Epidemiology, associated factors and outcomes of ICU-acquired infections caused by Gram-negative bacteria in critically ill patients: an observational, retrospective study

Evaluation of Short Versus Long Courses of Antibiotics in Critically Ill Patients With Gram-Negative Bloodstream Infections

BACKGROUND

Short courses of antibiotics (7-10 days) are effective for uncomplicated gram-negative bloodstream infections (GN-BSI). However, prior studies have been limited to small cohorts of critically ill patients.

OBJECTIVE

The objective of this study was to evaluate the safety and efficacy of short courses of therapy compared with longer courses in patients admitted to the intensive care unit (ICU) with GN-BSI.

METHODS

Propensity-matched, retrospective cohort study of critically ill patients with GN-BSI. The primary outcome was a composite of 30-day mortality or 60-day relapse. Secondary endpoints were components of the composite, 30-day relapse, cure with or without adverse drug events (ADE), and ADEs. Regression analysis was performed to identify factors predictive of the composite outcome.

RESULTS

225 patients were included in the propensity analysis, 145 in the long cohort and 80 in the short cohort. The primary outcome occurred in 3.8% of patients in the short group and 9.0% of patients in the long group (P = 0.24). There was no difference in 30-day mortality (3.8% vs 5.5%, P = 0.79), 60-day relapse (0% vs 3.4%, P = 0.23), or 30-day readmission (20% vs 22.8%, P = 0.76). ADEs were more common in the long group (47.2% vs 34.1%, OR 1.7, 95% CI 1.04-2.9), primarily attributable to diarrhea.

CONCLUSION AND RELEVANCE

In critically ill patients with GN-BSI, there were no efficacy outcome differences in patients treated with a short course of antibiotics compared with longer. However, patients in the short group were less likely to experience ADE. These findings suggest that short courses of antibiotics are effective for GN-BSI in critically ill patients.

An Observational Study of Nutritional Assessment, Prescription, Practices, and Its Outcome among Critically Ill Patients Admitted to an Intensive Care Unit

Aim and background

Optimal feeding strategy for critically ill patients of intensive care unit (ICU) is often a matter of debate as patients admitted to ICU are highly catabolic and reduction in muscle mass is very common. We aimed at early achievement of nutritional goals in preventing skeletal muscle breakdown and improving clinical outcomes among critically ill patients with high risk of malnutrition.

Materials and methods

Nutrition risk in the critically ill (mNUTRIC) Score was used to identify the risk of malnutrition within 24 hours of admission. Quadriceps muscle mass index was measured within 24 hours of admission to ICU and repeated on 7th day. Enteral feeding was monitored by the nutrition expert as part of routine patient care and clinical outcomes were monitored.

Results

A total of 287 patients admitted in ICU were screened for malnutrition and 60 (20.9%) of them had high score (>5). There was no statistically significant reduction in the quadriceps muscle mass index (p < 0.05) (t = 0.601) measured within 24 hours of admission and on the 7th day of ICU stay, signifying that the nutritional prescription and monitoring may be useful in preserving the muscle mass. This study did not find statistically significant association between the high mNUTRIC score on admission and the clinical outcomes, such as 28 days mortality, incidence of pressure ulcers, length of ICU stay, and hospital-acquired infection (p > 0.05).

Conclusion

Early initiation and maintenance of enteral nutrition is essential for meeting target calories and protein requirements. It may help to preserve muscle mass in critically ill patients who are otherwise at high risk of malnutrition.

How to cite this article

Sharon T, Nayak SG, Shanbhag V, Hebbar S. An Observational Study of Nutritional Assessment, Prescription, Practices, and Its Outcome among Critically Ill Patients Admitted to an Intensive Care Unit. Indian J Crit Care Med 2024;28(4):364-368.

Risk predict model using multi-drug resistant organism infection from Neuro-ICU patients: a retrospective cohort study

The aim of this study was to analyze the current situation and risk factors of multi-drug-resistant organism (MDRO) infection in Neuro-intensive care unit (ICU) patients, and to develop the risk predict model. The data was collected from the patients discharged from Neuro-ICU of grade-A tertiary hospital at Guizhou province from January 2018 to April 2020. Binary Logistics regression was used to analyze the data. The model was examined by receiver operating characteristic curve (ROC). The grouped data was used to verify the sensitivity and specificity of the model. A total of 297 patients were included, 131 patients infected with MDRO. The infection rate was 44.11%. The results of binary Logistics regression showed that tracheal intubation, artery blood pressure monitoring, fever, antibiotics, pneumonia were independent risk factors for MDRO infection in Neuro-ICU (P < 0.05), AUC = 0.887. The sensitivity and specificity of ROC curve was 86.3% and 76.9%. The risk prediction model had a good predictive effect on the risk of MDRO infection in Neuro ICU, which can evaluate the risk and provide reference for preventive treatment and nursing intervention.

Virtual screening, pharmacokinetics, and molecular dynamics simulations studies to identify potent approved drugs for Chlamydia trachomatis treatment

Background

The most frequent bacterial sexually transmitted disease is Chlamydia trachomatis (STD). In 2010, the Centers for Disease Control and Prevention (CDC) received 1.3 million reports of cases (CDC). Human chlamydial infections are linked to a variety of clinical symptoms. Inclusion (IncA) membranes are a promising drug target for the treatment of Chlamydia trachomatis. In the present study, molecular docking, ADMET, golden triangle, and molecular dynamics (MD) simulation studies were performed on a series of salicylidene acylhydrazides derivatives against Chlamydia trachomatis. Three types of docking software with different algorithms were used to screen the potential candidate against Chlamydia trachomatis.

Results

The results obtained from the docking analysis succeeded in screening nine novel hit compounds with high affinity to IncA membranes. Then, pharmacokinetics properties were calculated to spot out the drug-likeness of the selected compounds. Also, golden triangles were performed on the selected compounds. Compounds outside the golden triangle indicate that they would have clearance problems. Out of the nine novel hits drugs, four compounds pass the golden triangle screening and virtually all the quality assurance tests proposed by the model and were used for further analysis. One-ns molecular dynamics simulations on the docked complex of compound 44 (one of the highly active selected compounds of the dataset) aided in the further exploration of the binding interactions. Some crucial residues such as Ser111, Gln114, Asn107, Leu142, Gly144, Gln143, Lys104, Tyr149, Phe108, Phe145, and Arg146 were identified. Conventional and carbon–hydrogen bond interactions with amino residues Arg146, Asn107, Phe145, and Ser111 were critical for the binding of inclusion (IncA) membranes inhibitors.

Conclusion

Outcomes of the study can further be exploited to develop potent inclusion (IncA) membranes inhibitors.

Validating a prediction tool to determine the risk of nosocomial multidrug-resistant Gram-negative bacilli infection in critically ill patients: A retrospective case-control study

BACKGROUND

The Singapore GSDCS score was developed to enable clinicians predict the risk of nosocomial multidrug-resistant Gram-negative bacilli (RGNB) infection in critically ill patients. We aimed to validate this score in a UK setting.

METHOD

A retrospective case-control study was conducted including patients who stayed for more than 24h in intensive care units (ICUs) across two tertiary National Health Service hospitals in London, UK (April 2011-April 2016). Cases with RGNB and controls with sensitive Gram-negative bacilli (SGNB) infection were identified.

RESULTS

The derived GSDCS score was calculated from when there was a step change in antimicrobial therapy in response to clinical suspicion of infection as follows: prior Gram-negative organism, Surgery, Dialysis with end-stage renal disease, prior Carbapenem use and intensive care Stay of more than 5 days. A total of 110 patients with RGNB infection (cases) were matched 1:1 to 110 geotemporally chosen patients with SGNB infection (controls). The discriminatory ability of the prediction tool by receiver operating characteristic curve analysis in our validation cohort was 0.75 (95% confidence interval 0.65-0.81), which is comparable with the area under the curve of the derivation cohort (0.77). The GSDCS score differentiated between low- (0-1.3), medium- (1.4-2.3) and high-risk (2.4-4.3) patients for RGNB infection (P<0.001) in a UK setting.

CONCLUSION

A simple bedside clinical prediction tool may be used to identify and differentiate patients at low, medium and high risk of RGNB infection prior to initiation of prompt empirical antimicrobial therapy in the intensive care setting.

An overview of healthcare-associated infections in a tertiary care hospital in Egypt

Background

Healthcare-associated infection (HAI) is a major problem in healthcare facilities and is associated with increased morbidity and mortality and prolonged hospital stay. This study aims to determine the incidence rate, risk factors, and bacterial aetiology of HAI in a tertiary care hospital in Mansoura, Egypt.

Methods

This is a prospective observational study carried out over 12 months in different departments of Mansoura New General Hospital (MNGH). Data were collected from patient's records and laboratory results of the ongoing HAI surveillance program.

Results

The incidence of HAI was 3.7% among 6912 patients studied. The independent predictors of HAI were multiple devices (AOR=88.1), central venous catheter (CVC) (AOR=34), urinary catheter (AOR=28.9) and length of stay >20 days (AOR=3.1). Surgical site infections (SSI) were the most frequent (24%) followed by catheter associated urinary tract infections (CAUTI) (20%). The most frequently isolated pathogens were Klebsiella spp. (27.2%), and E. coli (18%).

Conclusions

HAI is a significant problem in MNGH. Klebsiella spp. were the predominant causative organisms of HAI, as has been described in other studies from developing countries.

Evaluating the Saliva of Burn ICU Patients for Resistant Infections Harbor Metallo-β-Lactamase Genes

Pseudomonas aeruginosa and Acinetobacter baumannii are the bacteria which increasingly account for nosocomial infections. Due to high virulence, the rate of Multi-Drug Resistance (MDR) and limited availability of new agents, these infections create significant clinical burdens, making it important to identify the possible sources of their occurrence. The aim of this study was to assess non-lactose fermenting bacteria and their metallo-β-lactamase (MBLs) genes expression in the Burn Intensive Care Unit (BICU) patients' saliva samples. This cross-sectional study was conducted from 2017 to 2018 on 124 saliva samples of BICU patients. Identified isolates were evaluated for drug susceptibility by disc diffusion method. MBLs production isolates were detected by Modified Hodge test and Imipenem-EDTA Combined disk. MBLs related genes were evaluated by polymerase chain reaction (PCR). A total of 86 Gram negative non-lactose fermenting bacteria (38; A. baumannii) and (48; P. aeruginosa), were detected. All of the A. baumannii isolates were resistant to Carbapenems, while more than 90% of them were sensitive to Colistin. However, the highest sensitivity in P. aeruginosa isolates was related to Carbapenems and Colistin. More than 95% of A. baumannii and 32% of P. aeruginosa were detected MDR. MBLs production was confirmed in 9 (33.33%) P. aeruginosa and 18 (66.67%) A. baumannii isolates. The blaVIM was the most prevalent gene, while this gene was detected in all of MBLs positive strains. This study confirmed the prevalence of carbapenemase producer Gram-negative bacilli in the saliva of BICU patients. The results of the present study provide a new data set about saliva infection source that could lead to the proper antibiotic regimen and better control of drug resistance.

Association of Standardized Tracheostomy Care Protocol Implementation and Reinforcement With the Prevention of Life-Threatening Respiratory Events

Importance

Mucus plugging after tracheostomy is a preventable cause of respiratory distress. Implementation of standardized tracheostomy care guidelines may reduce the occurrence of fatal respiratory compromise.

Objective

To determine the effect of implementing and reinforcing a standardized tracheostomy care protocol on the occurrence of acute life-threatening respiratory events.

Design, Setting, and Participants

Retrospective cohort study of adult patients who received a tracheostomy between May 2014 and August 2016 at a tertiary care center.

Main Outcomes and Measures

Patient demographics, tracheostomy indication, rapid response for mucus plugging and other acute events, duration of hospital stay, and levels of care that the patients received were recorded through examination of clinical logs. Statistical analysis was conducted between patients before protocol implementation and patients after protocol implementation in terms of rapid-response use, and intragroup comparison of the mean length of stay in various hospital units was also analyzed.

Results

A total of 247 patients (89 women [36%]; mean [SD] age, 58.5 [12.3] years), 117 preprotocol and 130 postprotocol, met inclusion criteria. Of the 130 patients in the postprotocol cohort, 123 (93%) were on the new tracheostomy care protocol. Preprotocol rapid-response rate was 21 of 117 patients (17.9%) and postprotocol response rate was 12 of 130 patients (9.2%) for a difference of 8.7% (95% CI, 0.2%-18.0%). In terms of mucus plugging, preprotocol rate was 8 of 117 patients (6.8%) and the postprotocol rate was 1 of 130 patients (0.8%) for a difference of 6.0% (95% CI, 1.3%-12.2%). Intragroup difference of the mean time spent (days) in various care units between patients in the no rapid-response group vs rapid-response group demonstrated clinically meaningful longer stay for rapid responses in both preprotocol and postprotocol groups for the intensive care unit (preprotocol, 2.03; 95% CI, 1.03-3.03 vs postprotocol, 3.02; 95% CI, 1.49-4.45) and step down units (preprotocol, 1.40; 95% CI, 0.77-2.02 vs postprotocol, 2.11; 95% CI, 0.78 to 3.44).

Conclusions and Relevance

Implementation and reinforcement of a standardized tracheostomy care protocol was associated with a reduction in the occurrences of rapid-response calls for life-threatening mucus plugging and is recommended for clinical practice. In addition, length of stay in the intensive care unit and intermediate surgical care unit was increased in a clinically meaningful way for patients who experienced a rapid-response event.

The clinical and epidemiological risk factors of infections due to multi-drug resistant bacteria in an adult intensive care unit of University Hospital Center in Marrakesh-Morocco

BACKGROUND

Intensive care units (ICUs) are considered epicenters of antibiotic resistance. The aim of this study is to determine clinical risk factors, epidemiology and the causative agents of multi-drug resistant bacteria in the ICU of the University Hospital in Marrakesh-Morocco.

METHODS

A one year case control study was carried out in our 10-bed clinical and surgical ICU from March 2015 to March 2016. The epidemiological surveillance was done by collecting data in the medical records with the help of a questionnaire. The antibiotic susceptibility testing was used following the recommendations of the Antibiogram Committee of the French Society of Microbiology and the European Committee for Antimicrobial Susceptibility Testing, 2015.

RESULTS

Among the 479 admitted patients, 305 bacteria were isolated and identified as Acinetobacter baumannii (31%), Enterobactereacae species (30%), and Staphylococcus (24%), P. aeruginosa (10%) and other bacterial strains (5%). The rate of MDR bacteria acquisition was 41% (124/305) with domination of A. baumannii resistant to imipenem (70%) and followed by Extended Spectrum β-lactamases producing Enterobacteriaceae, P. aeruginosa resistant to Ceftazidime, and Methicillin-resistant S. aureus (18%, 7%, and 5% respectively). The distribution of the common nosocomial infections were dominated by pneumonia, bacteremia, and catheter-related blood stream infections (39%, 29%, and 17%) respectively. Multivariate analysis identified lack of patient isolation precautions (OR: 7.500), use of quadri or triple therapy (OR: 5.596; OR: 5.175), and mechanical ventilation (OR: 4.926), as the most significant clinical and epidemiological factors associated with acquisition of MDR bacteria. The attributable mortality, in this ICU, of patients with MDR bacteria, is about 12%.

CONCLUSIONS

The incidence of MDR was higher compared with that of developed countries. The implementation of standard infection control protocols, active surveillance of MDR and generation of data on etiological agents and their antimicrobial susceptibility patterns are urgently needed in our hospital.

ESBL-colonization at ICU admission: impact on subsequent infection, carbapenem-consumption, and outcome

OBJECTIVE

To determine whether colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) predicts the risk for subsequent infection and impacts carbapenem-consumption and outcome in intensive care unit (ICU) patients.

DESIGN

Prospective cohort study.

SETTING

The 2 ICUs in the University Hospital Basel in Switzerland.

PATIENTS

All patients admitted to the 2 ICUs providing mechanical ventilation and an expected ICU stay &gt;48 hours.

METHODS

Patients were routinely screened for ESBL-PE carriage by rectal swab on admission. Competing risk regression analyses were applied to calculate hazard ratios (HRs) for infection with ESBL-PE and mortality. Length of hospital stay, length of ICU stay, and duration of carbapenem exposure were compared using the Mann-Whitney U test.

RESULTS

Among 302 patients, 24 (8.0%) were colonized with ESBL-PE on ICU admission. Infections with ESBL-PE occurred in 4 patients, of whom 3 (75%) were identified as ESBL-PE colonized on admission. ESBL-PE colonization on admission was associated with subsequent ESBL-PE infection (hazard ratio [HR], 25.52; 95% confidence interval [CI], 2.40-271.41; P = .007) and exposure to carbapenems (HR, 2.42; 95% CI, 1.01-5.79; P = .047), whereas duration of carbapenem exposure did not differ in relation to ESBL-PE colonization (median, 7 days [IQR, 3-8 days] vs median, 6 days [IQR 3-9 days]; P = 0.983). Patients colonized with ESBL-PE were not at increased risk for death overall (HR, 1.00; 95% CI, 0.44-2.30; P = .993) or death attributable to infection (HR, 1.20; 95% CI, 0.28-5.11; P = .808).

CONCLUSIONS

Screening strategies for detection of ESBL-PE colonization on ICU admission may allow the identification of patients at highest risk for ESBL-PE infection and the correct allocation of empiric carbapenem treatment.

Correlation between the invasive fungal infection among and their blood glucose levels

The purpose of this study was to study the association of deep fungal infection with glucose levels in critically ill intensive care unit (ICU) patients. Fasting blood glucose level was measured for 108 critically ill ICU patients in the morning. After analyzed according to the Spearman method found deep fungal infections in patients with the rise in blood glucose levels and the ratio increases, a positive correlation between the two. Deep infection in critically ill ICU patients and their blood glucose levels was closely related, and therefore, there should a focus on controlling blood sugar levels in patients.

Appropriateness of empiric antimicrobial therapy with imipenem/colistin in severe septic patients: observational cohort study

BACKGROUND

Empiric antimicrobial therapy (EAMT) using imipenem/colistin is commonly prescribed as a first line therapy in critically ill patients with severe sepsis. We aimed to assess the appropriateness of prescribing imipenem/colistin as EAMT in ICU patients.

METHODS

A 3-year observational prospective study included ICU patients that required imipenem/colistin as EAMT. The EAMT was assessed according to microbiological and clinical outcomes. The outcomes were: delay in apyrexia, delay in the decrease of the biological inflammatory parameters (BIP), the requirement for vasoactive agents, bacteriological eradication, length of stay, ventilator days and 30-day mortality.

RESULTS

79 administrations of EAMT in 70 patients were studied. EAMT was appropriate in 52% of the studied cases. An ICU stay > 6 days was related to inappropriateness, and chronic respiratory failure was associated with appropriateness. In the appropriate EAMT group, we showed: earlier apyrexia, shorter delay in the decrease of the BIP and a reduced significant vasopressors requirement. Furthermore, EAMT improved survival with a median gain of 4 days. Inappropriate EAMT increased the mortality risk by six. The acquisition of NI in ICU was also an independent factor of mortality.

CONCLUSIONS

EAMT using imipenem-colistin was appropriate in half of the cases and inappropriateness was associated with an increased ICU mortality risk.

Molecular epidemiology of Pseudomonas aeruginosa in University Clinical Center of Kosovo

Background

Pseudomonas aeruginosa is an important opportunistic pathogen. It is frequently resistant to many commonly used antibiotics and develops easily resistant forms. Colonization with this organism often precedes infection, and its prevention is, therefore, critical. There is no information on molecular epidemiological investigation of outbreaks caused by P. aeruginosa in Kosovo.

Materials and methods

The present investigation was carried out to enlighten molecular epidemiology of P. aeruginosa in University Clinical Center of Kosovo (UCCK) using pulsed-field gel electrophoresis (PFGE). During our study period, 80 isolates of P. aeruginosa were included. The overall antimicrobial susceptibility pattern showed a high level of resistance against amino-glycosides and the lowest against carbapenems. Forty isolates of P. aeruginosa were subjected to genotyping, of whom 31 (77.5%) were male patients and nine (22.5%) were female patients.

Results

The most common diagnosis upon admission was polytrauma, sepsis, and coma cerebri. Majority of the patients were in mechanical ventilation (76.2%). Bacterial isolates were most frequently recovered from respiratory tract specimens (60%) and wounds (22.5%). Majority of the samples were recovered from intensive care unit (ICU) (47.5%). The length of ICU stay was higher compared to patients from other units. Genotype analysis of P. aeruginosa isolates identified seven distinct PFGE patterns, with the predominance of PFGE clone A (40%) and PFGE clone N (12.5%). All of these isolates were indistinguishable. The appearance of the indistinguishable genotypes supports the possibility of a cross and horizontal transmission of P. aeruginosa due to insufficient preventive measures.

Conclusion

The results emphasize the need for strict infection control measures to prevent the nosocomial transmission of P. aeruginosa in our hospital.

Repeat gram-negative hospital-acquired infections and antibiotic susceptibility: A systematic review

Repeat HAIs among frequently hospitalized patients may be contributing to the high rates of antibiotic resistance seen in gram-negative bacteria (GNB) in hospital settings. This systematic review examines the state of the literature assessing the association between repeat GNB HAIs and changes in antibiotic susceptibility patterns. A systematic search of English language published literature was conducted to identify studies in peer-reviewed journals from 2000 to 2015. Studies must have assessed drug resistance in repeat GNB infections longitudinally at the patient level. Two researchers independently reviewed search results for papers meeting inclusion criteria and extracted data. Risk of bias was assessed using a modified quality assessment tool based on the Checklist for Measuring Study Quality and the Quality Assessment Checklist for Cases Series. From 3385 articles identified in the search, seven met inclusion criteria. Five reported lower antibiotic susceptibility in repeated infections, one found a change but did not specify in which direction, and one reported no change. All studies were of low to average quality. Despite the dearth of studies examining repeat GNB infections, evidence suggests that repeat infections result in lower antibiotic susceptibility among hospitalized patients. Larger scale studies with strong methodology are warranted.

Molecular β-Lactamase Characterization of Aerobic Gram-Negative Pathogens Recovered from Patients Enrolled in the Ceftazidime-Avibactam Phase 3 Trials for Complicated Intra-abdominal Infections, with Efficacies Analyzed against Susceptible and Resistant Subsets

The correlation of the clinical efficacy of ceftazidime-avibactam (plus metronidazole) with that of meropenem was evaluated in subjects infected with Gram-negative isolates having characterized β-lactam resistance mechanisms from the complicated intra-abdominal infection (cIAI) phase 3 clinical trials. Enterobacteriaceae isolates displaying ceftriaxone and/or ceftazidime MIC values of ≥2 μg/ml and Pseudomonas aeruginosa isolates with ceftazidime MIC values of ≥16 μg/ml were characterized for extended-spectrum-β-lactamase (ESBL) content. Enterobacteriaceae and P. aeruginosa isolates with imipenem and meropenem MIC values of ≥2 and ≥8 μg/ml, respectively, were tested for carbapenemase genes. The primary efficacy endpoint was clinical cure at test of cure (TOC) among the members of the microbiologically modified intention-to-treat (mMITT) population. A total of 14.5% (56/387) and 18.8% (74/394) of patients in the ceftazidime-avibactam and meropenem arms had isolates that met the MIC screening criteria at the baseline visit, respectively. CTX-M variants alone (29.7%; 41/138) or in combination with OXA-1/30 (35.5%; 49/138), most commonly, blaCTX-M group 1 variants (79/90; 87.8%), represented the β-lactamases most frequently observed among Enterobacteriaceae isolates. Among the patients infected with pathogens that did not meet the screening criteria, 82.2% showed clinical cure in the ceftazidime-avibactam group versus 85.9% in the meropenem group. Among patients infected with any pathogens that met the MIC screening criteria, clinical cure rates at TOC were 87.5% and 86.5% for the ceftazidime-avibactam and meropenem groups, respectively. Ceftazidime-avibactam had clinical cure rates of 92.5% to 90.5% among patients infected with ESBL- and/or carbapenemase-producing Enterobacteriaceae strains at the baseline visit, while meropenem showed rates of 84.9% to 85.4%. The ceftazidime-avibactam and meropenem groups had cure rates of 75.0% and 86.7%, respectively, among patients having any pathogens producing AmpC enzymes. The efficacy of ceftazidime-avibactam was similar to that of meropenem for treatment of cIAI caused by ESBL-producing organisms. (This study has been registered at ClinicalTrials.gov under registration no. NCT01499290 and NCT01500239.).

Nosocomial Infections in Intensive Care Unit: Pattern of Antibiotic-resistance in Iranian Community

Background:

Bacterial infections are responsible for great number of mortality in Intensive Care Unit (ICU). Knowledge about prevalence of bacterial infections and their antibiotic-resistance pattern would be a great step for their treatment and management.

Materials and Methods:

Data about nosocomial infections in ICUs of Alzahra Hospital (referral hospital in Isfahan, center of Iran) were gathered during the years 2007–2010. A questionnaire was fulfilled for any specific patient with nosocomial infection containing demographic data of patient and also characteristics of the infection.

Results:

Out of all patients, 707 individuals (65.6%) were male and 370 (34.4%) were female. Our data revealed that Pseudomonas aeruginosa (13.9%), Klebsiella (11%), and Escherichia coli (6.4%) were the most prevalent bacterial infections. The most common sites of nosocomial infections in the ICU were respiratory system (399 cases, 37%), urinary system (230 cases, 21.4%), and blood (102 cases, 9.5%). The antibiotic-resistance of each bacteria in ICU ward was assessed and data were categorized in a table. There were less documentary about bacterial cultures in the year 2007 when compared with the next years.

Conclusion:

We found some differences (such as bacterial prevalence in ICU wards which caused nosocomial infections) in our local prevalence of nosocomial infections and also in their resistance pattern compared to other centers. Knowing about our data will help physicians to administer the most suitable antibiotics for treatment of nosocomial infections in our area.

Analysis of the third- and fourth-generation cephalosporin use for the treatment of infections caused by Gram-negative bacteria in hospital settings

OBJECTIVE

The aims of our study were to assess the prevalence and distribution of Gram-negative (G-) bacteria in hospital isolates, their sensitivity to the third- and fourth-generation cephalosporins (c3 and c4), therapeutic use of c3 and c4 in the treatment of G- infections and drug utilisation data.

RESEARCH DESIGN AND METHODS

This cross-sectional study collected medical records data from the General Hospital "Gornji Milanovac" (GM) and the University Medical Center "Bezanijska kosa" (BK). The time frame of the study was 12 months. Microbiological and clinical parameters, and c3/c4 drug utilisation were analysed.

RESULTS

Escherichia coli were the most predominant pathogen in GM and BK, accounting for 43% and 28% of all G- isolates, respectively (GM), 884 G- isolates obtained from 606 patients; BK, 1766 isolates obtained from 1045 patients). Nearly half of the isolates (55% and 43%) were obtained from urine samples collected from the surgical ward (GM), and the internal medicine wards and intensive care unit (BK). On average, the resistance rate of G- strains against c3 and c4 reached 40% and 70%, respectively (lowest in E. coli, 8%-25%; highest in Acinetobacer baumannii, 67%-100%). Resistance rate of Pseudomonas spp. to cefepime and ceftazidime was low/moderate (0%-30% and 19%-47%). In BK, the adult patients were older than in GM (75 vs 66 years), with longer hospital stay (19 vs 10 days) and bacteria were isolated later during hospitalisation (10 vs 2 days). C3 and c4 were more often used in empirical therapy (83% vs 64%) in BK. Ceftazidime and cefepime were used more often in BK than in GM (2.036 vs 69 DDD/y and 586 vs. 126 DDD/y, respectively).

CONCLUSION

The use of c3 and c4 in the treatment of G- infections in both hospitals should be re-evaluated in accordance with current guidelines and local resistance.

Effects of continuous renal replacement therapy on linezolid pharmacokinetic/pharmacodynamics: a systematic review

Background

Major alterations in linezolid pharmacokinetic/pharmacodynamic (PK/PD) parameters might be expected in critically ill septic patients with acute kidney injury (AKI) who are undergoing continuous renal replacement therapy (CRRT). The present review is aimed at describing extracorporeal removal of linezolid and the main PK-PD parameter changes observed in critically ill septic patients with AKI, who are on CRRT.

Method

Citations published on PubMed up to January 2016 were systematically reviewed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. All authors assessed the methodological quality of the studies and consensus was used to ensure studies met inclusion criteria. In-vivo studies in adult patients with AKI treated with linezolid and on CRRT were considered eligible for the analysis only if operational settings of the CRRT machine, membrane type, linezolid blood concentrations and main PK-PD parameters were all clearly reported.

Results

Among 68 potentially relevant articles, only 9 were considered eligible for the analysis. Across these, 53 treatments were identified among the 49 patients included (46 treated with high-flux and 3 with high cut-off membranes). Continuous veno-venous hemofiltration (CVVH) was the most frequent treatment performed amongst the studies. The extracorporeal clearance values of linezolid across the different modalities were 1.2–2.3 L/h for CVVH, 0.9–2.2 L/h for hemodiafiltration and 2.3 L/h for hemodialysis, and large variability in PK/PD parameters was reported. The optimal area under the curve/minimum inhibitory concentration (AUC/MIC) ratio was reached for pathogens with an MIC of 4 mg/L in one study only.

Conclusions

Wide variability in linezolid PK/PD parameters has been observed across critically ill septic patients with AKI treated with CRRT. Particular attention should be paid to linezolid therapy in order to avoid antibiotic failure in these patients. Strategies to improve the effectiveness of this antimicrobial therapy (such as routine use of target drug monitoring, increased posology or extended infusion) should be carefully evaluated, both in clinical and research settings.