Incidence of antimicrobial-resistant ventilator associated pneumonia: an eighteen-month survey

AIM

Microbes commonly involved in ventilator associated pneumonia (VAP) are difficult to eradicate: Pseudomonas aeruginosa and Acinetobacter baumannii are often resistant to piperacillin, aztreonam and ceftazidim while Klebsiella pneumoniae and other Enterobacteriaceae are resistant to third generation cephalosporins. Physicians need to tailor their therapeutic approach depending on individual patients and clinical setting, firmly based on local epidemiology. The aim of this study was to assess the incidence of VAP caused by multidrug-resistant bacteria in our ICU.

METHODS

We conducted a retrospective review of all patients mechanically ventilated for longer than 72 h, who developed pneumonia over an eighteen-month period for whom final culture data were available. One-hundred and forty-three patients admitted to a University Hospital medical surgical ICU were included in this survey. VAP was diagnosed by Centers for Disease Control and Prevention criteria and confirmed by mini- bronchoalveolar lavage.

RESULTS

In this study, the incidence of VAP in the period January 1, 2002-June 31, 2003 was very high, accounting for about 20% of all at-risk cases. Multiresistant agents were involved in about 57% of VAP occurring within 7 days of mechanical ventilation, and in 80% of late VAP.

CONCLUSIONS

This study revealed differences in VAP incidence and features among our ICU and literature data, indicating a need for caution when using hospital infection surveillance data for comparisons and choice of therapy. In our setting, with high levels of antibiotic resistance, combined approaches of non-antibiotic using strategies and education programs might be beneficial.

Candidemia in Intensive Care patients. Risk factors and mortality

AIM

Aim of this study was to evaluate if the risk factors for candidemia could be used to identify patients who have a greater possibility of death after Candida spp blood infection.

METHODS

A retrospective observational comparative study.

SETTING

the Intensive Care Unit of an University Hospital.

PATIENTS

478 critical patients were included in this study. Neutropenic and immuno-suppressed patients were excluded.

INTERVENTIONS

routine care for acutely ill patients, with regard to their pathology.

MEASUREMENTS

age, APACHE II at the admission, length of stay in the ICU before the diagnosis of candidemia and whole length of stay, outcome, risk factors for candidemia (Candida colonisation, previous antibiotic therapy, central vein, mechanical ventilation, abdominal surgery, hemodialysis, adult respiratory distress syndrome, chronic obstructive pulmonary disease, diabetes, malignancy, splenectomy, immunosuppression, total parenteral nutrition, malnutrition) and clinical signs of multiorgan failure, systemic inflammatory response syndrome, sepsis or shock, concomitant presence of other infections.

RESULTS

Twelve Candida spp blood infections were diagnosed. All the risk factors were homogenously distributed between patients who survived and those who died with the exception of the malnutrition state, associated with a higher mortality rate.

CONCLUSION

If the candidemia is present, none of the risk factors for the onset of fungemia considered in this study, but the malnutrition state, are mortality predictors.

[Anesthesiologic and surgical problems in adenotonsillectomy in pediatric patients. Our current trend]

AIM

To verify, in dissection adenotonsillectomy (AT) performed in Rose position under general anaesthesia with oro-tracheal intubation, the following: 1) the ability of tramadol to produce an effective intra- and postoperative analgesia without any considerable side effects or interferences with the normal post-surgical course of the operation; 2) the possibility of obtaining, thanks to mivacurium, a myoresolution closer both to surgical times of the operation and to the necessity of a fast recovering of the pharyngo-laryngeal reflexes.

EXPERIMENTAL DESIGN

A perspective and retrospective clinical study.

SETTING

University clinic department (operating room and facility).

PATIENTS

110 patients submitted to adenotonsillectomy, aged 4-10, belonging to the I-II ASA categories and not taking any drug for at least 30 days.

INTERVENTIONS

Intravenous pre-medication with tramadol 2 mg/kg; myoresolution with mivacurium 0.2 mg/kg; postoperative analgesia with tramadol 2 mg/kg i.m. one hour after the first administration and, with an equivalent oral dose of tramadol, six hours later.

MEASUREMENTS

During surgery: ECG, HR, Sat HbO2, non-invasive arterial blood pressure; after surgery: clinical evaluation of pain, through a three-point scale, and of the surgical course.

RESULTS

Good analgesical level both during and after surgery; myoresolution especially suitable to adenotonsillectomy duration and characteristics; no considerable complications.

CONCLUSIONS

Tramadol intra- and postoperative analgesia and mivacurium myoresolution represents, in personal opinion, an efficient approach to dissection adenotonsillectomy performed in children under general anaesthesia.