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Valenzuela-Sánchez F, Valenzuela-Méndez B, Rodríguez-Gutiérrez JF, Estella Á. Latest developments in early diagnosis and specific treatment of severe influenza infection. JOURNAL OF INTENSIVE MEDICINE 2024; 4:160-174. [PMID: 38681787 PMCID: PMC11043645 DOI: 10.1016/j.jointm.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Influenza pandemics are unpredictable recurrent events with global health, economic, and social consequences. The objective of this review is to provide an update on the latest developments in early diagnosis and specific treatment of the disease and its complications, particularly with regard to respiratory organ failure. Despite advances in treatment, the rate of mortality in the intensive care unit remains approximately 30%. Therefore, early identification of potentially severe viral pneumonia is extremely important to optimize treatment in these patients. The pathogenesis of influenza virus infection depends on viral virulence and host response. Thus, in some patients, it is associated with an excessive systemic response mediated by an authentic cytokine storm. This process leads to severe primary pneumonia and acute respiratory distress syndrome. Initial prognostication in the emergency department based on comorbidities, vital signs, and biomarkers (e.g., procalcitonin, ferritin, human leukocyte antigen-DR, mid-regional proadrenomedullin, and lactate) is important. Identification of these biomarkers on admission may facilitate clinical decision-making to determine early admission to the hospital or the intensive care unit. These decisions are reached considering pathophysiological circumstances that are associated with a poor prognosis (e.g., bacterial co-infection, hyperinflammation, immune paralysis, severe endothelial damage, organ dysfunction, and septic shock). Moreover, early implementation is important to increase treatment efficacy. Based on a limited level of evidence, all current guidelines recommend using oseltamivir in this setting. The possibility of drug resistance should also be considered. Alternative options include other antiviral drugs and combination therapies with monoclonal antibodies. Importantly, it is not recommended to use corticosteroids in the initial treatment of these patients. Furthermore, the implementation of supportive measures for respiratory failure is essential. Current recommendations are limited, heterogeneous, and not regularly updated. Early intubation and mechanical ventilation is the basic treatment for patients with severe respiratory failure. Prone ventilation should be promptly performed in patients with acute respiratory distress syndrome, while early tracheostomy should be considered in case of planned prolonged mechanical ventilation. Clinical trials on antiviral treatment and respiratory support measures specifically for these patients, as well as specific recommendations for different at-risk populations, are necessary to improve outcomes.
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Affiliation(s)
- Francisco Valenzuela-Sánchez
- Intensive Care Unit, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Haematology Department, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Centro de Investigación Biomédica en Red, Enfermedades respiratorias, CIBERES, Instituto de Salud Carlos III, Av. de Monforte de Lemos, Madrid, Spain
| | - Blanca Valenzuela-Méndez
- Department of Oncological Surgery, Institut du Cancer de Montpellier (ICM), Parc Euromédecine, 208 Av. des Apothicaires,Montpellier, France
| | | | - Ángel Estella
- Intensive Care Unit, University Hospital of Jerez, Ronda de Circunvalación s/n, Jerez de la Frontera, Spain
- Department of Medicine, Faculty of Medicine, University of Cádiz, Calle Doctor Marañón, Cádiz, Spain
- Instituto de Investigación e Innovación Biomédica de Cádiz (INIBiCA), Avenida Ana de Viya 21, Cádiz, Spain
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Scheithauer S, Karasimos B, Manamayil D, Häfner H, Lewalter K, Mischke K, Heintz B, Tacke F, Brücken D, Lüring C, Heidenhain C, Tewarie L, Hilgers RD, Lemmen SW. A prospective cluster trial to increase antibiotic prescription quality in seven non-ICU wards. GMS HYGIENE AND INFECTION CONTROL 2023; 18:Doc14. [PMID: 37405250 PMCID: PMC10316282 DOI: 10.3205/dgkh000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Aim To evaluate general shortcomings and faculty-specific pitfalls as well as to improve antibiotic prescription quality (ABQ) in non-ICU wards, we performed a prospective cluster trial. Methods An infectious-disease (ID) consulting service performed a prospective investigation consisting of three 12-week phases with point prevalence evaluation conducted once per week (=36 evaluations in total) at seven non-ICU wards, followed by assessment of sustainability (weeks 37-48). Baseline evaluation (phase 1) defined multifaceted interventions by identifying the main shortcomings. Then, to distinguish intervention from time effects, the interventions were performed in four wards, and the 3 remaining wards served as controls; after assessing effects (phase 2), the same interventions were performed in the remaining wards to test the generalizability of the interventions (phase 3). The prolonged responses after all interventions were then analyzed in phase 4. ABQ was evaluated by at least two ID specialists who assessed the indication for therapy, the adherence to the hospital guidelines for empirical therapy, and the overall antibiotic prescription quality. Results In phase 1, 406 of 659 (62%) patients cases were adequately treated with antibiotics; the main reason for inappropriate prescription was the lack of an indication (107/253; 42%). The antibiotic prescription quality (ABQ) significantly increased, reaching 86% in all wards after the focused interventions (502/584; nDf=3, ddf=1,697, F=6.9, p=0.0001). In phase 2 the effect was only seen in wards that already participated in interventions (248/347; 71%). No improvement was seen in wards that received interventions only after phase 2 (189/295; 64%). A given indication significantly increased from about 80% to more than 90% (p<.0001). No carryover effects were observed. Discussion ABQ can be improved significantly by intervention bundles with apparent sustainable effects.
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Affiliation(s)
- Simone Scheithauer
- Department of Infection Control and Infectious Diseases, University Medical Center Göttingen (UMG), Georg-August University Göttingen, Germany
| | - Britta Karasimos
- Clinic for Orthopedics and Trauma Surgery, Hospital Düren, Düren, Germany
| | - David Manamayil
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Helga Häfner
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Karl Lewalter
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Karl Mischke
- Medical Clinic 1, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | - Bernhard Heintz
- Clinic for Nephrology, University Hospital Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte (CCM)/Campus Virchow-Klinikum (CVK, Charité – University Medical Center Berlin, Berlin, Germany
| | - David Brücken
- Clinic for Traumatology, University Hospital Aachen, Aachen, Germany
| | | | - Christoph Heidenhain
- Clinic for Visceral Surgery, AGAPLESION MARKUS Krankenhaus Frankfurt, Frankfurt/Main, Germany
| | | | | | - Sebastian W. Lemmen
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
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Grande B, Breckwoldt J, Kolbe M. „Die Puppe hat Luftnot“ – Simulation zum interprofessionellen Lernen im Team: aber sinnvoll! Notf Rett Med 2022. [DOI: 10.1007/s10049-021-00933-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
ZusammenfassungAusbildungskonzepte, die eine Simulation von Fällen und Szenarien aller Art nutzen, haben breiten Eingang in Curricula und Praxis gefunden. Ein Vertrauen in technische Simulationsmethoden ohne qualifizierte Ausbildung in der Methode kann schaden. Deswegen sollte nach der Auswahl der korrekten Simulationsmethode großer Wert auf die Durchführung der Simulation gelegt werden. Neben einem strukturierten Design der simulierten Szenarien und der korrekten technischen Durchführung ist für den Lernerfolg vor allem das Debriefing, die Nachbesprechung, entscheidend. Prüfungen mit Simulation als Methode sind nur zu empfehlen, wenn sie von Trainings getrennt durchgeführt werden und die Bewertung nach transparenten, validierten Kriterien erfolgt.
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Prävention der postoperativen Wundinfektion. Anaesthesist 2016; 65:328-36. [DOI: 10.1007/s00101-016-0169-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 03/08/2016] [Accepted: 03/18/2016] [Indexed: 01/28/2023]
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Kimpton G, Lewis White P, Barnes RA. The effect of sample storage on the performance and reproducibility of the galactomannan EIA test. Med Mycol 2014; 52:618-26. [DOI: 10.1093/mmy/myu014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Timing of therapy plays a pivotal role in intensive care patients. Although being evident and self-explanatory, it has to be considered that the appropriateness of a specific therapeutic intervention is likewise important. In view of antibiotic therapy of critically ill patients, the available evidence supports the concept of hitting hard, early (as soon as possible and at least before the onset of shock) and appropriately. There is increasing evidence that a positive fluid balance is not only a cosmetic problem but is associated with increased morbidity. However, prospective studies are needed to elucidate whether a positive net fluid balance represents the cause or the effect of a specific disease. Since central venous pressure (CVP) is an unreliable marker of fluid responsiveness, its clinical use to guide fluid therapy is questionable. Dynamic hemodynamic parameters seem to be superior to CVP in predicting fluid responsiveness in hemodynamically unstable patients. Sedation is often used to facilitate mechanical ventilation. Since there is no best evidence-based sedation protocol, weaning strategies should take the risk of iatrogenic arterial hypotension secondary to high doses of vasodilatory sedative agents into account. In this regard, the concept of daily wake-up calls should be challenged, because higher cumulative doses of sedatives may be required. The right dose and timing for renal replacement therapy is still discussed controversially and remains a subjective decision of the attending physician. New renal biomarkers may perhaps be helpful to validate when (and how) renal replacement therapy should be performed best. Last but not least, all therapeutic interventions should take the individual co-morbidities and underlying pathophysiological conditions into account.
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Affiliation(s)
- Martin Westphal
- Fresenius Kabi AG, Else-Kröner-Strasse 1, 61352 Bad Homburg, Germany.
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Juneja D, Singh O, Javeri Y, Arora V, Dang R, Kaushal A. Prevention and management of ventilator-associated pneumonia: A survey on current practices by intensivists practicing in the Indian subcontinent. Indian J Anaesth 2011; 55:122-8. [PMID: 21712867 PMCID: PMC3106383 DOI: 10.4103/0019-5049.79889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Implementation of evidence-based guidelines to prevent and manage ventilator-associated pneumonia (VAP) in the clinical setting may not be adequate. We aimed to assess the implementation of selected VAP prevention strategies, and to learn how VAP is managed by the intensivists practicing in the Indian Subcontinent. Three hundred 10-point questionnaires were distributed during an International Critical Care Conferenceheld at New Delhi in 2009. A total of 126 (42%) questionnaires distributed among delegates from India, Nepal and Sri Lanka were analyzed. Majority (96.8%) reported using VAP bundles with a high proportion including head elevation (98.4%), chlorhexidine mouthcare (83.3%), stress ulcer prophylaxis (96.8%), heat and moisture exchangers (HME, 92.9%), early weaning (94.4%), and hand washing (97.6%) as part of their VAP bundle. Use of subglottic secretion drainage (SSD, 45.2%) and closed suction systems (CSS, 74.6%) was also reported by many intensivists, whereas use of selective gut decontamination was reported by only 22.2%. Commonest method for sampling was endotracheal suction by 68.3%. Gram negative organisms were reported to be the most commonly isolated. Majority (39.7%) reported using proton pump inhibitors for stress ulcer prophylaxis and 84.1% believed that VAP contributed to increased mortality. De-escalating therapy was considered in patients responding to treatment by 57.9% and 65.9% considered adding empirical methicillin resistant Staphylococcus aureus (MRSA)coverage, while 63.5% considered adding nebulized antibiotics in certain high-risk patients. There was good concordance regarding VAP prophylaxis among the intensivists with a majority adhering to evidence-based guidelines. We could identify certain issues like the choice of agent for stress ulcer prophylaxis, use of HME filters, SSD and CSS, where there still exists some practice variability and opportunities for improvement.
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Affiliation(s)
- Deven Juneja
- Department of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi, India
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Better outcomes through continuous infusion of time-dependent antibiotics to critically ill patients? Curr Opin Crit Care 2008; 14:390-6. [DOI: 10.1097/mcc.0b013e3283021b3a] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
This review focuses on the top ten causes of ventilator-associated pneumonia (VAP), updating an earlier study. These pathogens have specific risk factors, different patterns of clinical resolution, and a wide range of attributable mortality. The discussion herein analyzes these aspects, placing particular emphasis on risk factors, attributable mortality, resistance, and the implications for management.
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Affiliation(s)
- Jordi Rello
- Critical Care Department, Joan XXIII University Hospital, University Rovira & Virgili, Carrer Dr. Mallafre Guasch 4, Tarragona 43007, Spain.
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Ferrara AM, Fietta AM. New Developments in Antibacterial Choice for Lower Respiratory Tract Infections in Elderly Patients. Drugs Aging 2004; 21:167-86. [PMID: 14979735 DOI: 10.2165/00002512-200421030-00003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Elderly patients are at increased risk of developing lower respiratory tract infections compared with younger patients. In this population, pneumonia is a serious illness with high rates of hospitalisation and mortality, especially in patients requiring admission to intensive care units (ICUs). A wide range of pathogens may be involved depending on different settings of acquisition and patient's health status. Streptococcus pneumoniae is the most common bacterial isolate in community-acquired pneumonia, followed by Haemophilus influenzae, Moraxella catarrhalis and atypical pathogens such as Chlamydia pneumoniae, Legionella pneumophila and Mycoplasma pneumoniae. However, elderly patients with comorbid illness, who have been recently hospitalised or are residing in a nursing home, may develop severe pneumonia caused by multidrug resistant staphylococci or pneumococci, and enteric Gram-negative bacilli, including Pseudomonas aeruginosa. Moreover, anaerobes may be involved in aspiration pneumonia. Timely and appropriate empiric treatment is required in order to enhance the likelihood of a good clinical outcome, prevent the spread of antibacterial resistance and reduce the economic impact of pneumonia. International guidelines recommend that elderly outpatients and inpatients (not in ICU) should be treated for the most common bacterial pathogens and the possibility of atypical pathogens. The algorithm for therapy is to use either a selected beta-lactam combined with a macrolide (azithromycin or clarithromycin), or to use monotherapy with a new anti-pneumococcal quinolone, such as levofloxacin, gatifloxacin or moxifloxacin. Oral (amoxicillin, amoxicillin/clavulanic acid, cefuroxime axetil) and intravenous (sulbactam/ampicillin, ceftriaxone, cefotaxime) beta-lactams are agents of choice in outpatients and inpatients, respectively. For patients with severe pneumonia or aspiration pneumonia, the specific algorithm is to use either a macrolide or a quinolone in combination with other agents; the nature and the number of which depends on the presence of risk factors for specific pathogens. Despite these recommendations, clinical resolution of pneumonia in the elderly is often delayed with respect to younger patients, suggesting that optimisation of antibacterial therapy is needed. Recently, some new classes of antibacterials, such as ketolides, oxazolidinones and streptogramins, have been developed for the treatment of multidrug resistant Gram-positive infections. However, the efficacy and safety of these agents in the elderly is yet to be clarified. Treatment guidelines should be modified on the basis of local bacteriology and resistance patterns, while dosage and/or administration route of each antibacterial should be optimised on the basis of new insights on pharmacokinetic/pharmacodynamic parameters and drug interactions. These strategies should be able to reduce the occurrence of risk factors for a poor clinical outcome, hospitalisation and death.
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Affiliation(s)
- Anna Maria Ferrara
- Department of Haematological, Pneumological, Cardiovascular Medical and Surgical Sciences, University of Pavia, IRCCS Policlinico San Matteo, Pavia, Italy.
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Sandiumenge A, Diaz E, Bodí M, Rello J. Therapy of ventilator-associated pneumonia. A patient-based approach based on the ten rules of "The Tarragona Strategy". Intensive Care Med 2003; 29:876-883. [PMID: 12677369 DOI: 10.1007/s00134-003-1715-1] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2002] [Accepted: 01/30/2003] [Indexed: 12/19/2022]
Abstract
Therapy of ventilator-associated pneumonia should be a patient-based approach focusing on some key features are listed here: early initial therapy should be based on broad-spectrum antibiotics. Empirical treatment may be targeted after direct staining and should be modified according to good-quality quantitative microbiological findings, but should never be withdrawn in presence of negative direct staining or delayed until microbiological results are available. Courses of therapy should be given at high doses according to pharmacodynamic and tissue penetration properties. Prolonging antibiotic treatment does not prevent recurrences. Methicillin-sensitive Staphylococcus aureus should be expected in comatose patients. Methicillin-resistant Staphylococcus aureus should not be expected in patients without previous antibiotic coverage. Pseudomonas aeruginosa should be covered with combination therapy. Antifungal therapy, even when Candida spp is isolated in significant concentrations, is not recommended for intubated nonneutropenic patients. Vancomycin, given at the standard doses and route of administration for the treatment of VAP caused by Gram-positive pathogens, is associated with poor outcomes. The choice of initial antibiotic should be based on the patient's previous antibiotic exposure and comorbidities, and local antibiotic susceptibility patterns, which should be updated regularly.
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Affiliation(s)
- Alberto Sandiumenge
- Department of Critical Care, Joan XXIII University Hospital, University Rovira and Virgili, C/ Doctor Mallafré Guasch, 4,, 43007, Tarragona, Spain. jrc@hjxxiii. scs. es
| | - Emili Diaz
- Department of Critical Care, Joan XXIII University Hospital, University Rovira and Virgili, C/ Doctor Mallafré Guasch, 4,, 43007, Tarragona, Spain
| | - Maria Bodí
- Department of Critical Care, Joan XXIII University Hospital, University Rovira and Virgili, C/ Doctor Mallafré Guasch, 4,, 43007, Tarragona, Spain
| | - Jordi Rello
- Department of Critical Care, Joan XXIII University Hospital, University Rovira and Virgili, C/ Doctor Mallafré Guasch, 4,, 43007, Tarragona, Spain
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Abstract
Ventilator-associated pneumonia is the most serious infectious complication in critically ill patients, associated with increased length of intensive care unit treatment and high mortality rates. Investigations focused on outcome variables have improved the database to estimate diagnostic and therapeutic management strategies. This knowledge has diminished the importance of the discussion on how to diagnose the pneumonia. This review summarizes recent data on epidemiology and mortality, risk factors and prevention, diagnosis, microbiology and antimicrobial treatment of ventilator-associated pneumonia.
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Affiliation(s)
- Alexandra Heininger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany.
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