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Malheiro R, Peleteiro B, Silva G, Lebre A, Paiva JA, Correia S. Hospital context in surgical site infection following colorectal surgery: a multi-level logistic regression analysis. J Hosp Infect 2023; 131:221-227. [PMID: 36414166 DOI: 10.1016/j.jhin.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/08/2022] [Accepted: 11/12/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are associated with poor health outcomes. Their incidence is highest after colorectal surgery, with little improvement in recent years. The role of hospital characteristics is undetermined. AIM To investigate whether SSI incidence after colorectal surgery varies between hospitals, and whether such variance may be explained by hospital characteristics. METHODS Data were retrieved from the electronic platform of the Directorate General of Health, from 2015 to 2019. Hospital characteristics were retrieved from publicly available data on the Portuguese public administration. Analysis considered a two-level hierarchical data structure, with individuals clustered in hospitals. To avoid overfitting, no models were built with more than one hospital characteristic. Cluster-level associations are presented through median odds ratio (MOR) and intraclass cluster coefficient (ICC). Beta coefficients were used to assess the contextual effects. FINDINGS A total of 11,219 procedures from 18 hospitals were included. The incidence of SSI was 16.8%. The ICC for the null model was 0.09. Procedural variables explained 25% of the variance, and hospital dimension explained another 17%. More than 50% of SSI variance remains unaccounted for. After adjustment, heterogeneity between hospitals (MOR: 1.51; ICC: 0.05) was still found. No hospital characteristic was significantly associated with SSI. CONCLUSION Procedural variables and hospital dimension explain almost half of SSI variance and should be taken into account when implementing prevention strategies. Future research should focus on compliance with preventive bundles and other process indicators in hospitals with significantly less SSI in colorectal surgery.
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Affiliation(s)
- R Malheiro
- EPI Unit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal.
| | - B Peleteiro
- EPI Unit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal; Department of Public Health and Forensic Sciences and Medical Education, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
| | - G Silva
- Programa de Prevenção e Controlo de Infeção e Resistência aos Antimicrobianos (PPCIRA), Direção-Geral de Saúde (Directorate General of Health), Lisboa, Portugal
| | - A Lebre
- Programa de Prevenção e Controlo de Infeção e Resistência aos Antimicrobianos (PPCIRA), Direção-Geral de Saúde (Directorate General of Health), Lisboa, Portugal; Instituto Português de Oncologia do Porto Francisco Gentil, E. P. E., Porto, Portugal
| | - J A Paiva
- Instituto Português de Oncologia do Porto Francisco Gentil, E. P. E., Porto, Portugal; Intensive Care Medicine Department, Centro Hospitalar Universitário São João, Porto, Portugal; Department of Medicine, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
| | - S Correia
- Department of Public Health and Forensic Sciences and Medical Education, Faculdade de Medicina, Universidade do Porto (University of Porto Medical School), Porto, Portugal
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Fernandes-Teles AR, Pina-Amado JM, Pereira JM, Paiva JA, Rocha-Silva S. Approaching the airway in prehospital emergency is a common and potentially life-saving practice. Rev Esp Anestesiol Reanim (Engl Ed) 2022; 69:65-70. [PMID: 35181262 DOI: 10.1016/j.redare.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 01/26/2021] [Indexed: 06/14/2023]
Abstract
Management by the environment is complex, which means a much higher percentage of difficult airways than in a regulated environment such as the operating room. Failure or prolonged attempt to tracheal intubation is associated with unfavorable outcomes and serious complications. Acute epiglottitis is a life-threatening disorder, classified as a medical emergency within the diseases of the upper respiratory airway and characterized by its sudden and deadly evolution if rapid intubation is not achieved to allow oxygenation of the patient. We describe a 36-year-old male patient with stridor, dyspnea e hypoxemia due to total obstruction of airway, caused by an acute epiglottitis. We aim to highlight this unusual injury and its management from the prehospital until discharge illustrating the severity of the clinical presentation, current treatment and outcome.
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Affiliation(s)
- A R Fernandes-Teles
- Department of Anaesthesiology, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal.
| | - J M Pina-Amado
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal
| | - J M Pereira
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - J A Paiva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - S Rocha-Silva
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal
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Fernandes-Teles AR, Pina-Amado JM, Pereira JM, Paiva JA, Rocha-Silva S. Approaching the airway in prehospital emergency is a common and potentially life-saving practice. Rev Esp Anestesiol Reanim (Engl Ed) 2021; 69:S0034-9356(21)00109-2. [PMID: 34544597 DOI: 10.1016/j.redar.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 06/13/2023]
Abstract
Management by the environment is complex, which means a much higher percentage of difficult airways than in a regulated environment such as the operating room. Failure or prolonged attempt to tracheal intubation is associated with unfavorable outcomes and serious complications. Acute epiglottitis is a life-threatening disorder, classified as a medical emergency within the diseases of the upper respiratory airway and characterized by its sudden and deadly evolution if rapid intubation is not achieved to allow oxygenation of the patient. We describe a 36-year-old male patient with stridor, dyspnea e hypoxemia due to total obstruction of airway, caused by an acute epiglottitis. We aim to highlight this unusual injury and its management from the prehospital until discharge illustrating the severity of the clinical presentation, current treatment and outcome.
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Affiliation(s)
- A R Fernandes-Teles
- Department of Anaesthesiology, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal.
| | - J M Pina-Amado
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal
| | - J M Pereira
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - J A Paiva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - S Rocha-Silva
- Department of Intensive Care, Centro Hospitalar e Universitário São João, EPE, Porto, Portugal
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Pereira JM, Gonçalves-Pereira J, Ribeiro O, Baptista JP, Froes F, Paiva JA. Impact of antibiotic therapy in severe community-acquired pneumonia: Data from the Infauci study. J Crit Care 2017; 43:183-189. [PMID: 28915392 DOI: 10.1016/j.jcrc.2017.08.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/23/2017] [Accepted: 08/31/2017] [Indexed: 11/17/2022]
Abstract
Antibiotic therapy (AT) is the cornerstone of the management of severe community-acquired pneumonia (CAP). However, the best treatment strategy is far from being established. To evaluate the impact of different aspects of AT on the outcome of critically ill patients with CAP, we performed a post hoc analysis of all CAP patients enrolled in a prospective, observational, multicentre study. Of the 502 patients included, 76% received combination therapy, mainly a β-lactam with a macrolide (80%). AT was inappropriate in 16% of all microbiologically documented CAP (n=177). Hospital and 6months mortality were 34% and 35%. In adjusted multivariate logistic regression analysis, combination AT with a macrolide was independently associated with a reduction in hospital (OR 0.17, 95%CI 0.06-0.51) and 6months (OR 0.21, 95%CI 0.07-0.57) mortality. Prolonged AT (>7days) was associated with a longer ICU (14 vs. 7days; p<0.001) and hospital length of stay (LOS) (25 vs. 17days; p<0.001). Combination AT with a macrolide may be the most suitable AT strategy to improve both short and long term outcome of severe CAP patients. AT >7days had no survival benefit and was associated with a longer LOS.
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Affiliation(s)
- J M Pereira
- Emergency and Intensive Care Department, Centro Hospitalar S. João, Porto, Portugal; Department of Medicine, University of Porto Medical School, Porto, Portugal; Grupo de Infecção e Sepsis, Portugal.
| | - J Gonçalves-Pereira
- Intensive Care Unit, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal; Nova Medical School, Lisboa, Portugal
| | - O Ribeiro
- Department of Health Information and Decision Sciences, Center for Research in Health Technologies and Information Systems, CINTESIS, University of Porto Medical School, Porto, Portugal
| | - J P Baptista
- Intensive Care Service, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - F Froes
- Intensive Care Unit, Hospital Pulido Valente, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - J A Paiva
- Emergency and Intensive Care Department, Centro Hospitalar S. João, Porto, Portugal; Department of Medicine, University of Porto Medical School, Porto, Portugal; Grupo de Infecção e Sepsis, Portugal
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Pereira JM, Azevedo A, Basílio C, Sousa-Dias C, Mergulhão P, Paiva JA. Mid-regional proadrenomedullin: An early marker of response in critically ill patients with severe community-acquired pneumonia? Rev Port Pneumol (2006) 2016; 22:308-314. [PMID: 27160747 DOI: 10.1016/j.rppnen.2016.03.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Mid-regional proadrenomedullin (MR-proADM) is a novel biomarker with potential prognostic utility in patients with community-acquired pneumonia (CAP). PURPOSE To evaluate the value of MR-proADM levels at ICU admission for further severity stratification and outcome prediction, and its kinetics as an early predictor of response in severe CAP (SCAP). MATERIALS AND METHODS Prospective, single-center, cohort study of 19 SCAP patients admitted to the ICU within 12h after the first antibiotic dose. RESULTS At ICU admission median MR-proADM was 3.58nmol/l (IQR: 2.83-10.00). No significant association was found between its serum levels at admission and severity assessed by SAPS II (Spearman's correlation=0.24, p=0.31) or SOFA score (SOFA<10: <3.45nmol/l vs. SOFA≥10: 3.90nmol/l, p=0.74). Hospital and one-year mortality were 26% and 32%, respectively. No significant difference in median MR-proADM serum levels was found between survivors and non-survivors and its accuracy to predict hospital mortality was bad (aROC 0.53). After 48h of antibiotic therapy, MR-proADM decreased in all but 5 patients (median -20%; IQR -56% to +0.1%). Its kinetics measured by the percent change from baseline was a good predictor of clinical response (aROC 0.80). The best discrimination was achieved by classifying patients according to whether MR-proADM decreased or not within 48h. No decrease in MR-proADM serum levels significantly increased the chances of dying independently of general severity (SAPS II-adjusted OR 174; 95% CI 2-15,422; p=0.024). CONCLUSIONS In SCAP patients, a decrease in MR-proADM serum levels in the first 48h after ICU admission was a good predictor of clinical response and better outcome.
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Affiliation(s)
- J M Pereira
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal; Department of Medicine, University of Porto Medical School, Porto, Portugal.
| | - A Azevedo
- Hospital Epidemiology Centre, Centro Hospitalar São João EPE, Porto, Portugal; Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Portugal; EPIUnit - Institute of Public Health, University of Porto, Portugal
| | - C Basílio
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal
| | - C Sousa-Dias
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal
| | - P Mergulhão
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal; Department of Medicine, University of Porto Medical School, Porto, Portugal
| | - J A Paiva
- Emergency and Intensive Care Department, Centro Hospitalar São João EPE, Porto, Portugal; Department of Medicine, University of Porto Medical School, Porto, Portugal
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Montravers P, Blot S, Dimopoulos G, Eckmann C, Eggimann P, Guirao X, Paiva JA, Sganga G, De Waele J. Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med 2016; 42:1234-47. [PMID: 26984317 DOI: 10.1007/s00134-016-4307-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/04/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE The management of peritonitis in critically ill patients is becoming increasingly complex due to their changing characteristics and the growing prevalence of multidrug-resistant (MDR) bacteria. METHODS A multidisciplinary panel summarizes the latest advances in the therapeutic management of these critically ill patients. RESULTS Appendicitis, cholecystitis and bowel perforation represent the majority of all community-acquired infections, while most cases of healthcare-associated infections occur following suture leaks and/or bowel perforation. The micro-organisms involved include a spectrum of Gram-positive and Gram-negative bacteria, as well as anaerobes and fungi. Healthcare-associated infections are associated with an increased likelihood of MDR pathogens. The key elements for success are early and optimal source control and adequate surgery and appropriate antibiotic therapy. Drainage, debridement, abdominal cleansing, irrigation, and control of the source of contamination are the major steps to ensure source control. In life-threatening situations, a "damage control" approach is the safest way to gain time and achieve stability. The initial empirical antiinfective therapy should be prescribed rapidly and must target all of the micro-organisms likely to be involved, including MDR bacteria and fungi, on the basis of the suspected risk factors. Dosage adjustment needs to be based on pharmacokinetic parameters. Supportive care includes pain management, optimization of ventilation, haemodynamic and fluid monitoring, improvement of renal function, nutrition and anticoagulation. CONCLUSIONS The majority of patients with peritonitis develop complications, including worsening of pre-existing organ dysfunction, surgical complications and healthcare-associated infections. The probability of postoperative complications must be taken into account in the decision-making process prior to surgery.
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Affiliation(s)
- P Montravers
- APHP, CHU Bichat-Claude Bernard, Département d'Anesthésie Réanimation, Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.
| | - S Blot
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - G Dimopoulos
- Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
| | - C Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Peine, Germany
| | - P Eggimann
- Department of Intensive Care Medicine and Burn Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - X Guirao
- Department of Endocrine and Head and Neck Surgery, Corporació Sanitaria del Parc Tauli, University Hospital, Sabadell, Barcelona, Spain
| | - J A Paiva
- Emergency and Intensive Care Department, Centro Hospitalar S. João EPE, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - G Sganga
- Department of Surgery, Catholic University of Sacred Heart, Policlinico A Gemelli, Rome, Italy
| | - J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
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Pereira JM, Paiva JA, Froes F, Baptista JP, Gonçalves-Pereira J. Outcome of severe community-acquired pneumonia: the impact of comorbidities. Crit Care 2013. [PMCID: PMC3642891 DOI: 10.1186/cc11979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Sousa A, Paiva JA, Fonseca S, Raposo F, Valente L, Vyas D, Ribeiro O, Pinto R. Rhabdomyolysis: risk factors and incidence in polytrauma patients in the absence of major disasters. Eur J Trauma Emerg Surg 2012; 39:131-7. [PMID: 26815069 DOI: 10.1007/s00068-012-0233-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 10/07/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Rhabdomyolysis is a syndrome caused by musculoskeletal tissue damage that leads to the release of large amounts of intracellular elements, which particularly affect renal function. The most common causes are severe trauma, ischemia, surgical procedures, and drug abuse. We aimed to determine the incidence of rhabdomyolysis by measuring muscle injury markers (CK, myoglobin), to identify pre/post-admission as well as iatrogenic risk factors for rhabdomyolysis in severe polytrauma, to clarify the relevance of orthopedic injuries and surgical treatment in the onset/worsening of rhabdomyolysis, and to correlate risk factors with its main complication-acute renal failure (ARF). METHODS Prospective study of severe polytrauma patients (Injury Severity Score (ISS) >15), with CK and myoglobin values measured at admission and after 24, 48, and 72 h. Peak values, variations between admission and peak, and variations between admission and day 3 were all determined. The correlations of those values with the onset of ARF and other negative outcomes were assessed. RESULTS A total of 57 consecutive patients with a median ISS of 29 were included. ARF was present in 20 patients (38 %). CK-0 level was correlated with male gender (p < 0.027) and ISS (0.014); Mb-0 level was correlated with hypovolemic shock (0.003) and skeletal fracture (p < 0.043). CK-max was correlated with surgery (p < 0.038) and surgery duration (p < 0.014); Mb-max was correlated with surgery (p < 0.002) and anesthesia duration (p < 0.005). Δ-CK was correlated with surgery (p < 0.01) and surgery duration (p < 0.017), and Δ0-3-CK was correlated with surgery (p < 0.042). Logistic regression analysis found relationships between Δ0-3-CK and both ICU admission (p < 0.003) and MODS (p < 0.012), and between Mb-max and ARF (p < 0.034). CONCLUSION We found that a large number of factors are implicated in CK and Mb variations. Rhabdomyolysis is a very frequent complication, but increase in CK marker alone does not seem to be correlated with the incidence of ARF. Therefore, Mb level should be considered in this group of patients.
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Affiliation(s)
- A Sousa
- Orthopaedic Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - J A Paiva
- Emergency and Intensive Care Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - S Fonseca
- Anesthesiology Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - F Raposo
- Orthopaedic Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - L Valente
- Orthopaedic Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - D Vyas
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA.
| | - O Ribeiro
- Department of Decision and Information Sciences in Health, Faculdade de Medicina da UP, Alameda Prof. Hernani Monteiro, Porto, Portugal.
| | - R Pinto
- Orthopaedic Department, Centro Hospitalar de São João, Alameda Prof. Hernani Monteiro, Porto, Portugal.
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Abstract
A retrospective study was performed on adult patients admitted for surgical drainage of deep neck infections and admitted to the intensive care unit (ICU) during a period of 52 months. Severe infection was defined as septic shock/severe sepsis, mediastinitis, empyema or necrotising fasciitis. Complicated course was defined as ICU stay >8 days, reintubation, tracheostomy, renal replacement therapy, critical illness, myopathy or mortality. Chi-square or Fisher's exact test were used to assess differences and the significance level was controlled for multiple comparisons applying Bonferroni's correction. Fifty-four patients were studied. Variables associated with severe infection (43%) were abscess location (retropharyngeal [52 vs 7%; P<0.001] or multiple [52 vs 13%; P=0.002]), Acute Physiology and Chronic Health Evaluation II>7 (78 vs 13%; P<0.001), Simplified Acute Physiology Score II>29 (73 vs 21%; P<0.001) and first ICU day Sequential Organ Failure Assessment score>2 (77 vs 21%; P<0.001). Variables associated with complicated course (56%) were: parapharyngeal location (60 vs 8%; P<0.001)], Acute Physiology and Chronic Health Evaluation II>7 (67 vs 14%; P=0.001), Simplified Acute Physiology Score II>29 (62 vs 18%; P=0.002) and Sequential Organ Failure Assessment score>2 (68 vs 17%; P<0.001). Serious complications occur frequently in patients with deep neck infections surgically drained and admitted to the ICU. Higher severity scores are associated with both severe infection and a complicated course. Retropharyngeal and parapharyngeal locations are associated with severe infection and a complicated course respectively.
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Affiliation(s)
- T Garcia
- Department of Intensive Care Medicine, Centro Hospitalar São João, and Faculty of Medicine, University of Porto, Porto, Portugal.
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Ruhnke M, Paiva JA, Meersseman W, Pachl J, Grigoras I, Sganga G, Menichetti F, Montravers P, Auzinger G, Dimopoulos G, Borges Sá M, Miller PJ, Marček T, Kantecki M. Anidulafungin for the treatment of candidaemia/invasive candidiasis in selected critically ill patients. Clin Microbiol Infect 2012; 18:680-7. [PMID: 22404732 PMCID: PMC3510306 DOI: 10.1111/j.1469-0691.2012.03784.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A prospective, multicentre, phase IIIb study with an exploratory, open-label design was conducted to evaluate efficacy and safety of anidulafungin for the treatment of candidaemia/invasive candidiasis (C/IC) in specific ICU patient populations. Adult ICU patients with confirmed C/IC meeting ≥1 of the following criteria were enrolled: post-abdominal surgery, solid tumour, renal/hepatic insufficiency, solid organ transplant, neutropaenia, and age ≥65 years. Patients received anidulafungin (200 mg on day 1, 100 mg/day thereafter) for 10–42 days, optionally followed by oral voriconazole/fluconazole. The primary efficacy endpoint was global (clinical and microbiological) response at the end of all therapy (EOT). Secondary endpoints included global response at the end of intravenous therapy (EOIVT) and at 2 and 6 weeks post-EOT, survival at day 90, and incidence of adverse events (AEs). The primary efficacy analysis was performed in the modified intent-to-treat (MITT) population, excluding unknown/missing responses. The safety and MITT populations consisted of 216 and 170 patients, respectively. The most common pathogens were Candida albicans (55.9%), C. glabrata (14.7%) and C. parapsilosis (10.0%). Global success was 69.5% (107/154; 95% CI, 61.6–76.6) at EOT, 70.7% (111/157) at EOIVT, 60.2% (77/128) at 2 weeks post-EOT, and 50.5% (55/109) at 6 weeks post-EOT. When unknown/missing responses were included as failures, the respective success rates were 62.9%, 65.3%, 45.3% and 32.4%. Survival at day 90 was 53.8%. Treatment-related AEs occurred in 33/216 (15.3%) patients, four (1.9%) of whom had serious AEs. Anidulafungin was effective, safe and well tolerated for the treatment of C/IC in selected groups of ICU patients.
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Affiliation(s)
- M Ruhnke
- Department of Medicine, Charité University Hospital, Berlin, Germany.
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Pereira JM, Paiva JA, Baptista JP, Froes F, Gonçalves-Pereira J. Severe community-acquired pneumonia: risk factors for in-hospital mortality. Crit Care 2012. [PMCID: PMC3363456 DOI: 10.1186/cc10645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Vaz AP, Amorim A, Espinar MJ, Oliveira T, Pereira JM, Paiva JA. [Positive bronchoalveolar lavage and quantitative cultures results in suspected late-onset ventilator associated penumonia evaluation--retrospective study]. Rev Port Pneumol 2011; 17:117-23. [PMID: 21549670 DOI: 10.1016/j.rppneu.2011.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Accepted: 11/16/2010] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Bronchoalveolar lavage (BAL) with quantitative cultures has been used in order to increase ventilator associated pneumonia (VAP) diagnosis specificity, although the accurate technique for this entity diagnosis remains controversial. OBJECTIVES To evaluate the influence of using positive BAL and quantitative cultures results in microbiologic diagnosis and treatment of patients with suspected late VAP and prior antibiotherapy. MATERIAL AND METHODS Retrospective analysis of intensive care unit (UCI) patients, during a one year period, with clinical suspicion of late VAP and prior use of antibiotics that presented a growth in BAL cultures. RESULTS Of 243 BAL performed, there were 71 (29.2%) positive cultures (60 patients, 76.7% male, 54 ± 19 years). BAL was done after 13 days (median) of invasive mechanical ventilation, 11 days of ICU antibiotherapy and in the day in which a new antibiotic for VAP suspicion was started. Colony forming units (CFU)/ml count was performed in 71.8% and endotracheal aspirate (ETA) simultaneously collected for qualitative analysis in 85.9%. Therapeutic approach was changed in 38.0%: correction (16.9%), de-escalation (12.7%) and directed antibiotherapy start (8.4%). Therapeutic changes were made in the presence of CFU > 10(4) in 84.2% and in agreement with ETA in 70.8%. In cases in which antibiotherapy was maintained (62.0%), quantitative cultures would have allowed de-escalation in 9.1%. Changes in prescription were more frequent when CFU was > 10(4) (48.5%), comparing with situations in which counts were lower and BAL analysis was qualitative (28.9%), p = 0.091. There were no significant differences between patients submitted to different therapeutic approaches concerning to ICU mortality or length of stay. CONCLUSION In late onset VAP, positive BAL and quantitative cultures allowed therapeutic changes, leading to antibiotic adequacy and consumption reduction, which can however be maximised.
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Affiliation(s)
- A P Vaz
- Serviço de Pneumologia, Hospital de São João - EPE, Porto, Portugal.
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Ribeiro MD, Paiva JA, Landeiro N, Duarte J. Patients with severe acute pancreatitis should be more often treated in an Intensive Care Department. Rev Esp Enferm Dig 2002; 94:523-32. [PMID: 12587232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) is a serious disease with a frustrating mortality rate, but with a very good quality of life reported among survivors, that justifies an optimised allocation of therapy intensity. PURPOSE To audit monitoring and treatment of severe AP in our Intensive Care Department based upon Atlanta severity classification and following recommendations. METHODS Retrospective study of all AP admitted to our ICU between 1st January, 1993 and 31st December, 1999 in a tertiary University Hospital in Northern Portugal. RESULTS Our sample (n = 44) represents less than 1% of all patients observed in our ICU and approximately 3% of all patients with AP admitted to our Hospital between 1993 and 1999. All cases fulfilled at least one Atlanta criteria of severe AP. Mean length of stay was 11.6 days. Diagnosis of AP was established in less than 48 hours in 86% of cases: amylasemia and lypasemia were determined in 84 and 7%, respectively and 64% of cases were submitted to ultrasonography. The median time between diagnosis and ICU admission was 2 days. Biliary calculus was responsible for 38% of cases and ethanol for 14%: Thirty-six per cent were considered idiopathic (in none was ERCP performed). Concerning local complications, necrosis was diagnosed in 56% and pseudocysts or abscesses in 23%. Infection was diagnosed by US/CT guided punction or by the presence of gas in CT (performed in 83% during the first ten days of disease) in 18% of the cases. 68% were put on parenteral nutrition (beginning on the 2nd day after admission to ICU in 50% of patients); and 51% had enteric feeding (median day of start = 8.5 days). Antibiotics were prescribed in 91%. Forty-five per cent of patients were submitted to surgery (median day of surgery was 6 days). No statistically significant differences were found concerning local or systemic complications according to different therapies. Mortality rate in our ICU was 36%, mostly during first and second weeks. Patients admitted to ICU later than the second day after diagnosis seem to die earlier (P < 0.005). Outcome (death) was statistically related with organ dysfunction criteria, namely Atlanta criteria (renal failure), SOFA and proportion of days with organ dysfunction. CONCLUSIONS In our Institution (a tertiary hospital) AP diagnosis is quickly made, local and systemic complications are clearly diagnosed and monitored, but at least 50% of patient waited for 2 days until ICU admission, representing those who die earlier.
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Abstract
Catheter-related infections constitute 10-15% of all nosocomial infections, and constitute a relevant and growing problem, with an impact that is far from irrelevant, especially in the intensive care unit. The most frequent pathogens implicated come from the skin flora; Gram-positive cocci are responsible for about two-thirds of the infections, and Candida has emerged as another important cause. Questions about drug, route of administration, dosage and duration of antibiotherapy for patients who have become apyretic and with no signs of sepsis after catheter removal are still under debate, and far from being definitively answered. Decisions regarding these questions are based on three main factors: namely, which is the microoorganism responsible for the infection, what was the time to response, and what kind of patient are we dealing with? However, the microorganism is clearly the main factor in making a decision. In summary, all catheter-related infections should be treated with appropriate antibiotics, regardless of the removal of the catheter, with parenteral drugs, using high doses and short courses, namely 1 week, and de-escalating to narrow-spectrum drugs on the basis of susceptibility tests as soon as possible. Staphylococcus aureus catheter-related infections constitute an exception, needing longer courses, as it is difficult to predict who will be high-risk patients.
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Affiliation(s)
- J A Paiva
- Serviço de Cuidados Intensivos, Hospital de S. Joao, Porto, Portugal.
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Rello J, Paiva JA, Baraibar J, Barcenilla F, Bodi M, Castander D, Correa H, Diaz E, Garnacho J, Llorio M, Rios M, Rodriguez A, Solé-Violán J. International Conference for the Development of Consensus on the Diagnosis and Treatment of Ventilator-associated Pneumonia. Chest 2001; 120:955-70. [PMID: 11555535 DOI: 10.1378/chest.120.3.955] [Citation(s) in RCA: 167] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) is an important health problem that still generates great controversy. A consensus conference attended by 12 researchers from Europe and Latin America was held to discuss strategies for the diagnosis and treatment of VAP. Commonly asked questions concerning VAP management were selected for discussion by the participating researchers. Possible answers to the questions were presented to the researchers, who then recorded their preferences anonymously. This was followed by open discussion when the results were known. In general, peers thought that early microbiological examinations are warranted and contribute to improving the use of antibiotherapy. Nevertheless, no consensus was reached regarding choices of antimicrobial agents or the optimal duration of therapy. Piperacillin/tazobactam was the preferred choice for empiric therapy, followed by a cephalosporin with antipseudomonal activity and a carbapenem. All the peers agreed that the pathogens causing VAP and multiresistance patterns in their ICUs were substantially different from those reported in studies in the United States. Pathogens and multiresistance patterns also varied from researcher to researcher inside the group. Consensus was reached on the importance of local epidemiology surveillance programs and on the need for customized empiric antimicrobial choices to respond to local patterns of pathogens and susceptibilities.
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Affiliation(s)
- J Rello
- Hospital Universitari Joan XXIII, Tarragona, Spain.
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Paiva JA, Carneiro A, Morais J, Belo A, Mourão E, Rodrigues I. The Portuguese resuscitation council: a child in maturation--report of the first year of life. Resuscitation 1999; 40:111-3. [PMID: 10225285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- J A Paiva
- UCIB-Hospital Geral de St. Antonio, Presidente Conselho Portugues de Portugues de Resuscitacao, Porto
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Frutos F, Nuñez C, Garrido P, Lorenzo JM, Aranda M, Revuelta P, Chinea C, Rico M, Ibáñez-Nolla J, León-Regidor MA, Díaz-Boladeras RM, García-Hernández F, Nolla-Salas M, Sirvent JM, Torres A, El-Ebiary M, Castro P, de Batlle J, de Velasco JG, Alvarez A, Bonet A, Thomas ML, McLure HA, Soni N, Roberts AP, Azadian BF, Tibby SM, Cheema IU, Cox S, Gransden WR, Murdoch IA, Tayoro J, Legras A, Dequin PF, Hazouard E, Perrotin D, Anglès R, de Latorre FJ, Ferrer A, Palomar M, Burgueńo MJ, Bosque MD, Pont T, Bermejo B, Melgar JL, Chamorro C, Romera MA, Borrallo JM, de Luna RR, De la Calle N, Sousa-Dias C, Paiva JA, Pereira AC, Ribeiro T, Gomes J, Carmo E, Gaspar I, Simões I, Monteiro E, Neves JL, Abecasis P, Álvarez-Lerma F, de la Cal MA, Insausti J, Olaechea P, Anđelić N, Ćosić O, Risović M, Todorović K, Đukić V, Karamarković A, Ricart A, Garrigosa F, Prieto AD, Casanovas T, Rodriguez P, Avila FJ, Pujol M, Ariza X, Shunko E, Polishchuk O, Kostiuk O, Poluliakh O, Nys M, Damas P, Ledoux D, De Mol P, Melin P, Lamy M, Ivanović D, Radonić R, Gaŝparović V, Merkler M, Gjuraŝin M, van ’t Veen A, Gommers D, Mouton JW, Kluytmans JAJW, Lachmann B, Adnet F, Bekka R, Vicaut E, Lapostolle F, Giraudeaux V, Bismuth C, Baud F, Young SP, Haj MA, Robbie LA, Adey G, Croll AM, Booth NA, Bennett B, Santos JA, Ormaechea E, Barcons M, Quintana E, Rialp G, Bak E, Puzo C, Coll P, Net A, Blazková M, Ŝteparová P, Nejdlová H, Jelínková L, Winkelhoferová H, Rokyta R, Matejovic M, Ŝrámck V, Novák I, Blinzler L, Franz-Kilian K, Benda N, Heuser D, Lerma FA, Maladorno D, Hager H, Richelo B, Teller S, Berkowicz C, O’Brien D, Leighton A, Dougnac A, Hernandez G, Angus D, Ojeda M, Castro J, Labarca E, Castillo L, Andresen M, Bugedo G, Diaz O, Arriagada D, Dagnino J. Posters. Intensive Care Med 1996. [DOI: 10.1007/bf03216423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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