently demonstrates reduction in ventilator-associated pneumonia rates and mortality but its broader use is limited by concerns of increasing resistance. The continued positive results from selective decontamination of the digestive tract require that this strategy receive significant attention in future studies. Regarding catheter-related bloodstream infections, the recommendations suggest education should be used to reduce infection rates, but it is likely that the impact of these directives is undervalued. The data demonstrate marked reduction in catheter-related bloodstream infections in both Latin America and the USA by employing a very low-tech intervention of education, performance feedback, and initiating process controls.

SUMMARY

By preventing infections in the intensive care unit, not only is the expected effect to reduce injury related to the disease process, but the long-term effect is to also reduce resistance by decreasing the need for antibiotics.

Epidemiology of intensive care unit-acquired urinary tract infections

PURPOSE OF REVIEW

The development of urinary tract infections in critically ill adult patients is associated with considerable morbidity, prolonged hospitalization, and greater healthcare expenditures. We review the occurrence, microbiology, risk factors for acquisition, and outcomes associated with intensive care unit-acquired urinary tract infections.

RECENT FINDINGS

Reports from several countries indicate that nosocomial urinary tract infections frequently complicate the course of patients admitted to intensive care units. Virtually all patients who develop an intensive care unit-acquired urinary tract infection have indwelling urinary catheters; other factors associated with the development of these infections include increased duration of urinary catheterization, female sex, intensive care unit length of stay, and preceding systemic antimicrobial therapy. The most frequent pathogens include Escherichia coli, Pseudomonas aeruginosa, enterococci, and Candida albicans; both the species distribution and rates of resistance vary considerably among institutions and regions. Secondary bloodstream infections are uncommon. Although acquisition of an intensive care unit-acquired urinary tract infection has been associated with a prolongation of intensive care unit length of stay, higher cost, and a higher crude case fatality rate, they do not appear to independently increase the risk for death.

SUMMARY

Urinary tract infection is a common complication of critical illness that is associated with increased patient morbidity but not mortality. There is a relative paucity of research on nosocomial urinary tract infection specifically acquired in the intensive care unit and further studies are needed to better define the epidemiology and management of these infections.