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Rodríguez A, Gómez J, Franquet Á, Trefler S, Díaz E, Sole-Violán J, Zaragoza R, Papiol E, Suberviola B, Vallverdú M, Jimenez-Herrera M, Albaya-Moreno A, Canabal Berlanga A, Del Valle Ortíz M, Carlos Ballesteros J, López Amor L, Sancho Chinesta S, de Alba-Aparicio M, Estella A, Martín-Loeches I, Bodi M. Applicability of an unsupervised cluster model developed on first wave COVID-19 patients in second/third wave critically ill patients. Med Intensiva 2024:S2173-5727(24)00042-0. [PMID: 38462398 DOI: 10.1016/j.medine.2024.02.006] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/04/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To validate the unsupervised cluster model (USCM) developed during the first pandemic wave in a cohort of critically ill patients from the second and third pandemic waves. DESIGN Observational, retrospective, multicentre study. SETTING Intensive Care Unit (ICU). PATIENTS Adult patients admitted with COVID-19 and respiratory failure during the second and third pandemic waves. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Collected data included demographic and clinical characteristics, comorbidities, laboratory tests and ICU outcomes. To validate our original USCM, we assigned a phenotype to each patient of the validation cohort. The performance of the classification was determined by Silhouette coefficient (SC) and general linear modelling. In a post-hoc analysis we developed and validated a USCM specific to the validation set. The model's performance was measured using accuracy test and area under curve (AUC) ROC. RESULTS A total of 2330 patients (mean age 63 [53-82] years, 1643 (70.5%) male, median APACHE II score (12 [9-16]) and SOFA score (4 [3-6]) were included. The ICU mortality was 27.2%. The USCM classified patients into 3 clinical phenotypes: A (n = 1206 patients, 51.8%); B (n = 618 patients, 26.5%), and C (n = 506 patients, 21.7%). The characteristics of patients within each phenotype were significantly different from the original population. The SC was -0.007 and the inclusion of phenotype classification in a regression model did not improve the model performance (0.79 and 0.78 ROC for original and validation model). The post-hoc model performed better than the validation model (SC -0.08). CONCLUSION Models developed using machine learning techniques during the first pandemic wave cannot be applied with adequate performance to patients admitted in subsequent waves without prior validation.
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Affiliation(s)
- Alejandro Rodríguez
- Critical Care Department - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Universidad Rovira & Virgili/Institut d'Investigació Sanitaria Pere Virigili/CIBERES, Tarragona, Spain.
| | - Josep Gómez
- Technical Secretary - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Álvaro Franquet
- Technical Secretary - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Sandra Trefler
- Critical Care Department - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Emili Díaz
- Critical Care Department - Hospital Parc Tauli, Sabadell, Spain
| | - Jordi Sole-Violán
- Critical Care Department - Hospital Universitario Dr. Negrin/Universidad Fernando Pessoa, Las Palmas de Gran Canaria, Spain
| | - Rafael Zaragoza
- Critical Care Department - Hospital Dr. Peset, Valencia, Spain
| | - Elisabeth Papiol
- Critical Care Department - Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Borja Suberviola
- Critical Care Department - Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Montserrat Vallverdú
- Critical Care Department - Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | - Antonio Albaya-Moreno
- Critical Care Department - Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | | | | | - Lucía López Amor
- Critical Care Department - Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - Angel Estella
- Critical Care Department - Hospital Universitario de Jerez, Jerez de la Frontera, Spain
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | - María Bodi
- Critical Care Department - Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Universidad Rovira & Virgili/Institut d'Investigació Sanitaria Pere Virigili/CIBERES, Tarragona, Spain
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2
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Rodríguez A, Martín-Loeches I, Moreno G, Díaz E, Ferré C, Salgado M, Marín-Corral J, Estella A, Solé-Violán J, Trefler S, Zaragoza R, Socias L, Borges-Sa M, Restrepo MI, Guardiola JJ, Reyes LF, Albaya-Moreno A, Berlanga AC, Ortiz MDV, Ballesteros JC, Chinesta SS, Laderas JCP, Gómez J, Bodí M. Association of obesity on the outcome of critically ill patients affected by COVID-19. Med Intensiva 2024; 48:142-154. [PMID: 37923608 DOI: 10.1016/j.medine.2023.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 06/03/2023] [Revised: 07/19/2023] [Accepted: 08/16/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To evaluate the impact of obesity on ICU mortality. DESIGN Observational, retrospective, multicentre study. SETTING Intensive Care Unit (ICU). PATIENTS Adults patients admitted with COVID-19 and respiratory failure. INTERVENTIONS None. PRIMARY VARIABLES OF INTEREST Collected data included demographic and clinical characteristics, comorbidities, laboratory tests and ICU outcomes. Body mass index (BMI) impact on ICU mortality was studied as (1) a continuous variable, (2) a categorical variable obesity/non-obesity, and (3) as categories defined a priori: underweight, normal, overweight, obesity and Class III obesity. The impact of obesity on mortality was assessed by multiple logistic regression and Smooth Restricted cubic (SRC) splines for Cox hazard regression. RESULTS 5,206 patients were included, 20 patients (0.4%) as underweight, 887(17.0%) as normal, 2390(46%) as overweight, 1672(32.1) as obese and 237(4.5%) as class III obesity. The obesity group patients (n = 1909) were younger (61 vs. 65 years, p < 0.001) and with lower severity scores APACHE II (13 [9-17] vs. 13[10-17, p < 0.01) than non-obese. Overall ICU mortality was 28.5% and not different for obese (28.9%) or non-obese (28.3%, p = 0.65). Only Class III obesity (OR = 2.19, 95%CI 1.44-3.34) was associated with ICU mortality in the multivariate and SRC analysis. CONCLUSIONS COVID-19 patients with a BMI > 40 are at high risk of poor outcomes in the ICU. An effective vaccination schedule and prolonged social distancing should be recommended.
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Affiliation(s)
- Alejandro Rodríguez
- Critical Care Department, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Universidad Rovira & Virgili/Institut d'Investigació Sanitaria Pere Virigili/CIBERES, Tarragona, Spain.
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland.
| | - Gerard Moreno
- Critical Care Department, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain.
| | - Emili Díaz
- Critical Care Department, Hospital Parc Tauli, Sabadell, Spain.
| | - Cristina Ferré
- Critical Care Department, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain.
| | - Melina Salgado
- Critical Care Department, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain.
| | | | - Angel Estella
- Critical Care Department, Hospital Universitario de Jerez, Jerez de la Frontera, Spain.
| | - Jordi Solé-Violán
- Critical Care Department, Hospital Universitario Dr. Negrin/Universidad Fernando Pessoa, Las Palmas de Gran Canaria, Spain.
| | - Sandra Trefler
- Critical Care Department, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain.
| | - Rafael Zaragoza
- Critical Care Department, Hospital Dr. Peset, Valencia, Spain.
| | - Lorenzo Socias
- Critical Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain.
| | - Marcio Borges-Sa
- Critical Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain.
| | - Marcos I Restrepo
- Medical Intensive Care Unit South Texas Veterans Health Care System Audie L. Murphy Division/University of Texas Health San Antonio, San Antonio, TX, USA.
| | - Juan J Guardiola
- Robley Rex VA Medical Center/University of Louisville, Louisville, USA.
| | - Luis F Reyes
- Unisabana Center for Translational Science, Universidad de La Sabana, Clinica Universidadde La Sabana, Chía, Colombia/Pandemic Sciences Institute, University of Oxford, Oxford, UK.
| | - Antonio Albaya-Moreno
- Critical Care Department, Hospital Universitario de Guadalajara, Guadalajara, Spain.
| | | | | | | | | | | | - Josep Gómez
- Technical Secretary, Hospital Universitario de Tarragona Joan XXIII/URV, Tarragona, Spain.
| | - María Bodí
- Critical Care Department, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Universidad Rovira & Virgili/Institut d'Investigació Sanitaria Pere Virigili/CIBERES, Tarragona, Spain.
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3
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Candel FJ, Salavert M, Estella A, Ferrer M, Ferrer R, Gamazo JJ, García-Vidal C, del Castillo JG, González-Ramallo VJ, Gordo F, Mirón-Rubio M, Pérez-Pallarés J, Pitart C, del Pozo JL, Ramírez P, Rascado P, Reyes S, Ruiz-Garbajosa P, Suberviola B, Vidal P, Zaragoza R. Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review. J Clin Med 2023; 12:6526. [PMID: 37892664 PMCID: PMC10607368 DOI: 10.3390/jcm12206526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 09/03/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.
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Affiliation(s)
- Francisco Javier Candel
- Clinical Microbiology and Infectious Diseases, Transplant Coordination, IdISSC & IML Health Research Institutes, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Miguel Salavert
- Infectious Diseases Unit, La Fe (IIS) Health Research Institute, Hospital Universitario y Politécnico La Fe, 46026 València, Spain
| | - Angel Estella
- Intensive Medicine Service, Hospital Universitario de Jerez, 11407 Jerez, Spain
- Departamento de Medicina, INIBICA, Universidad de Cádiz, 11003 Cádiz, Spain
| | - Miquel Ferrer
- UVIR, Servei de Pneumologia, Institut Clínic de Respiratori, Hospital Clínic de Barcelona, IDIBAPS, CibeRes (CB06/06/0028), Universitat de Barcelona, 08007 Barcelona, Spain;
| | - Ricard Ferrer
- Intensive Medicine Service, Hospital Universitario Valle de Hebrón, 08035 Barcelona, Spain;
| | - Julio Javier Gamazo
- Servicio de Urgencias, Hospital Universitario de Galdakao, 48960 Bilbao, Spain;
| | | | | | | | - Federico Gordo
- Intensive Medicine Service, Hospital Universitario del Henares, 28822 Coslada, Spain;
| | - Manuel Mirón-Rubio
- Servicio de Hospitalización a Domicilio, Hospital Universitario de Torrejón, 28850 Torrejón de Ardoz, Spain;
| | - Javier Pérez-Pallarés
- Division of Respiratory Medicine, Hospital Universitario Santa Lucía, 30202 Cartagena, Spain;
| | - Cristina Pitart
- Department of Clinical Microbiology, ISGlobal, Hospital Clínic-University of Barcelona, CIBERINF, 08036 Barcelona, Spain;
| | - José Luís del Pozo
- Servicio de Enfermedades Infecciosas, Servicio de Microbiología, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Paula Ramírez
- Intensive Medicine Service, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | - Pedro Rascado
- Intensive Care Unit, Complejo Hospitalario Universitario Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Soledad Reyes
- Neumology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Borja Suberviola
- Intensive Medicine Service, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Sanitaria IDIVAL, 39011 Santander, Spain;
| | - Pablo Vidal
- Intensive Medicine Service, Complexo Hospitalario Universitario de Ourense, 32005 Ourense, Spain;
| | - Rafael Zaragoza
- Intensive Care Unit, Hospital Dr. Peset, 46017 Valencia, Spain;
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4
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Maseda E, Martín-Loeches I, Zaragoza R, Pemán J, Fortún J, Grau S, Aguilar G, Varela M, Borges M, Giménez MJ, Rodríguez A. Critical appraisal beyond clinical guidelines for intraabdominal candidiasis. Crit Care 2023; 27:382. [PMID: 37789338 PMCID: PMC10546659 DOI: 10.1186/s13054-023-04673-6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/28/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Regardless of the available antifungals, intraabdominal candidiasis (IAC) mortality continues to be high and represents a challenge for clinicians. MAIN BODY This opinion paper discusses alternative antifungal options for treating IAC. This clinical entity should be addressed separately from candidemia due to the peculiarity of the required penetration of antifungals into the peritoneal cavity. Intraabdominal concentrations may be further restricted in critically ill patients where pathophysiological facts alter normal drug distribution. Echinocandins are recommended as first-line treatment in guidelines for invasive candidiasis. However, considering published data, our pharmacodynamic analysis suggests the required increase of doses, postulated by some authors, to attain adequate pharmacokinetic (PK) levels in peritoneal fluid. Given the limited evidence in the literature on PK/PD-based treatments of IAC, an algorithm is proposed to guide antifungal treatment. Liposomal amphotericin B is advocated as first-line therapy in patients with sepsis/septic shock presenting candidemia or endophthalmitis, or with prior exposure to echinocandins and/or fluconazole, or with infections by Candida glabrata. Other situations and alternatives, such as new compounds or combination therapy, are also analysed. CONCLUSION There is a critical need for more robust clinical trials, studies examining patient heterogeneity and surveillance of antifungal resistance to enhance patient care and optimise treatment outcomes. Such evidence will help refine the existing guidelines and contribute to a more personalised and effective approach to treating this serious medical condition. Meanwhile, it is suggested to broaden the consideration of other options, such as liposomal amphotericin B, as first-line treatment until the results of the fungogram are available and antifungal stewardship could be implemented to prevent the development of resistance.
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Affiliation(s)
- Emilio Maseda
- Service of Anesthesia, Hospital Quirónsalud Valle del Henares, Av. de La Constitución, 249, 28850, Torrejón de Ardoz, Madrid, Spain.
| | - Ignacio Martín-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, James Street, Leinster, Dublin 8, D08 NHY1, Ireland.
- Pulmonary Intensive Care Unit, Respiratory Institute, Hospital Clinic of Barcelona, IDIBAPS (Institut d'Investigacions Biomèdiques August Pi I Sunyer), University of Barcelona, CIBERes, Barcelona, Spain.
| | | | - Javier Pemán
- Microbiology Department, Hospital Universitari I Politecnic La Fe, Valencia, Spain
- Fundación Micellium, La Eliana, Valencia, Spain
| | - Jesús Fortún
- Infectious Diseases Service, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Santiago Grau
- Service of Pharmacy, Hospital del Mar, Barcelona, Spain
| | - Gerardo Aguilar
- Service of Anesthesia, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Marina Varela
- Service of Anesthesia, Área Sanitaria de Pontevedra, Pontevedra, Spain
| | - Marcio Borges
- ICU, Hospital Universitario Son Llátzer, Palma, Spain
| | - María-José Giménez
- Faculty of Sports Sciences and Physiotherapy, Universidad Europea de Madrid, Madrid, Spain
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Martínez-Castro S, Navarro R, García-Pérez ML, Segura JM, Carbonell JA, Hornero F, Guijarro J, Zaplana M, Bruño MÁ, Tur A, Martínez-León JB, Zaragoza R, Núñez J, Domínguez-Gil B, Badenes R. Evaluation of functional warm ischemia time during controlled donation after circulatory determination of death using normothermic regional perfusion (ECMO-TT): A prospective multicenter cohort study. Artif Organs 2023; 47:1371-1385. [PMID: 37042612 DOI: 10.1111/aor.14539] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability. METHODS We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis. RESULTS A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal of life-sustaining therapy (61%), followed by anoxic encephalopathy (21%). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs. CONCLUSIONS Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis.
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Affiliation(s)
- Sara Martínez-Castro
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Rosalía Navarro
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - María Luisa García-Pérez
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - José Manuel Segura
- Department of Medical Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- Transplant Coordination Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - José A Carbonell
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
| | - Fernando Hornero
- Department of Cardiac Surgery, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Jorge Guijarro
- Department of Interventional Radiology, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Marta Zaplana
- Department of Vascular Surgery, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - María Ángeles Bruño
- Cardiovascular Perfussion Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
| | - Ana Tur
- Transplant Coordination Unit, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Juan Bautista Martínez-León
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
- Department of Cardiac Surgery, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Rafael Zaragoza
- Department of Intensive Care Medicine, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Julio Núñez
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Cardiology, Hospital Clínic Universitari de Valencia, Valencia, Spain
- Department of Medicine. School of Medicine, University of Valencia, Valencia, Spain
| | | | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain
- Transplant Coordination Unit, Hospital Clínic Universitari de Valencia, Valencia, Spain
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Vidal-Cortés P, Martin-Loeches I, Rodríguez A, Bou G, Cantón R, Diaz E, De la Fuente C, Torre-Cisneros J, Nuvials FX, Salavert M, Aguilar G, Nieto M, Ramírez P, Borges M, Soriano C, Ferrer R, Maseda E, Zaragoza R. Current Positioning against Severe Infections Due to Klebsiella pneumoniae in Hospitalized Adults. Antibiotics (Basel) 2022; 11:antibiotics11091160. [PMID: 36139940 PMCID: PMC9495006 DOI: 10.3390/antibiotics11091160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/21/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Infections due to Klebsiella pneumoniae have been increasing in intensive care units (ICUs) in the last decade. Such infections pose a serious problem, especially when antimicrobial resistance is present. We created a task force of experts, including specialists in intensive care medicine, anaesthesia, microbiology and infectious diseases, selected on the basis of their varied experience in the field of nosocomial infections, who conducted a comprehensive review of the recently published literature on the management of carbapenemase-producing Enterobacterales (CPE) infections in the intensive care setting from 2012 to 2022 to summarize the best available treatment. The group established priorities regarding management, based on both the risk of developing infections caused by K. pneumoniae and the risk of poor outcome. Moreover, we reviewed and updated the most important clinical entities and the new antibiotic treatments recently developed. After analysis of the priorities outlined, this group of experts established a series of recommendations and designed a management algorithm.
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Affiliation(s)
| | - Ignacio Martin-Loeches
- ICU, Trinity Centre for Health Science HRB-Welcome Trust, St. James’s Hospital Dublin, D08 NHY1 Dublin, Ireland
| | - Alejandro Rodríguez
- ICU, Hospital Universitari Joan XXIII, 43005 Tarragona, Spain
- Institut d’Investigació Sanitària Pere Virgil, 43007 Tarragona, Spain
- Departament Medicina I Ciruurgia, Universitat Rovira i Virgili, 43003 Tarragona, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Germán Bou
- Microbiology Department, Complejo Hospitalario Universitario A Coruña, 15006 A Coruña, Spain
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Rafael Cantón
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Microbiology Department, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Emili Diaz
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Critical Care Department, Corporació Sanitària Parc Taulí, 08208 Sabadell, Spain
- Department of Medicine, Universitat Autonoma de Barcelona (UAB), 08193 Barcelona, Spain
| | | | - Julián Torre-Cisneros
- Centro de Investigación en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Infectious Diseases Service, Hospital Universitario Reina Sofía, 14004 Córdoba, Spain
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, 14004 Córdoba, Spain
| | | | - Miguel Salavert
- Infectious Diseases Department, Hospital Universitari I Politecnic La Fe, 46026 Valencia, Spain
| | - Gerardo Aguilar
- SICU, Department of Anesthesiology and Critical Care, Hospital Clínico Universitario Valencia, 46014 Valencia, Spain
- School of Medicine, Universitat de Valencia, 46010 Valencia, Spain
| | - Mercedes Nieto
- ICU, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain
| | - Paula Ramírez
- ICU, Hospital Universitari I Politecnic La Fe, 46026 Valencia, Spain
| | - Marcio Borges
- ICU, Hospital Universitario Son Llázter, 07198 Palma de Mallorca, Spain
- Fundación Micellium, 46183 Valencia, Spain
| | - Cruz Soriano
- ICU, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | | | - Emilio Maseda
- Fundación Micellium, 46183 Valencia, Spain
- SICU, Hospital Universitario La Paz, 28046 Madrid, Spain
| | - Rafael Zaragoza
- Fundación Micellium, 46183 Valencia, Spain
- ICU, Hospital Universitario Dr. Peset, 46017 Valencia, Spain
- Correspondence:
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Claverias L, Daniel X, Martín-Loeches I, Vidal-Cortez P, Gómez-Bertomeu F, Trefler S, Zaragoza R, Borges-Sa M, Reyes LF, Quindós G, Peman J, Bodí M, Díaz E, Sarvisé C, Pico E, Papiol E, Solé-Violan J, Marín-Corral J, Guardiola JJ, Rodríguez A. Impact of Aspergillus spp. isolation in the first 24 hours of admission in critically ill patients with severe influenza virus pneumonia. Med Intensiva 2022; 46:426-435. [PMID: 35868719 DOI: 10.1016/j.medine.2021.12.013] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/05/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine the incidence and impact of Aspergillus spp. isolation (AI) on ICU mortality in critically ill patients with severe influenza pneumonia during the first 24h of admission. DESIGN Secondary analysis of an observational and prospective cohort study. SETTING ICUs voluntary participating in the Spanish severe Influenza pneumonia registry, between June 2009 and June 2019. PATIENTS Consecutive patients admitted to the ICU with diagnosis of severe influenza pneumonia, confirmed by real-time polymerase chain reaction. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Incidence of AI in respiratory samples. Demographic variables, comorbidities, need for mechanical ventilation and the presence of shock according at admission. Acute Physiology and Chronic Health Evaluation II (APACHE II) scale calculated on ICU admission. RESULTS 3702 patients were analyzed in this study. AI incidence was 1.13% (n=42). Hematological malignancies (OR 4.39, 95% CI 1.92-10.04); HIV (OR 3.83, 95% CI 1.08-13.63), and other immunosuppression situations (OR 4.87, 95% CI 1.99-11.87) were factors independently associated with the presence of Aspergillus spp. The automatic CHAID decision tree showed that hematologic disease with an incidence of 3.3% was the most closely AI related variable. Hematological disease (OR 2.62 95% CI 1.95-3.51), immunosuppression (OR 2.05 95% CI 1.46-2.88) and AI (OR 3.24, 95% CI 1.60-6.53) were variables independently associated with ICU mortality. CONCLUSIONS Empirical antifungal treatment in our population may only be justified in immunocompromised patients. In moderate-high risk cases, active search for Aspergillus spp. should be implemented.
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Affiliation(s)
- L Claverias
- Critical Care Department, Hospital Universitari Joan XXIII, Tarragona, Spain; Institut d'Investigació Sanitaria Pere Virgili, Reus, Spain.
| | - X Daniel
- Critical Care Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - I Martín-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St James's University Hospital, Dublin, Ireland
| | - P Vidal-Cortez
- Critical Care Department, Complejo Hospitalario Universitario Ourense, Spain
| | - F Gómez-Bertomeu
- Microbiology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - S Trefler
- Critical Care Department, Hospital Universitari Joan XXIII, Tarragona, Spain; Institut d'Investigació Sanitaria Pere Virgili, Reus, Spain
| | - R Zaragoza
- Critical Care Department, Hospital Dr Peset, Valencia, Spain
| | - M Borges-Sa
- Multidisciplinar Sepsis Unit, Critical Care Department, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | - L F Reyes
- Infectious Diseases Department, Universidad de La Sabana, Chía, Colombia; Critical Care Department, Clinica Universidad de La Sabana, Chía, Colombia
| | - G Quindós
- Department of Immunology, Microbiology and Parasitology, Faculty of Medicine and Nursery, University of the Basque Country (UPV/EHU), Bilbao, Spain
| | - J Peman
- Institute of Sanitary Investigation La Fe, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - M Bodí
- Critical Care Department URV/IISPV/CIBERES, Hospital Universitari Joan XXIII Tarragona, Spain
| | - E Díaz
- Critical Care Department, Hospital Parc Taulí, Sabadell, Spain
| | - C Sarvisé
- Microbiology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - E Pico
- Microbiology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - E Papiol
- Critical Care Department, Hospital Valle Hebrón, Barcelona, Spain
| | - J Solé-Violan
- Critical Care Department Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - J Marín-Corral
- Critical Care Department, Hospital del Mar, Barcelona, Spain
| | - J J Guardiola
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Louisville, USA
| | - A Rodríguez
- Critical Care Department URV/IISPV/CIBERES, Hospital Universitari Joan XXIII Tarragona, Spain
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8
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Madrazo M, Piles L, López-Cruz I, Alberola J, Eiros JM, Zaragoza R, Artero A. Comparison of quick Pitt to quick sofa and sofa scores for scoring of severity for patients with urinary tract infection. Intern Emerg Med 2022; 17:1321-1326. [PMID: 35048314 PMCID: PMC9352610 DOI: 10.1007/s11739-022-02927-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/04/2022] [Indexed: 12/25/2022]
Abstract
Quick Pitt (qPitt), which includes temperature, systolic blood pressure, respiratory rate, cardiac arrest, and mental status, is a new prognostic score derived from the Pitt Bacteremia score. The aim of our study is to compare qPitt with quick SOFA (qSOFA) and SOFA for scoring of severity in patients with urinary tract infection (UTI). Prospective observational study of patients diagnosed with UTI. Area under the ROC curve, sensibility, and specificity to predict 30-day mortality were calculated for qPitt, qSOFA and SOFA and compared. 382 UTI cases were analyzed. Thirty-day mortality (18.8% vs. 5.9%, p < 0.001) and longer hospital stay (6 [1-11] vs. 4 [1-7] days, p < 0.001) were associated with qPitt ≥ 2. However, qPitt had a worse performance to predict 30-day mortality compared to qSOFA and SOFA (AUROC 0.692 vs. 0.832 and 0.806, respectively, p = 0.010 and p = 0.041). The sensitivity of qPitt was lower than the sensitivity of qSOFA and SOFA (70.45 vs. 84.09 for both qSOFA and SOFA, p < 0.001), with a specificity lower than qSOFA and similar to SOFA (60.36 vs. 82.25 and 63.61, p < 0.001 and p = 0.742, respectively). Quick Pitt had moderate prognostic accuracy and performed worse than qSOFA and SOFA scores for predicting mortality in patients with UTI.
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Affiliation(s)
- Manuel Madrazo
- grid.5338.d0000 0001 2173 938XDoctor Peset University Hospital, Universitat de València, Avda Gaspar Aguilar n 90, 46017 Valencia, Spain
| | - Laura Piles
- grid.411289.70000 0004 1770 9825Doctor Peset University Hospital, Valencia, Spain
| | - Ian López-Cruz
- grid.411289.70000 0004 1770 9825Doctor Peset University Hospital, Valencia, Spain
| | - Juan Alberola
- grid.5338.d0000 0001 2173 938XDoctor Peset University Hospital, Universitat de València, Avda Gaspar Aguilar n 90, 46017 Valencia, Spain
| | - José María Eiros
- grid.5239.d0000 0001 2286 5329Rio Hortega University Hospital, Universidad de Valladolid, Valladolid, Spain
| | - Rafael Zaragoza
- grid.5338.d0000 0001 2173 938XDoctor Peset University Hospital, Universitat de València, Avda Gaspar Aguilar n 90, 46017 Valencia, Spain
| | - Arturo Artero
- grid.5338.d0000 0001 2173 938XDoctor Peset University Hospital, Universitat de València, Avda Gaspar Aguilar n 90, 46017 Valencia, Spain
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9
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Claverias L, Daniel X, Martín-Loeches I, Vidal-Cortez P, Gómez-Bertomeu F, Trefler S, Zaragoza R, Borges-Sa M, Reyes L, Quindós G, Peman J, Bodí M, Díaz E, Sarvisé C, Pico E, Papiol E, Solé-Violan J, Marín-Corral J, Guardiola J, Rodríguez A. Impact of Aspergillus spp. isolation in the first 24 hours of admission in critically ill patients with severe influenza virus pneumonia. Med Intensiva 2022. [DOI: 10.1016/j.medin.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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10
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Estella Á, Vidal-Cortés P, Rodríguez A, Andaluz Ojeda D, Martín-Loeches I, Díaz E, Suberviola B, Gracia Arnillas MP, Catalán González M, Álvarez-Lerma F, Ramírez P, Nuvials X, Borges M, Zaragoza R. [Management of infectious complications associated with coronavirus infection in severe patients admitted to ICU]. Med Intensiva 2021; 45:485-500. [PMID: 33994616 PMCID: PMC8086823 DOI: 10.1016/j.medin.2021.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 12/29/2022]
Abstract
Infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia admitted in ICU. Poor immune status, frequent development of organic failure requiring invasive supportive treatments, and prolonged ICU length of stay in saturated structural areas of patients are risk factors for infection development. The Working Group on Infectious Diseases and Sepsis GTEIS of the Spanish Society of Intensive Medicine and Coronary Units SEMICYUC emphasizes the importance of infection prevention measures related to health care, the detection and early treatment of major infections in the patient with SARS-CoV-2 infections. Bacterial co-infection, respiratory infections related to mechanical ventilation, catheter-related bacteremia, device-associated urinary tract infection and opportunistic infections are review in the document.
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Affiliation(s)
- Á Estella
- Servicio de Medicina Intensiva, Hospital Universitario de Jerez, Departamento de Medicina, Facultad de Medicina de Cádiz, Jerez de la Frontera, Cádiz, España
| | - P Vidal-Cortés
- Servicio de Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, España
| | - A Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Joan XXIII de Tarragona, Tarragona, España
| | - D Andaluz Ojeda
- Servicio de Medicina Intensiva, Hospital Universitario de Sanchinarro de Madrid, Madrid, España
| | - I Martín-Loeches
- PhD JFICMI Consultant in Intensive Care Medicine, CLOD Dublin Midlands group, St James's University Hospital, Trinity Centre for Health Sciences, HRB-Welcome Trust St James's Hospital, Dublín, EIRE, Universidad de Barcelona, Barcelona, España
| | - E Díaz
- Servicio de Medicina Intensiva, Hospital Parc Tauli, Sabadell, España
| | - B Suberviola
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla. Santander, España
| | - M P Gracia Arnillas
- Servicio de Medicina Intensiva, Hospital Universitario del Mar, Barcelona, España
| | - M Catalán González
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - F Álvarez-Lerma
- Servicio de Medicina Intensiva, Parc de Salut Mar, Hospital del Mar, Barcelona, España
| | - P Ramírez
- Servicio de Medicina Intensiva, Hospital La Fe de Valencia, Valencia, España
| | - X Nuvials
- Servicio de Medicina Intensiva, Hospital Vall d'Hebrón, Barcelona, España
| | - M Borges
- Unidad Multidisciplinar de Sepsis, Servicio de Medicina Intensiva, Hospital Universitario Son Llatzer, IDISBA, Enfermedades Infecciosas UIB, Palma de Mallorca, Área de Sepsis e Infecciosas, Federación Ibérica y Panamericana de Medicina Intensiva (FEPIMCTI), Palma de Mallorca, España
| | - R Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, España
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11
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Madrazo M, López-Cruz I, Zaragoza R, Piles L, Eiros JM, Alberola J, Artero A. Prognostic accuracy of Quick SOFA in older adults hospitalised with community acquired urinary tract infection. Int J Clin Pract 2021; 75:e14620. [PMID: 34240521 DOI: 10.1111/ijcp.14620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/01/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Quick [Sepsis-related] Sequential Organ Failure Assessment (qSOFA) is a prognostic score based on sepsis-3 definition, easy to carry out, whose application has been studied in older adults with sepsis from different sources and respiratory sepsis. However, to date no study has analysed its prognostic accuracy in older adults admitted to hospital with community urinary tract infection. METHODS In a prospective study of 282 older adults admitted to hospital with community acquired urinary tract infection, the application of qSOFA to predict hospital mortality was analysed. The predictive capacity of qSOFA for in-hospital mortality was compared with Systemic Inflammatory Response Syndrome score (SIRS) and Sequential Organ Failure Assessment (SOFA), which require laboratory test in order to be calculated. RESULTS In a population with a median age of 81 years, where 51.8% were males and 10.6% had septic shock, qSOFA showed sensibility and specificity of 88.46 and 75.78% and area under the receiver operating characteristic curves (AUROC) of 0.810. AUROC for qSOFA was significantly higher than that of SIRS (AUROC 0.597, P = .005) and with no statistical differences with SOFA (AUROC 0.841, P = .635). CONCLUSION qSOFA showed a better predictive prognostic accuracy than SIRS and similar to SOFA in older adults admitted to hospital with community acquired urinary tract infection, having the advantage of not requiring laboratory tests.
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Affiliation(s)
- Manuel Madrazo
- Department of Internal Medicine, Doctor Peset University Hospital, Valencia, Spain
| | - Ian López-Cruz
- Department of Internal Medicine, Doctor Peset University Hospital, Valencia, Spain
| | - Rafael Zaragoza
- Intensive Medicine Unit, Doctor Peset University Hospital, Valencia, Spain
| | - Laura Piles
- Department of Internal Medicine, Doctor Peset University Hospital, Valencia, Spain
| | - José María Eiros
- Department of Microbiology and Parasitology, Rio Hortega University Hospital, University of Valladolid, Valladolid, Spain
| | - Juan Alberola
- Department of Microbiology, Doctor Peset University Hospital, University of Valencia, Valencia, Spain
| | - Arturo Artero
- Department of Internal Medicine, Doctor Peset University Hospital, University of Valencia, Valencia, Spain
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12
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Estella Á, Vidal-Cortés P, Rodríguez A, Andaluz Ojeda D, Martín-Loeches I, Díaz E, Suberviola B, Gracia Arnillas MP, Catalán González M, Álvarez-Lerma F, Ramírez P, Nuvials X, Borges M, Zaragoza R. Management of infectious complications associated with coronavirus infection in severe patients admitted to ICU. Med Intensiva 2021; 45:485-500. [PMID: 34475008 PMCID: PMC8382590 DOI: 10.1016/j.medine.2021.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/17/2021] [Indexed: 12/29/2022]
Abstract
Infections have become one of the main complications of patients with severe SARS-CoV-2 pneumonia admitted in ICU. Poor immune status, frequent development of organic failure requiring invasive supportive treatments, and prolonged ICU length of stay in saturated structural areas of patients are risk factors for infection development. The Working Group on Infectious Diseases and Sepsis GTEIS of the Spanish Society of Intensive Medicine and Coronary Units SEMICYUC emphasizes the importance of infection prevention measures related to health care, the detection and early treatment of major infections in the patient with SARS-CoV-2 infections. Bacterial co-infection, respiratory infections related to mechanical ventilation, catheter-related bacteremia, device-associated urinary tract infection and opportunistic infections are review in the document.
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Affiliation(s)
- Á Estella
- Servicio de Medicina Intensiva, Hospital Universitario de Jerez, Departamento de Medicina, Facultad de Medicina de Cádiz, Jerez de la Frontera, Cádiz, Spain.
| | - P Vidal-Cortés
- Servicio de Medicina Intensiva, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - A Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Joan XXIII de Tarragona, Tarragona, Spain
| | - D Andaluz Ojeda
- Servicio de Medicina Intensiva, Hospital Universitario de Sanchinarro de Madrid, Madrid, Spain
| | - I Martín-Loeches
- PhD JFICMI Consultant in Intensive Care Medicine, CLOD Dublin Midlands Group, St James's University Hospital, Trinity Centre for Health Sciences, HRB-Welcome Trust St James's Hospital, Dublin, EIRE, Universidad de Barcelona, Barcelona, Spain
| | - E Díaz
- Servicio de Medicina Intensiva, Hospital Parc Tauli, Sabadell, Spain
| | - B Suberviola
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - M P Gracia Arnillas
- Servicio de Medicina Intensiva, Hospital Universitario del Mar, Barcelona, Spain
| | - M Catalán González
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - F Álvarez-Lerma
- Servicio de Medicina Intensiva, Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
| | - P Ramírez
- Servicio de Medicina Intensiva, Hospital La Fe de Valencia, Valencia, Spain
| | - X Nuvials
- Servicio de Medicina Intensiva, Hospital Vall d'Hebrón, Barcelona, Spain
| | - M Borges
- Unidad Multidisciplinar de Sepsis, Servicio de Medicina Intensiva, Hospital Universitario Son Llatzer, IDISBA, Enfermedades Infecciosas UIB, Palma de Mallorca, Área de Sepsis e Infecciosas, Federación Ibérica y Panamericana de Medicina Intensiva (FEPIMCTI), Palma de Mallorca, Spain
| | - R Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
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13
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Zaragoza R, Maseda E, Pemán J. [Individualized antifungal therapy in critically ill patients with invasive fungal infection]. Rev Iberoam Micol 2021; 38:68-74. [PMID: 34301466 DOI: 10.1016/j.riam.2021.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 02/23/2021] [Revised: 04/16/2021] [Accepted: 04/28/2021] [Indexed: 12/12/2022] Open
Abstract
Invasive candidiasis (IC) is the most common invasive fungal infection (IFI) affecting critically ill patients, followed by invasive pulmonary aspergillosis (IPA). International guidelines provide different recommendations for a first-line antifungal therapy and, in most of them, echinocandins are considered the first-line treatment for IC, and triazoles are so for the treatment of IPA. However, liposomal amphotericinB (L-AmB) is still considered a second-line therapy for both clinical entities. Although in the last decade the management of IFI has improved, several controversies persist. The antifungal drugs currently available may have a suboptimal activity, or be wrongly used in certain IFI involving critically ill patients. The aim of this review is to analyze when to provide individualized antifungal therapy to critically ill patients suffering from IFI, emphasizing the role of L-AmB. Drug-drug interactions, the clinical status, infectious foci (peritoneal candidiasis is discussed), the fungal species involved, and the need of monitoring the concentration of the antifungal drug in the patient are considered.
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Affiliation(s)
- Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, España.
| | - Emilio Maseda
- Unidad de Críticos Quirúrgicos, Servicio de Anestesia y Reanimación, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Javier Pemán
- Servicio de Microbiología, Hospital Universitario y Politécnico la Fe, Valencia, España
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14
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Domínguez-Gil B, Coll E, Fernández-Ruiz M, Corral E, del Río F, Zaragoza R, Rubio JJ, Hernández D. COVID-19 in Spain: Transplantation in the midst of the pandemic. Am J Transplant 2020; 20:2593-2598. [PMID: 32359194 PMCID: PMC7267131 DOI: 10.1111/ajt.15983] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023]
Abstract
Spain has been one of the most affected countries by the COVID-19 outbreak. As of April 28, 2020, the number of confirmed cases is 210 773, including 102 548 patients recovered, more than 10 300 admitted to the ICU, and 23 822 deaths, with a global case fatality rate of 11.3%. From the perspective of donation and transplantation, the Spanish system first focused on safety issues, providing recommendations for donor evaluation and testing, and to rule out SARS-CoV-2 infection in potential recipients prior to transplantation. Since the country entered into an epidemiological scenario of sustained community transmission and saturation of intensive care, developing donation and transplantation procedures has become highly complex. Since the national state of alarm was declared in Spain on March 13, 2020, the mean number of donors has declined from 7.2 to 1.2 per day, and the mean number of transplants from 16.1 to 2.1 per day. Increased mortality on the waiting list may become a collateral damage of this terrible pandemic.
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Affiliation(s)
- Beatriz Domínguez-Gil
- Organización Nacional de Trasplantes, Madrid, Spain,Correspondence Beatriz Domínguez-Gil
| | | | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain,Chair of the Group for the Study of Infection in Transplantation and the Immunocompromised Host (GESITRA-IC) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Spain
| | - Esther Corral
- Transplant Coordination of the Autonomous Region of the Basque Country, Vitoria, Spain
| | - Francisco del Río
- Transplant Coordination of the Autonomous Region of Madrid, Madrid, Spain
| | - Rafael Zaragoza
- Transplant Coordination of the Autonomous Region of Valencia, Valencia, Spain
| | - Juan J. Rubio
- Intensive Care Unit, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain,Chair of the Transplant Group of the Spanish Society of Intensive and Critical Care and Coronary Units (SEMICYUC), Spain
| | - Domingo Hernández
- Nephrology Service, Hospital Regional Universitario de Málaga, Málaga, Spain,IBIMA, RD16/0009/0006, Málaga, Spain,President of the Spanish Society of Transplantation (SET), Spain
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15
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Zaragoza R, Vidal-Cortés P, Aguilar G, Borges M, Diaz E, Ferrer R, Maseda E, Nieto M, Nuvials FX, Ramirez P, Rodriguez A, Soriano C, Veganzones J, Martín-Loeches I. Update of the treatment of nosocomial pneumonia in the ICU. Crit Care 2020; 24:383. [PMID: 32600375 PMCID: PMC7322703 DOI: 10.1186/s13054-020-03091-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/12/2020] [Indexed: 12/19/2022]
Abstract
In accordance with the recommendations of, amongst others, the Surviving Sepsis Campaign and the recently published European treatment guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), in the event of a patient with such infections, empirical antibiotic treatment must be appropriate and administered as early as possible. The aim of this manuscript is to update treatment protocols by reviewing recently published studies on the treatment of nosocomial pneumonia in the critically ill patients that require invasive respiratory support and patients with HAP from hospital wards that require invasive mechanical ventilation. An interdisciplinary group of experts, comprising specialists in anaesthesia and resuscitation and in intensive care medicine, updated the epidemiology and antimicrobial resistance and established clinical management priorities based on patients' risk factors. Implementation of rapid diagnostic microbiological techniques available and the new antibiotics recently added to the therapeutic arsenal has been reviewed and updated. After analysis of the categories outlined, some recommendations were suggested, and an algorithm to update empirical and targeted treatment in critically ill patients has also been designed. These aspects are key to improve VAP outcomes because of the severity of patients and possible acquisition of multidrug-resistant organisms (MDROs).
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Affiliation(s)
- Rafael Zaragoza
- Critical Care Department, Hospital Universitario Dr. Peset, Valencia, Spain. .,Fundación Micellium, Valencia, Spain.
| | | | - Gerardo Aguilar
- SICU, Hospital Clínico Universitario Valencia, Valencia, Spain
| | - Marcio Borges
- Fundación Micellium, Valencia, Spain.,ICU, Hospital Universitario Son Llázter, Palma de Mallorca, Spain
| | - Emili Diaz
- Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.,Critical Care Department, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain.,CIBERES Ciber de Enfermedades Respiratorias, Madrid, Spain
| | | | - Emilio Maseda
- Fundación Micellium, Valencia, Spain.,SICU, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Nieto
- ICU, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - Paula Ramirez
- ICU, Hospital Universitari I Politecnic La Fe, Valencia, Spain
| | | | - Cruz Soriano
- ICU, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ignacio Martín-Loeches
- ICU, Trinity Centre for Health Science HRB-Wellcome Trust, St James's Hospital, Dublin, Ireland
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16
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José P, Alvarez-Lerma F, Maseda E, Olaechea P, Pemán J, Soriano C, Zaragoza R. Invasive fungal infection in crtically ill patients: hurdles and next challenges. J Chemother 2019; 31:64-73. [PMID: 30761948 DOI: 10.1080/1120009x.2018.1557799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
A narrative review from a multidisciplinary task force of experts in critical care medicine and clinical mycology was carried out. The multi drug-resistant species Candida auris has emerged simultaneously on several continents, causing hospital outbreaks, especially in critically ill patients. Although there are not enough data to support the routine use of continuous antibiotic prophylaxis in patients subjected to extracorporeal membrane oxygenator, a clear increase of invasive fungal infection (IFI) has been described with the use of this device. Possible IFI treatment failures could be related with suboptimal antifungal concentrations despite dose adjustment. Invasive aspergillosis has become an important life-threating infection in intensive care unit related with new risk factors described. IFI remain important problem in critical patients due to the appearance of new risk factors, new species, and resistance increase. Multidisciplinary packages of measures designed to reduce IFI incidence and improve diagnostics tools may reduce the high mortality associated.
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Affiliation(s)
- Peral José
- a Intensive Care Unit , Hospital General Universitario Gregorio Marañón , Madrid , Spain
| | | | - Emilio Maseda
- c Surgical Intensive Care Unit , Hospital Universitario La Paz , Madrid , Spain
| | - Pedro Olaechea
- d Intensive Care Unit , Hospital Universitario de Galdákano- Usansolo , Galdakao , Spain
| | - Javier Pemán
- e Microbiology Department , Hospital Universitari i Politecnic La Fe , Valencia , Spain
| | - Cruz Soriano
- f Intensive Care Unit , Hospital Universitario Ramón y Cajal , Madrid , Spain
| | - Rafael Zaragoza
- g Intensive Care Unit , Hospital Universitario Dr. Peset , Valencia , Spain
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Ferrer R, Martínez ML, Gomà G, Suárez D, Álvarez-Rocha L, de la Torre MV, González G, Zaragoza R, Borges M, Blanco J, Herrejón EP, Artigas A. Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study. Crit Care 2018. [PMID: 29933756 DOI: 10.1186/s13054-18-2091-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
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Affiliation(s)
- Ricard Ferrer
- Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain. .,CIBER Enfermedades Respiratorias, Madrid, Spain.
| | - María Luisa Martínez
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
| | - Gemma Gomà
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - David Suárez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - Luis Álvarez-Rocha
- Intensive Care Department, Hospital Universitario de la Coruña, A Coruña, Spain
| | | | - Gumersindo González
- Intensive Care Department, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Marcio Borges
- Intensive Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Jesús Blanco
- CIBER Enfermedades Respiratorias, Madrid, Spain.,Intensive Care Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Antonio Artigas
- CIBER Enfermedades Respiratorias, Madrid, Spain.,Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain.,Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
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18
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Ferrer R, Martínez ML, Gomà G, Suárez D, Álvarez-Rocha L, de la Torre MV, González G, Zaragoza R, Borges M, Blanco J, Herrejón EP, Artigas A. Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study. Crit Care 2018; 22:167. [PMID: 29933756 PMCID: PMC6013897 DOI: 10.1186/s13054-018-2091-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/08/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
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Affiliation(s)
- Ricard Ferrer
- Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.
- CIBER Enfermedades Respiratorias, Madrid, Spain.
| | - María Luisa Martínez
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
| | - Gemma Gomà
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - David Suárez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - Luis Álvarez-Rocha
- Intensive Care Department, Hospital Universitario de la Coruña, A Coruña, Spain
| | | | - Gumersindo González
- Intensive Care Department, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Marcio Borges
- Intensive Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Jesús Blanco
- CIBER Enfermedades Respiratorias, Madrid, Spain
- Intensive Care Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Antonio Artigas
- CIBER Enfermedades Respiratorias, Madrid, Spain
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
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Mensa J, Barberán J, Soriano A, Llinares P, Marco F, Cantón R, Bou G, del Castillo JG, Maseda E, Azanza JR, Pasquau J, García-Vidal C, Reguera JM, Sousa D, Gómez J, Montejo M, Borges M, Torres A, Alvarez-Lerma F, Salavert M, Zaragoza R, Oliver A. Antibiotic selection in the treatment of acute invasive infections by Pseudomonas aeruginosa: Guidelines by the Spanish Society of Chemotherapy. Rev Esp Quimioter 2018; 31:78-100. [PMID: 29480677 PMCID: PMC6159363] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pseudomonas aeruginosa is characterized by a notable intrinsic resistance to antibiotics, mainly mediated by the expression of inducible chromosomic β-lactamases and the production of constitutive or inducible efflux pumps. Apart from this intrinsic resistance, P. aeruginosa possess an extraordinary ability to develop resistance to nearly all available antimicrobials through selection of mutations. The progressive increase in resistance rates in P. aeruginosa has led to the emergence of strains which, based on their degree of resistance to common antibiotics, have been defined as multidrug resistant, extended-resistant and panresistant strains. These strains are increasingly disseminated worldwide, progressively complicating the treatment of P. aeruginosa infections. In this scenario, the objective of the present guidelines was to review and update published evidence for the treatment of patients with acute, invasive and severe infections caused by P. aeruginosa. To this end, mechanisms of intrinsic resistance, factors favoring development of resistance during antibiotic exposure, prevalence of resistance in Spain, classical and recently appeared new antibiotics active against P. aeruginosa, pharmacodynamic principles predicting efficacy, clinical experience with monotherapy and combination therapy, and principles for antibiotic treatment were reviewed to elaborate recommendations by the panel of experts for empirical and directed treatment of P. aeruginosa invasive infections.
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Affiliation(s)
- José Mensa
- Servicio de Enfermedades Infecciosas, Hospital Clinic, Barcelona, Spain
| | - José Barberán
- Servicio de Medicina Enfermedades infecciosas, Hospital Universitario HM Montepríncipe, Universidad San Pablo CEU. Madrid, Spain
| | - Alex Soriano
- Servicio de Enfermedades Infecciosas, Hospital Clinic, Barcelona, Spain
| | - Pedro Llinares
- Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario A Coruña, Spain
| | - Francesc Marco
- Servicio de Microbiología, Hospital Clinic, Barcelona, Spain
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). Madrid, Spain
| | - German Bou
- Servicio de Microbiología, Complejo Hospitalario Universitario A Coruña, Spain
| | | | - Emilio Maseda
- Servicio de Anestesiología, Hospital Universitario La Paz, Madrid, Spain
| | - José Ramón Azanza
- Servicio de Farmacología, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Juan Pasquau
- Servicio de Enfermedades Infecciosas, Hospital Universitario Virgen de la Nieves, Granada, Spain
| | | | - José María Reguera
- Servicio de Enfermedades Infecciosas, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Dolores Sousa
- Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario A Coruña, Spain
| | - Joaquín Gómez
- Servicio de Enfermedades Infecciosas, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Miguel Montejo
- Servicio de Enfermedades Infecciosas, Hospital Universitario Cruces, Bilbao, Spain
| | - Marcio Borges
- Servicio de Medicina Intensiva, Hospital Son Llátzer, Palma de Mallorca, Spain
| | - Antonio Torres
- Departamento de Neumología, Hospital Clinic, Barcelona, Spain
| | | | - Miguel Salavert
- Unidad de Enfermedades Infecciosas. Hospital Univeristario la Fe, Valencia, Spain
| | - Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Antonio Oliver
- Servicio de Microbiología, Hospital Universitari Son Espases, Instituto de Investigación Sanitaria Illes Balears (idISBa), Palma de Mallorca, Spain
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Zaragoza R, Ferrer R, Llinares P, Maseda E, Rodríguez A, Grau S, Quindós G. EPICO 4.0. 'Total quality' in the management of invasive candidiasis in critically ill patients by analysing the integrated process. Rev Iberoam Micol 2017; 34:143-157. [PMID: 28734773 DOI: 10.1016/j.riam.2017.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 01/23/2017] [Revised: 03/12/2017] [Accepted: 03/30/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND A high quality integrated process in the clinical setting of non-neutropenic critically ill patients at risk for invasive candidiasis is a necessary tool to improve the management of these patients. AIMS To identify the key points on invasive candidiasis in order to develop a set of recommendations with a high level of consensus required for the creation of a total quality integrated process for the management of non-neutropenic critically ill patients at risk of invasive candidiasis. METHODS After a thorough review of the literature of the previous five years, a Spanish prospective questionnaire, which measured consensus by the Delphi technique, was anonymously conducted by e-mail, including 31 national multidisciplinary experts with extensive experience in invasive fungal infections, from six national scientific societies. The experts included a specialist in intensive care medicine, anesthetists, microbiologists, pharmacologists, and specialists in infectious diseases that responded 27 questions prepared by the coordination group. The educational objectives considered six processes that included knowledge of the local epidemiology, the creation and development of multidisciplinary teams, the definitions of the process, protocols, and indicators (KPI), an educational phase, hospital implementation, and the measurement of outcomes. The level of agreement among experts in each category to be selected should exceed 70%. In a second phase, after drawing up the recommendations of the selected processes, a face to face meeting with more than 60 specialists was held. The specialists were asked to validate the pre-selected recommendations. MEASURES AND MAIN OUTCOMES Firstly, 20 recommendations from all the sections were pre-selected: Knowledge of local epidemiology (3 recommendations), creation and development of multidisciplinary teams (3), definition of the process, protocols and indicators (1), educational phase (3), hospital implementation (3), and measurement of outcomes (7). After the second phase, 18 recommendations were validated, and it was concluded that the minimum team or core necessary for the development of an efficient program in the use of antifungal drugs in non-neutropenic critically ill patients must consist of a specialist in infectious diseases, a clinical pharmacist, a microbiologist, a specialist in intensive care medicine, a specialist in anesthesia and recovery, and an administrator or member of the medical management team, and, in order to be cost-effective, it should be implemented in hospitals with over 200 beds. In addition, it is recommended to apply a consensual check list for the evaluation of the diagnostic process and treatment of invasive candidiasis in patients that have started an antifungal treatment. The management of external knowledge and individual learning stand out as active educational strategies. The main strategies for measuring patient safety outcomes are the analysis of the results achieved, and learning activities; assess, review and refine the deployment of the processes; quality control; epidemiological surveillance and applied research; benchmarking; and basic research. The results of the integrated process should be annually disseminated outside the hospital. CONCLUSIONS Optimizing the management of invasive candidiasis requires the application of the knowledge and skills detailed in our recommendations. These recommendations, based on the Delphi methodology, facilitate the creation of a total quality integrated process in critically-ill patients at risk for invasive candidiasis.
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Affiliation(s)
- Rafael Zaragoza
- Unidad de Sepsis, Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain.
| | - Ricard Ferrer
- Servicio de Medicina Intensiva, Hospital Universitario Valle de Hebrón, Barcelona, Spain
| | - Pedro Llinares
- Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Emilio Maseda
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - Alejandro Rodríguez
- Unidad de Cuidados Intensivos, Hospital Universitario Juan XXIII, Tarragona, Spain
| | - Santiago Grau
- Servicio de Farmacia, Hospital del Mar, Barcelona, Spain
| | - Guillermo Quindós
- Departamento de Inmunología, Microbiología y Parasitología, Facultad de Medicina y Odontología, Universidad del País Vasco (UPV/EHU), Bilbao, Vizcaya, Spain
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Pemán J, Aguilar G, Valía JC, Salavert M, Navarro D, Zaragoza R. Jávea consensus guidelines for the treatment of Candida peritonitis and other intra-abdominal fungal infections in non-neutropenic critically ill adult patients. Rev Iberoam Micol 2017; 34:130-142. [DOI: 10.1016/j.riam.2016.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/24/2016] [Accepted: 12/02/2016] [Indexed: 12/28/2022] Open
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Maseda E, Rodríguez AH, Aguilar G, Pemán J, Zaragoza R, Ferrer R, Llinares P, Grau S. Erratum to: “EPICO 3.0. Recommendations on invasive candidiasis in patients with complicated intra-abdominal infection and surgical patients with ICU extended stay” [Rev Iberoam Micol. 33 (4) (2016) 196–205]. Rev Iberoam Micol 2017; 34:61. [DOI: 10.1016/j.riam.2017.02.002] [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] [Received: 02/02/2017] [Accepted: 02/03/2017] [Indexed: 11/26/2022] Open
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Llinares P, Ruiz I, Zaragoza R, Ferrer R, Rodríguez AH, Maseda E, Grau S. Erratum to "EPICO 3.0. Empirical antifungal therapy in critically-ill hematology patients" [Rev Iberoam Micol. 33 (4) (2016) 206-215]. Rev Iberoam Micol 2017; 34:62. [PMID: 28249672 DOI: 10.1016/j.riam.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/06/2017] [Indexed: 10/20/2022] Open
Affiliation(s)
- Pedro Llinares
- Infectious Diseases Service, A Coruña University Complex Hospital, A Coruña, Spain
| | - Isabel Ruiz
- Infectious Diseases Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Rafael Zaragoza
- Intensive Care Medicine Service, Dr. Peset University Hospital, Valencia, Spain.
| | - Ricard Ferrer
- Intensive Care Medicine Service, Mutua de Terrassa University Hospital, Barcelona, Spain
| | | | - Emilio Maseda
- Anesthesiology Service, La Paz University Hospital, Madrid, Spain
| | - Santiago Grau
- Pharmacy Service, Hospital del Mar, Barcelona, Spain
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Zaragoza R, Aguado JM, Ferrer R, Rodríguez AH, Maseda E, Llinares P, Grau S, Muñoz P, Fortún J, Bouzada M, del Pozo JC, León R. Erratum to: “EPICO 3.0. Antifungal prophylaxis in solid organ transplant recipients” [Rev Iberoam Micol. 33 (4) (2016) 187–195]. Rev Iberoam Micol 2017; 34:60. [DOI: 10.1016/j.riam.2017.02.001] [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] [Received: 02/02/2017] [Accepted: 02/07/2017] [Indexed: 11/26/2022] Open
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Ferrer R, Zaragoza R, Rodríguez AH, Maseda E, Llinares P, Grau S, Álvarez-Lerma F, Quindós G, Salavert M, Huarte R. Erratum to: "EPICO 3.0. Management of non-neutropenic patients in medical wards" [Rev Iberoam Micol. 33 (4) (2016) 216-223]. Rev Iberoam Micol 2017; 34:63. [PMID: 28249673 DOI: 10.1016/j.riam.2017.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/07/2017] [Indexed: 10/20/2022] Open
Affiliation(s)
- Ricardo Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital. Shock, organ dysfunction and Resuscitation Research Group (SODIR), VHIR, Barcelona, Spain.
| | - Rafael Zaragoza
- Intensive Care Medicine Service, Dr. Peset University Hospital, Valencia, Spain
| | | | - Emilio Maseda
- Anesthesiology Service, La Paz University Hospital, Madrid, Spain
| | - Pedro Llinares
- Infectious Diseases Service, A Coruña University Complex Hospital, A Coruña, Spain
| | - Santiago Grau
- Pharmacy Service, Hospital del Mar, Barcelona, Spain
| | | | - Guillermo Quindós
- Microbiology Service, Faculty of Medicine and Dentistry, Basque Country University, Spain
| | - Miguel Salavert
- Infectious Diseases Service, Hospital La Fe, Valencia, Spain
| | - Rafael Huarte
- Pharmacy Service, Miguel Servet University Hospital, Zaragoza, Spain
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Ferrer R, Zaragoza R, Rodríguez AH, Maseda E, Llinares P, Grau S, Álvarez-Lerma F, Quindós G, Salavert M, Huarte R. EPICO 3.0. Management of non-neutropenic patients in medical wards. Rev Iberoam Micol 2016; 33:216-223. [PMID: 27769740 DOI: 10.1016/j.riam.2016.06.003] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/16/2016] [Accepted: 06/17/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although the management of invasive fungal infection (IFI) has improved, a number of controversies persist regarding the approach to invasive fungal infection in non-neutropenic medical ward patients. AIMS To identify the essential clinical knowledge to elaborate a set of recommendations with a high level of consensus necessary for the management of IFI in non-neutropenic medical ward patients. METHODS A prospective, Spanish questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all specialists (intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases) in IFI and belonging to six scientific national societies. They responded to five questions prepared by the coordination group after a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each category had to be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting held after extracting the recommendations from the chosen topics, and validated the pre-selected recommendations and derived algorithm. RESULTS The following recommendations were validated and included in the algorithm: 1. several elements were identified as risk factors for invasive candidiasis (IC) in non-hematologic medical patients; 2. no agreement on the use of the colonization index to decide whether prescribing an early antifungal treatment to stable patients (no shock), with sepsis and no other evident focus and IC risk factors; 3. agreement on the use of the Candida Score to decide whether prescribing early antifungal treatment to stable patients (no shock) with sepsis and no other evident focus and IC risk factors; 4. agreement on initiating early antifungal treatment in stable patients (no shock) with a colonization index>0.4, sepsis with no other evident focus and IC risk factors; 5. agreement on the performance of additional procedures in stable patients (no shock) with sepsis and no other evident focus, IC risk factors, without colonization index>0.4, but with a high degree of suspicion. CONCLUSIONS Based on the expert's recommendations, an algorithm for the management of non-neutropenic medical patients was constructed and validated. This algorithm may be useful to support bedside prescription.
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Affiliation(s)
- Ricardo Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital. Shock, organ dysfunction and Resuscitation Research Group (SODIR), VHIR, Barcelona, Spain.
| | - Rafael Zaragoza
- Intensive Care Medicine Service, Dr. Peset University Hospital, Valencia, Spain
| | | | - Emilio Maseda
- Anesthesiology Service, La Paz University Hospital, Madrid, Spain
| | - Pedro Llinares
- Infectious Diseases Service, A Coruña University Complex Hospital, A Coruña, Spain
| | - Santiago Grau
- Pharmacy Service, Hospital del Mar, Barcelona, Spain
| | | | - Guillermo Quindós
- Microbiology Service, Faculty of Medicine and Dentistry, Basque Country University, Spain
| | - Miguel Salavert
- Infectious Diseases Service, Hospital La Fe, Valencia, Spain
| | - Rafael Huarte
- Pharmacy Service, Miguel Servet University Hospital, Zaragoza, Spain
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Llinares P, Ruiz I, Zaragoza R, Ferrer R, Rodríguez AH, Maseda E, Grau S. EPICO 3.0. Empirical antifungal therapy in critically-ill hematology patients. Rev Iberoam Micol 2016; 33:206-215. [PMID: 27751781 DOI: 10.1016/j.riam.2016.06.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/06/2016] [Accepted: 06/20/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Although in the past decade the management of invasive fungal infections has improved, a number of controversies persist regarding empirical antifungal treatment in critically-ill hematology patients. AIMS To identify key clinical knowledge to elaborate a set of recommendations, with a high level of consensus, necessary for the approach to fungal infections in critically-ill hematology patients. METHODS A Spanish prospective questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all specialists in fungal invasive infections from six scientific national societies; intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases. They responded to 10 questions prepared by the coordination group after a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each category must be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting held after extracting the recommendations from the chosen topics, and validated the pre-selected recommendations and derived algorithm. RESULTS Assess administering antifungal treatment to patients with high/medium risk factors and fever for over 4 days after onset of antibiotic therapy, and in the event of negative galactomannan or if no detection analysis has been performed and no relevant findings in the sinus and chest computed tomography (CT) have been detected, (1) in the case the patient did not receive prophylaxis, or was administered fluconazole, caspofungin treatment is recommended; (2) in the event the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B is recommended and caspofungin as second choice therapy; (3) in the event that the prophylaxis received was an echinocandin, liposomal amphotericin B therapy is recommended and voriconazole as second choice. Assess administering antifungal treatment in patients with high/medium risk factors and fever for more than 4 days after onset of antibiotic therapy, and in the event of a positive galactomannan and/or sinus and chest CT suggests fungal infection caused by filamentous fungi, (1) in the event the patient did not receive antifungal prophylaxis or was administered fluconazole, the recommended treatment of choice is voriconazole or liposomal amphotericin B; (2) if the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B with caspofungin is recommended and monotherapy with liposomal amphotericin B or the combination of voriconazole and anidulafungin are recommended as second choice therapies; (3) in the event an echinocandin was administered as prophylaxis, liposomal amphotericin B or voriconazole are the recommended treatments of choice. Consider the administration of antifungal treatment in patients with high/medium risk factors and fever for more than 4 days after onset of antibiotic therapy, and in the event of a negative galactomannan and the sinus and chest CT suggests fungal infection caused by filamentous fungi, (1) if the patient did not receive prophylaxis or was administered fluconazole, the recommended treatment of choice is liposomal amphotericin B or voriconazole; (2) in the case the patient received prophylaxis with an azole with activity against filamentous fungi, the administration of liposomal amphotericin B is recommended as first choice therapy and liposomal amphotericin B combined with caspofungin as second choice; (3) in the event an echinocandin was administered as prophylaxis, liposomal amphotericin B or voriconazole are the recommended treatments of choice. CONCLUSIONS The empirical antifungal approach in critically-ill hematology patients requires the application of the broad range of knowledge and skills described in our recommendations and algorithm. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their management and improve overall prognosis.
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Affiliation(s)
- Pedro Llinares
- Infectious Diseases Service, A Coruña University Complex Hospital, A Coruña, Spain.
| | - Isabel Ruiz
- Infectious Diseases Service, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Rafael Zaragoza
- Intensive Care Medicine Service, Dr. Peset University Hospital, Valencia, Spain
| | - Ricard Ferrer
- Intensive Care Medicine Service, Mutua de Terrassa University Hospital, Barcelona, Spain
| | | | - Emilio Maseda
- Anesthesiology Service, La Paz University Hospital, Madrid, Spain
| | - Santiago Grau
- Pharmacy Service, Hospital del Mar, Barcelona, Spain
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Bouza E, Martínez-Alarcón J, Maseda E, Palomar M, Zaragoza R, Pérez-Granda MJ, Muñoz P, Burillo A. Quality of the aetiological diagnosis of ventilator-associated pneumonia in Spain in the opinion of intensive care specialists and microbiologists. Enferm Infecc Microbiol Clin 2016; 35:153-164. [PMID: 27743679 DOI: 10.1016/j.eimc.2016.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 05/09/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Current guidelines for the microbiological diagnosis of ventilator-associated pneumonia (VAP) are imprecise. Based on data provided by intensive care specialists (ICS) and microbiologists, this study defines the clinical practices and microbiological techniques currently used for an aetiological diagnosis of VAP and pinpoints deficiencies. METHODS Eighty hospitals in the national health network with intensive care and microbiology departments were sent two questionnaires, one for each department, in order to collect data on VAP diagnosis for the previous year. RESULTS Out of the 80 hospitals, 35 (43.8%) hospitals participated. These included 673 ICU beds, 32,020 ICU admissions, 173,820 ICU days stay, and generated 27,048 lower respiratory tract specimens in the year. A third of the hospitals (35%) had a microbiology department available 24/7. Most samples (83%) were tracheal aspirates. Gram stain results were immediately reported in around half (47%) of the hospitals. Quantification was made in 75% of hospitals. Molecular techniques and direct susceptibility testing were performed in 12% and one institution, respectively. Mean turnaround time for a microbiological report was 1.7 (SD; 0.7), and 2.2 (SD; 0.6) days for a negative and positive result, respectively. Telephone/in-person information was offered by 65% of the hospitals. Most (89%) ICS considered microbiological information as very useful. No written procedures were available in half the ICUs. CONCLUSIONS Both ICS and microbiologists agreed that present guidelines for the diagnosis of VAP could be much improved, and that a new set of consensus guidelines is urgently required. A need for guidelines to be more effectively implemented was also identified in order to improve outcomes in patients with VAP.
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Affiliation(s)
- Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - José Martínez-Alarcón
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; The present affiliation of José Martínez-Alarcón is Department of Microbiology, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Emilio Maseda
- Department of Anesthesia, Hospital General Universitario La Paz, Madrid, Spain
| | - Mercedes Palomar
- Intensive Care Dept., Hospital Universitari Arnau de Vilanova, Lérida, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0036), Spain
| | - Rafael Zaragoza
- Intensive Care Dept., Hospital Universitario Doctor Peset, Valencia, Spain
| | - María Jesús Pérez-Granda
- Department of Anesthesia, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Spain
| | - Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
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Zaragoza R, Aguado JM, Ferrer R, Rodríguez AH, Maseda E, Llinares P, Grau S, Muñoz P, Fortún J, Bouzada M, Pozo JCD, León R. EPICO 3.0. Antifungal prophylaxis in solid organ transplant recipients. Rev Iberoam Micol 2016; 33:187-195. [DOI: 10.1016/j.riam.2016.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/12/2016] [Indexed: 12/12/2022] Open
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Rello J, Diaz E, Mañez R, Sole-Violan J, Valles J, Vidaur L, Zaragoza R, Gattarello S. Improved survival among ICU-hospitalized patients with community-acquired pneumonia by unidentified organisms: a multicenter case-control study. Eur J Clin Microbiol Infect Dis 2016; 36:123-130. [PMID: 27655267 DOI: 10.1007/s10096-016-2779-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 10/21/2022]
Abstract
A retrospective analysis from prospectively collected data was conducted in intensive care units (ICUs) at 33 hospitals in Europe comparing the trend in ICU survival among adults with severe community-acquired pneumonia (CAP) due to unknown organisms from 2000 to 2015. The secondary objective was to establish whether changes in antibiotic policies were associated with different outcomes. ICU mortality decreased (p = 0.02) from 26.9 % in the first study period (2000-2002) to 15.7 % in the second period (2008-2015). Demographic data and clinical severity at admission were comparable between groups, except for age over 65 years and incidence of cardiomyopathy. Over time, patients received higher rates of combination therapy (94.3 vs. 77.2 %; p < 0.01) and early (<3 h) antibiotic delivery (72.9 vs. 50.3 %; p < 0.01); likewise, the 2008-2015 group was more likely to receive adequate antibiotic prescription [as defined by the Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines] than the 2000-2002 group (70.7 vs. 48.2 %; p < 0.01). Multivariate analysis showed an independent association between decreased ICU mortality and early (<3 h) antibiotic administration [odds ratio (OR) 3.48 [1.70-7.15], p < 0.01] or adequate antibiotic prescription according to guidelines (OR 2.22 [1.11-4.43], p = 0.02). In conclusion, our findings suggest that ICU mortality in severe CAP due to unidentified organisms has decreased in the last 15 years. Several changes in management and better compliance with guidelines over time were associated with increased survival.
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Affiliation(s)
- J Rello
- Universitat Autonoma de Barcelona, Barcelona, Spain. .,CIBERES, Barcelona, Spain.
| | - E Diaz
- CIBERES, Barcelona, Spain.,Hospital Joan XXIII, Tarragona, Spain
| | - R Mañez
- Hospital de Bellvitge, Barcelona, Spain
| | - J Sole-Violan
- CIBERES, Barcelona, Spain.,Hospital Negrin, Las Palmas de Gran Canaria, Spain
| | - J Valles
- CIBERES, Barcelona, Spain.,Hospital Parc Tauli, Sabadell, Spain
| | - L Vidaur
- CIBERES, Barcelona, Spain.,Hospital de Donostia, Donostia, Spain
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Ferrer R, Zaragoza R, Llinares P, Maseda E, Rodríguez A, Quindós G. Impact of a multifaceted educational intervention including serious games to improve the management of invasive candidiasis in critically ill patients. Med Intensiva 2016; 41:3-11. [PMID: 27645566 DOI: 10.1016/j.medin.2016.07.003] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Infections caused by Candida species are common in critically ill patients and contribute to significant morbidity and mortality. The EPICO Project (Epico 1 and Epico 2.0 studies) recently used a Delphi approach to elaborate guidelines for the diagnosis and treatment of this condition in critically ill adult patients. We aimed to evaluate the impact of a multifaceted educational intervention based on the Epico 1 and Epico 2.0 recommendations. DESIGN Specialists anonymously responded to two online surveys before and after a multifaceted educational intervention consisting of 60-min educational sessions, the distribution of slide kits and pocket guides with the recommendations, and an interactive virtual case presented at a teleconference and available for online consultation. SETTING A total of 74 Spanish hospitals. PARTICIPANTS Specialists of the Intensive Care Units in the participating hospitals. VARIABLES OF INTEREST Specialist knowledge and reported practices evaluated using a survey. The McNemar test was used to compare the responses in the pre- and post-intervention surveys. RESULTS A total of 255 and 248 specialists completed both surveys, in both periods, respectively. The pre-intervention surveys showed many specialists to be unaware of the best approach for managing invasive candidiasis. After both educational interventions, specialist knowledge and reported practices were found to be more in line with nearly all the recommendations of the Epico 1 and Epico 2.0 guidelines, except as regards de-escalation from echinocandins to fluconazole in Candida glabrata infections (p=0.055), and the duration of antifungal treatment in both candidemia and peritoneal candidiasis. CONCLUSIONS This multifaceted educational intervention based on the Epico Project recommendations improved specialist knowledge of the management of invasive candidiasis in critically ill patients.
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Affiliation(s)
- R Ferrer
- Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Shock, Organ Dysfunction and Resuscitation Research Group (SODIR), VHIR, Barcelona, Spain.
| | - R Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
| | - P Llinares
- Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - E Maseda
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - A Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario Juan XXIII, Tarragona, Spain
| | - G Quindós
- Facultad de Medicina y Odontología de la Universidad del País Vasco, Spain
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Maseda E, Rodríguez AH, Aguilar G, Pemán J, Zaragoza R, Ferrer R, Llinares P, Grau S. EPICO 3.0. Recommendations on invasive candidiasis in patients with complicated intra-abdominal infection and surgical patients with ICU extended stay. Rev Iberoam Micol 2016; 33:196-205. [PMID: 27422492 DOI: 10.1016/j.riam.2016.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 01/21/2016] [Accepted: 02/12/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Although in the last decade the management of invasive fungal infections has improved, a number of controversies persist regarding the management of complicated intra-abdominal infection and surgical extended length-of-stay (LOS) patients in intensive care unit (ICU). AIMS To identify the essential clinical knowledge and elaborate a set of recommendations, with a high level of consensus, necessary for the management of postsurgical patients with complicated intra-abdominal infection and surgical patients with ICU extended stay. METHODS A Spanish prospective questionnaire, which measures consensus through the Delphi technique, was anonymously answered and e-mailed by 30 multidisciplinary national experts, all of them specialists in fungal invasive infections from six scientific national societies; these experts were intensivists, anesthesiologists, microbiologists, pharmacologists and specialists in infectious diseases. They answered 11 questions drafted by the coordination group after conducting a thorough review of the literature published in the last few years. For a category to be selected, the level of agreement among the experts in each should be equal to or greater than 70%. In a second round, 73 specialists attended a face-to-face meeting which was held after extracting recommendations from the chosen topics and in which they validated the pre-selected recommendations and derived algorithm. RESULTS After the second Delphi round, the following 11 recommendations with high degree of consensus were validated. For "surgical patients" seven recommendations were validated: (1) risk factors for invasive candidiasis (IC), (2) usefulness of blood culture and direct examination of abdominal fluid to start empirical treatment; (3) PCR for treatment discontinuation; (4) start antifungal treatment in patients with anastomotic leaks; (5) usefulness of Candida score (CS) but not (6) the Dupont score for initiating antifungal therapy in the event of anastomotic leakage or tertiary peritonitis, and (7) the administration of echinocandins as first line treatment in this special population. For "surgical ICU extended LOS patients" four recommendations were validated: (1) risk factors for IC, (2) presence of multi-colonization by Candida as a required variable of the CS, (3) starting antifungal treatment with CS≥4, and (4) to perform non-culture-based microbiological techniques in stable septic patients without evident focus. CONCLUSIONS The diagnosis and management of IC in ICU surgical patients requires the application of a broad range of knowledge and skills that we summarize in our recommendations. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their global management and improve their outcomes.
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Affiliation(s)
- Emilio Maseda
- Servicio de Anestesiología, Hospital Universitario La Paz, Madrid, Spain.
| | - Alejandro H Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII/URV/IISPV/CIBERES, Spain
| | - Gerardo Aguilar
- Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Spain
| | - Javier Pemán
- Servicio de Microbiología, Hospital Universitario La Fe de Valencia, Spain
| | - Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Vall D'Hebron, Spain
| | - Ricard Ferrer
- Servicio de Medicina Intensiva, Hospital Universitario Mútua de Terrassa, Spain
| | - Pedro Llinares
- Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario A Coruña, Spain
| | - Santiago Grau
- Servicio de Farmacia, Hospital del Mar, Barcelona, Spain
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Zaragoza R, Ramírez P, Borges M, Pemán J. [Update on invasive candidiasis in non-neutropenic critically ill adult patients]. Rev Iberoam Micol 2016; 33:145-51. [PMID: 27395022 DOI: 10.1016/j.riam.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 07/17/2015] [Revised: 02/23/2016] [Accepted: 03/02/2016] [Indexed: 12/29/2022] Open
Abstract
Invasive candidiasis in non-neutropenic critically ill patients remains a challenge for clinicians due to its association with high morbidity and mortality rates, increased incidence, and health-care costs. It is well known that early diagnosis and treatment are associated with a better prognosis. For these reasons a thorough update has been performed in this setting focused on recent Spanish epidemiology, new predictive scores and microbiological tests such as mannan antigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, molecular techniques for the detection of fungal-specific DNA, advances in antifungal treatment and educational programs in Spain. An early diagnostic and therapeutic algorithm is proposed based on the combination of scores and microbiological test. The aim of this review is to provide physicians with the best information available in order to improve the prognosis of these patients.
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Affiliation(s)
- Rafael Zaragoza
- Unidad de Sepsis, Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, España.
| | - Paula Ramírez
- Servicio de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Marcio Borges
- Unidad de Sepsis, Servicio de Medicina Intensiva, Hospital Sont Llàtzer, Palma de Mallorca, España
| | - Javier Pemán
- Servicio de Microbiología, Hospital Universitario La Fe, Valencia, España
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Rodríguez AH, Avilés-Jurado FX, Díaz E, Schuetz P, Trefler SI, Solé-Violán J, Cordero L, Vidaur L, Estella Á, Pozo Laderas JC, Socias L, Vergara JC, Zaragoza R, Bonastre J, Guerrero JE, Suberviola B, Cilloniz C, Restrepo MI, Martín-Loeches I, Cobo P, Martins J, Carbayo C, Robles-Musso E, Cárdenas A, Fierro J, Fernández DO, Sierra R, Huertos MJ, Carmona Pérez ML, Pozo Laderas JC, Guerrero R, Robles JC, León ME, Gómez AB, Márquez E, Rodríguez-Carvajal M, Estella Á, Pomares J, Ballesteros JL, Romero OM, Fernández Y, Lobato F, Prieto JF, Albofedo-Sánchez J, Martínez P, de la Torre MV, Nieto M, Sola EC, Díaz Castellanos MA, Soler GS, Leyba CO, Garnacho-Montero J, Hinojosa R, Fernández E, Loza A, León C, López SG, Arenzana A, Ocaña D, Navarrete I, Beryanaki MZ, Sánchez I, Pérez Alé M, Poullet Brea AM, Machado Casas JF, Serón C, Avellanas ML, Lander A, de Arellano SGR, Lacueva MM, Luque P, Serrano EP, Martín Lázaro JF, Polo CS, Cia IG, Bartolomé BJ, Nuñez CL, González I, Tomás Marsilla JI, Andrés CJ, Ibañes PG, Aguilar PA, Montón JM, Regil PD, Iglesias L, González CP, Fernández BQ, Iglesias LM, Soria LV, Escudero RY, Revuelta MDRM, Quiroga, García-Rodríguez Á, Cuadrado MM, Balán Mariño AL, Socias L, Ibánez P, Borges-Sa M, Socias A, Del Castillo A, Marcos RJ, Muñoz C, Bonell JM, Amestarán I, López MAG, Pàmies CV, Bonell Goytisolo JM, Morales Carbonero JA, Bonell Goytisolo JM, Morales Carbonero JA, Senoff RP, López de Medrano MG, Ruiz-Santana S, Díaz JJ, Ramírez CS, Sisón M, Hernández D, Trujillo A, Regalado L, Fndez SR, Lorente L, Rivero JC, Mora Quintero ML, Martín M, Martínez S, Cáceres J, Sanchez Palacio M, Marcos, García Rodríguez D, Leria MR, Suberviola B, Ugarte P, García-López F, Iniesta RS, Alonso AÁ, Padilla A, Palacios BM, Grande MLG, Martín Rodríguez MC, Adbel-Hadi Álvarez H, Ambros Checa A, Hernández HM, Albaya A, Obregón AS, Crespo CM, Estrella CA, Benito Puncel C, Oyargue EQ, Canabal A, Marina L, López de Toro I, Simón A, Añón JM, López Messa JB, López Pueyo MJ, del valle Sergio Ossa Echeverri OM, Ferreras Z, Ballesteros Herraez JC, Macias S, Berezo JÁ, Varela JB, Schweizer PB, Salamanca AG, Lomas LT, Anzález AO, Cicuéndez Avila R, Francisco Javier PG, Terrero AÁ, Ezpeleta FT, Sala C, López O, Paez Z, García Á, Carriedo Ule D, Crespo MR, Rebolledo JP, Andrés NH, Zirena ACC, García BR, López Messa JB, del Valle Ortiz M, Echeverri SO, Catalán RM, Ferrer M, Torres A, Cilloniz C, Ansorregui SB, Cabré L, Baeza I, Rovira A, Álvarez-Lerma F, Vázquez A, Nolla J, Fernández F, Cervelló JR, Iglesia R, Mañéz R, Ballús J, Granada RM, Vallés J, Díaz E, Ortíz M, Guía C, Martín-Loeches I, Páez J, Almirall J, Balanzo X, Güell E, Yebenes JC, Rello J, Arnau E, Pérez M, Laborda C, Souto J, Lagunes L, Catalán I, Sirvent JM, de Arbina NL, Serra AB, Sánchez A, Cuenca; SM, Badía M, Baseda-Garrido B, Valverdú-Vidal M, Barcenilla F, Palomar M, Nuvials X, Benedicto PG, Campo FR, Esteban M, Luna J, Eixarch GM, Diago AP, Nava JM, González de Molina J, Trenado J, Ferrer R, Josic Z, Casanovas M, Gurri F, Rodríguez P, Rodríguez A, Claverias L, Trefler S, Bodí M, Magret M, Ferri C, Díaz RM, Mesalles E, Arméstar F, de Mendoza D, Fernández CL, Berrade JJ, Saris AB, Pechkova M, Jiménez CM, Gil SP, Juliá-Narváez J, Marcos MR, Mallqui VF, Santiago Triviño MA, García PM, Fernández-Zapata A, Recio T, Arrascaeta A, García-Ramos MJ, Gallego E, Rodrigo ES, Bueno F, Díaz M, Pérez NG, Hormigo DL, Delgado JDJ, Frutos P, Rivera Pinna M, Cordero ML, Pastor JA, Álvarez-Rocha L, Ceniceros Barros A, Pedreira AV, Vila D, González CF, Pérez JB, Piquer MO, Merayo E, López-Ciudad VJ, Cañones JC, Vilaboy E, Chao JV, Cid López FS, Cortés PV, Pérez Veloso MA, Saborido EM, Pardavila EA, Montes AO, González RJ, Freita S, Alemparte E, Ortega A, López AM, Canabal J, Ferres E, Pérez JB, Piquer MO, Ramos SF, Cendón LL, Casal VG, Adrio SV, Fernández EM, Prado SG, Franco AV, Monzón JL, Goñi F, Del Nogal Sáez F, Navalpotro MB, Abad RD, Lasierra JLF, García-Torrejón MC, Pérez–Calvo C, López D, Arnaiz L, Sánchez-Alonso S, Velayos C, del Río F, González MÁ, Nieto M, Cesteros CS, Martín MC, Molina JM, Montejo JC, Catalán M, Albert P, de Pablo A, Guerrero JE, Zurita; M, Peyrat JB, Cámara MD, Cerdá E, Alvarez M, Pey C, Riestra EM, Martinez-Fidalgo C, Rodríguez M, Palencia E, Caballero R, Vaquero C, Mariscal F, García S, Cepeda R, Carrasco N, Prieto I, Liétor A, Ramos R, Casas RC, Cuesta CS, Sánchez Alonso S, Galván B, Figueira JC, Soriano MC, Martín BC, Caballero AR, Galdós P, Moreno BB, Alcántara Carmona S, del Cabo F, Hermosa C, Gordo F, Algora A, Paredes A, Carmona TG, Cambroner J, Ramos EL, de Zárate YO, Gómez-Rosado S, Lodo MM, Garrobo NF, Hernández SÁ, Honrubia T, Prado López LM, Esteban A, Lorente J, Nin N, Sotomayor CJ, Arnaiz L, Silvero EM, de la Reguera EMF, de la Casa Monje RM, Serrano FM, Trasmonte Martínez MV, Martín Delgado MC, Martínez S, Abad FF, Navalon IC, Velis MV, Martínez M, Martínez Baño D, Andreu E, Butí SM, Rueda BG, García F, Fernández NL, Para LH, Freire AO, Nvarro Ruiz MR, Romero CH, Maraví-Poma E, Urra IJ, Redin LM, Tellería A, Insansti J, Garcia NA, Macaya L, Palanco JL, González N, Marco P, Vidaur L, Salas E, Udabe RS, Santamaría B, Rodríguez T, Vergara JC, Amiano JRI, Santos IG, Manzano A, Arenal CC, Olaechea PM, Hernández HM, López AM, San Miguel FF, Blanquer J, Carbonell N, Franco JF, Valero RR, Belenger A, Altaba S, Álvarez–Sánchez B, Robles JC, Francisco JS, Sánchez MR, Picos SA, Llanes AA, Gutiérrez EH, Zapata AF, Sánchez-Miralles Á, Antón Pascual JL, Bonastre J, Palamo M, Cebrian J, Cuñat J, Sahuquillo MG, Romero B, Pallé SB, de León Belmar J, Zaragoza R, Tormo C, Chinesta SS, Paricio V, Marques A, Sánchez-Morcillo S, Tormo S, Latour J, García MÁ, Palomo M, Royo FT, Hinojosa PM, Sánchez Pino MS, Ribes CM, Luis RG, Ribas A. Procalcitonin (PCT) levels for ruling-out bacterial coinfection in ICU patients with influenza: A CHAID decision-tree analysis. J Infect 2016; 72:143-51. [DOI: 10.1016/j.jinf.2015.11.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Revised: 11/12/2015] [Accepted: 11/28/2015] [Indexed: 01/22/2023]
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Zaragoza R, Buceta N, Sancho S, Hurtado C, Camarena J, González R, Puchades F, Martinez C, Cervera M. Severe sepsis and sepsis shock secondary to non ventilator associated nosocomial pneumonia. principal features and predictors of outcome. Intensive Care Med Exp 2015. [PMCID: PMC4797386 DOI: 10.1186/2197-425x-3-s1-a708] [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: 12/04/2022] Open
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Zaragoza R, Sancho S, Hurtado C, Camarena J, González R, Borrás S, Cervera M. Intermediate results of implementation of automatic electronic alert program for early detection of severe sepsis patients in an hospital with sepsis unit. analysis of two years period. Intensive Care Med Exp 2015. [PMCID: PMC4797600 DOI: 10.1186/2197-425x-3-s1-a218] [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: 11/29/2022] Open
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González De Molina FJ, Rodríguez A, Barbadillo S, Díaz E, Solé-Violán J, Socias L, Vergara JC, Zaragoza R, Suberviola B, Vidaur L, Ferrer R, Martín-Loeches I. Pneumococcal pneumonia coinfection in critically ill patients with influenza a (h1n1) primary viral pneumonia. Intensive Care Med Exp 2015. [PMCID: PMC4798473 DOI: 10.1186/2197-425x-3-s1-a829] [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: 11/10/2022] Open
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Gattarello S, Lagunes L, Vidaur L, Solé-Violán J, Zaragoza R, Vallés J, Torres A, Sierra R, Sebastian R, Rello J. Improvement of antibiotic therapy and ICU survival in severe non-pneumococcal community-acquired pneumonia: a matched case-control study. Crit Care 2015; 19:335. [PMID: 26369551 PMCID: PMC4570589 DOI: 10.1186/s13054-015-1051-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 08/26/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION We aimed to compare intensive care unit mortality due to non-pneumococcal severe community-acquired pneumonia between the periods 2000-2002 and 2008-2014, and the impact of the improvement in antibiotic strategies on outcomes. METHODS This was a matched case-control study enrolling 144 patients with non-pneumococcal severe pneumonia: 72 patients from the 2000-2002 database (CAPUCI I group) were paired with 72 from the 2008-2014 period (CAPUCI II group), matched by the following variables: microorganism, shock at admission, invasive mechanical ventilation, immunocompromise, chronic obstructive pulmonary disease, and age over 65 years. RESULTS The most frequent microorganism was methicillin-susceptible Staphylococcus aureus (22.1%) followed by Legionella pneumophila and Haemophilus influenzae (each 20.7%); prevalence of shock was 59.7%, while 73.6% of patients needed invasive mechanical ventilation. Intensive care unit mortality was significantly lower in the CAPUCI II group (34.7% versus 16.7%; odds ratio (OR) 0.78, 95% confidence interval (CI) 0.64-0.95; p = 0.02). Appropriate therapy according to microorganism was 91.5% in CAPUCI I and 92.7% in CAPUCI II, while combined therapy and early antibiotic treatment were significantly higher in CAPUCI II (76.4 versus 90.3% and 37.5 versus 63.9%; p < 0.05). In the multivariate analysis, combined antibiotic therapy (OR 0.23, 95% CI 0.07-0.74) and early antibiotic treatment (OR 0.07, 95% CI 0.02-0.22) were independently associated with decreased intensive care unit mortality. CONCLUSIONS In non-pneumococcal severe community-acquired pneumonia , early antibiotic administration and use of combined antibiotic therapy were both associated with increased intensive care unit survival during the study period.
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Affiliation(s)
- Simone Gattarello
- Critical Care Department, Vall d'Hebron Hospital, Ps. Vall d'Hebron, 119-129, Anexe AG-5a planta, 08035, Barcelona, Spain. .,Department of Medicine of the Universitat Autònoma de Barcelona, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
| | - Leonel Lagunes
- Critical Care Department, Vall d'Hebron Hospital, Ps. Vall d'Hebron, 119-129, Anexe AG-5a planta, 08035, Barcelona, Spain.,Department of Medicine of the Universitat Autònoma de Barcelona, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Loreto Vidaur
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Intensive Care Department, Donostia University Hospital, Donostia, Spain
| | - Jordi Solé-Violán
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Intensive Care Department, Dr. Negrin University Hospital, Las Palmas de Gran Canaria, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Dr. Peset University Hospital, Valencia, Spain
| | - Jordi Vallés
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Critical Care Centre, Sabadell Hospital, Consorci Hospitalari Universitari Parc Taulí, Sabadell, Spain
| | - Antoni Torres
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Disease Department, Hospital Clinic i Provincial de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rafael Sierra
- Critical Care Unit, Puerta del Mar University Hospital, Cadiz, Spain
| | - Rosa Sebastian
- Intensive Care Department, Donostia University Hospital, Donostia, Spain
| | - Jordi Rello
- Critical Care Department, Vall d'Hebron Hospital, Ps. Vall d'Hebron, 119-129, Anexe AG-5a planta, 08035, Barcelona, Spain.,Department of Medicine of the Universitat Autònoma de Barcelona, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Gattarello S, Borgatta B, Solé-Violán J, Vallés J, Vidaur L, Zaragoza R, Torres A, Rello J. Decrease in mortality in severe community-acquired pneumococcal pneumonia: impact of improving antibiotic strategies (2000-2013). Chest 2014; 146:22-31. [PMID: 24371840 DOI: 10.1378/chest.13-1531] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE The objective of the present study was to compare antibiotic prescribing practices and survival in the ICU for patients with pneumococcal severe community-acquired pneumonia (SCAP) between 2000 and 2013. METHODS This was a matched case-control study of two prospectively recorded cohorts in Europe. Eighty patients from the Community-Acquired Pneumonia en la Unidad de Cuidados Intensivos (CAPUCI) II study (case group) were matched with 80 patients from CAPUCI I (control group) based on the following: shock at admission, need of mechanical ventilation, COPD, immunosuppression, and age. RESULTS Demographic data were comparable in the two groups. Combined antibiotic therapy increased from 66.2% to 87.5% (P < .01), and the percentage of patients receiving the first dose of antibiotic within 3 h increased from 27.5% to 70.0% (P < .01). ICU mortality was significantly lower (OR, 0.82; 95% CI, 0.68-0.98) in cases, both in the whole population and in the subgroups of patients with shock (OR, 0.67; 95% CI, 0.50-0.89) or receiving mechanical ventilation (OR, 0.73; 95% CI, 0.55-0.96). In the multivariate analysis, ICU mortality increased in patients requiring mechanical ventilation (OR, 5.23; 95% CI, 1.60-17.17) and decreased in patients receiving early antibiotic treatment (OR, 0.36; 95% CI, 0.15-0.87) and combined therapy (OR, 0.19; 95% CI, 0.07-0.51). CONCLUSIONS In pneumococcal SCAP, early antibiotic prescription and use of combination therapy increased. Both were associated with improved survival.
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Affiliation(s)
- Simone Gattarello
- Critical Care Department, Vall d'Hebron Hospital, Universitat Autonoma de Barcelona and Medicine Department, Vall d'Hebron Institut de Recerca (VHIR), Barcelona.
| | - Bárbara Borgatta
- Critical Care Department, Vall d'Hebron Hospital, Universitat Autonoma de Barcelona and Medicine Department, Vall d'Hebron Institut de Recerca (VHIR), Barcelona
| | - Jordi Solé-Violán
- Intensive Care Unit, Dr Negrin University Hospital, Las Palmas de Gran Canaria, Sabadell; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
| | - Jordi Vallés
- Critical Care Center, Sabadell Hospital, Consorci Hospitalari Universitari Parc Taulí, Sabadell; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
| | - Loreto Vidaur
- Intensive Care Department, Donostia Hospital, Donostia; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Dr Peset University Hospital, Valencia
| | - Antoni Torres
- Respiratory Disease Department, Hospital Clínic i Provincial de Barcelona, University of Barcelona, Institut d'investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
| | - Jordi Rello
- Critical Care Department, Vall d'Hebron Hospital, Universitat Autonoma de Barcelona and Medicine Department, Vall d'Hebron Institut de Recerca (VHIR), Barcelona; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Bunyola, Islas Baleares, Spain
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Malinow I, Rivera-Santiago R, López-Malpica F, Zaragoza R, Velázquez V, Acantilado C, Rodríguez R, Rivera A, López-Almodóvar C, Nazario S. Association of the Asthma Control Test with peak flow measures in a population in Puerto Rico. P R Health Sci J 2014; 33:122-128. [PMID: 25244881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE The Asthma Control Test (ACT) questionnaire has been widely used and validated in various ethnic groups, showing an adequate correlation with physician assessment of asthma control. We sought to evaluate the relationship between ACT-defined asthma control and peak flow measures in subjects living in Puerto Rico. METHODS A retrospective evaluation of data collected by a mobile asthma clinic in 2 cities in Puerto Rico was conducted. The participants completed an asthma and rhinitis survey. Self-reported asthmatics answered the age-appropriate Spanish version of the ACT. Peak flows (PEF) were measured. Subjects were skin-tested against the common local aeroallergens. The study was approved by the University of Puerto Rico's IRB. RESULTS We evaluated data from 70 subjects aged 4 to 68. Of them, 82.85% were 12 years old or older, 64.3% reported having a history of asthma, 57.14% reported that they still suffered from asthma, 81.4% reported that they suffered from rhinitis, and 78.57% were sensitized to at least 1 antigen. The mean ACT score of current asthmatics was 18.97, while that of past asthmatics was 23.83 (p = 6.6e-6). The variability of PEF increased as the ACT score increased. Age had no impact on asthma control (p > 0.25), while the effect of PEF on the control of asthma was tied to gender. Rhinitis was also associated with poor asthma control as defined by the ACT score. No other covariate was found to be statistically significant (p < 0.05). CONCLUSION Our study supports the use of the ACT to evaluate asthma control in asthmatics living in Puerto Rico. Research into factors associated with poor asthma control, and the importance of rhinitis with regard to such control, is needed.
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Zaragoza R, Ferrer R, Maseda E, Llinares P, Rodríguez A. EPICO 2.0 PROJECT. Development of educational therapeutic recommendations using the DELPHI technique on invasive candidiasis in critically ill adult patients in special situations. Rev Esp Quimioter 2014; 27:196-212. [PMID: 25229375] [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: 06/03/2023]
Abstract
INTRODUCTION Although there has been an improved management of Invasive Candidiasis in the last decade, still controversial issues remain, especially in different therapeutic critical care scenarios. OBJECTIVES We sought to identify the core clinical knowledge and to achieve high agreement recommendations required to care for critically ill adult patients with Invasive Candidiasis for antifungal treatment in special situations and different scenarios. METHODS Second Prospective Spanish survey reaching consensus by the Delphi technique, conducted anonymously by electronic e-mail in the first phase to 23 national multidisciplinary experts in invasive fungal infections from five national scientific societies including Intensivists, Anesthesiologists, Microbiologists, Pharmacologists and Infectious disease specialists, answering 30 questions prepared by a coordination group after a strict review of literature in the last five years. The educational objectives spanned four categories, including peritoneal candidiasis, immunocompromised patients, special situations and organ failures. The agreement among panelists in each item should be higher than 75% to be selected. In a second phase, after extracting recommendations from the selected items, a meeting was held with more than 60 specialists in a second round invited to validate the preselected recommendations. MEASUREMENTS AND MAIN RESULTS In the first phase, 15 recommendations were preselected (peritoneal candidiasis (3), immunocompromised patients (6), special situations (3) and organ failures (3)). After the second round the following 13 were validated: Peritoneal candidiasis (3): Source control and early adequate antifungal treatment is mandatory; empirical antifungal treatment is recommended in secondary nosocomial peritonitis with Candida spp. colonization risk factors and in tertiary peritonitis. Immunocompromised patients (5): Consider hepatotoxicity and interactions before starting antifungal treatment with azoles in transplanted patients; treat candidemia in neutropenic adult patients with antifungal drugs at least 14 days after the first negative blood culture and until normalization of neutrophil count is achieved. Caspofungin, if needed, is the echinocandin with most scientific evidence to treat candidemia in neutropenic adult patients; Caspofungin is also the first choice drug to treat febrile candidemia; in neutropenic patients with candidemia remove catheter. Special situations (2): In moderate hepatocellular failure, patients with invasive candidiasis use echinocandins (preferably low doses of anidulafungin and caspofungin) and try to avoid azoles; in case of possible interactions review all of the drugs involved and preferably use Anidulafungin. Organ failures (3): Echinocandins are the safest antifungal drugs; reconsider the use of azoles in patients under renal replacement therapy; all of the echinocandins are accepted for the treatment of patients under continuous renal replacement therapy and do not require dosage adjustment. CONCLUSIONS Treatment of Invasive Candidiasis in ICU patients requires a broad range of knowledge and skills as summarized in our recommendations. These recommendations may help to optimize the therapeutic management of these patients in special situations and different scenarios and improve their outcome based on the DELPHI methodology.
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Affiliation(s)
- R Zaragoza
- Rafael Zaragoza, Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
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Forteza MJ, Zaragoza R, De Dios E, Hervas A, Bonanad C, Chaustre F, Minana G, Ruiz-Sauri A, Vina JR, Bodi V. P674Metabolic deregulation in myocardial infarction is mediated by PGC-1 alpha pathway. Cardiovasc Res 2014. [DOI: 10.1093/cvr/cvu098.99] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Zaragoza R, Ferrer R, Maseda E, Llinares P, Rodriguez A. EPICO 2.0 project. Development of educational therapeutic recommendations using the DELPHI technique on invasive candidiasis in critically ill adult patients in special situations. Rev Iberoam Micol 2014; 31:157-75. [PMID: 25113990 DOI: 10.1016/j.riam.2014.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [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: 05/12/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Although there has been an improved management of invasive candidiasis in the last decade, still controversial issues remain, especially in different therapeutic critical care scenarios. AIMS We sought to identify the core clinical knowledge and to achieve high agreement recommendations required to care for critically ill adult patients with invasive candidiasis for antifungal treatment in special situations and different scenarios. METHODS Second prospective Spanish survey reaching consensus by the DELPHI technique, conducted anonymously by electronic e-mail in the first phase to 23 national multidisciplinary experts in invasive fungal infections from five national scientific societies including intensivists, anesthesiologists, microbiologists, pharmacologists and infectious disease specialists, answering 30 questions prepared by a coordination group after a strict review of literature in the last five years. The educational objectives spanned four categories, including peritoneal candidiasis, immunocompromised patients, special situations, and organ failures. The agreement among panelists in each item should be higher than 75% to be selected. In a second phase, after extracting recommendations from the selected items, a meeting was held with more than 60 specialists in a second round invited to validate the preselected recommendations. MEASUREMENTS AND MAIN RESULTS In the first phase, 15 recommendations were preselected (peritoneal candidiasis (3), immunocompromised patients (6), special situations (3), and organ failures (3)). After the second round the following 13 were validated: Peritoneal candidiasis (3): Source control and early adequate antifungal treatment is mandatory; empirical antifungal treatment is recommended in secondary nosocomial peritonitis with Candida spp. colonization risk factors and in tertiary peritonitis. Immunocompromised patients (5): consider hepatotoxicity and interactions before starting antifungal treatment with azoles in transplanted patients; treat candidemia in neutropenic adult patients with antifungal drugs at least 14 days after the first blood culture negative and until normalization of neutrophils is achieved. Caspofungin, if needed, is the echinocandin with most scientific evidence to treat candidemia in neutropenic adult patients; caspofungin is also the first choice drug to treat febrile candidemia; in neutropenic patients with candidemia remove catheter. Special situations (2): in moderate hepatocellular failure, patients with invasive candidiasis use echinocandins (preferably low doses of anidulafungin and caspofungin) and try to avoid azoles; in case of possible interactions review all the drugs involved and preferably use anidulafungin. Organ failures (3): echinocandins are the safest antifungal drugs; reconsider the use of azoles in patients under renal replacement therapy; all of the echinocandins to treat patients under continuous renal replacement therapy are accepted and do not require dosage adjustment. CONCLUSIONS Treatment of invasive candidiasis in ICU patients requires a broad range of knowledge and skills as summarized in our recommendations. These recommendations may help to optimize the therapeutic management of these patients in special situations and different scenarios and improve their outcome based on the DELPHI methodology.
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Affiliation(s)
- Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain.
| | - Ricard Ferrer
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Emilio Maseda
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Pedro Llinares
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
| | - Alejandro Rodriguez
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain
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Fernández-Ruiz M, Aguado JM, Almirante B, Lora-Pablos D, Padilla B, Puig-Asensio M, Montejo M, García-Rodríguez J, Pemán J, Ruiz Pérez de Pipaón M, Cuenca-Estrella M, Padilla B, Muñoz P, Guinea J, Paño Pardo JR, García-Rodríguez J, Cerrada CG, Fortún J, Martín P, Gómez E, Ryan P, Campelo C, de los Santos Gil I, Buendía V, Gorricho BP, Alonso M, Sanz FS, Aguado JM, Merino P, Romo FG, Gorgolas M, Gadea I, Losa JE, Delgado-Iribarren A, Ramos A, Romero Y, Romero IS, Zaragoza O, Cuenca-Estrella M, Rodriguez-Baño J, Suarez AI, Loza A, Aller García AI, Martín-Mazuelos E, de Pipaón MRP, Garnacho J, Ortiz C, Chávez M, Maroto FL, Salavert M, Pemán J, Blanquer J, Navarro D, Camarena JJ, Zaragoza R, Abril V, Gimeno C, Hernáez S, Ezpeleta G, Bereciartua E, Hernández Almaraz JL, Montejo M, Rivas RA, Ayarza R, Ma Planes A, Ruiz Camps I, Almirante B, Mensa J, Almela M, Gurgui M, Sánchez-Reus F, Martinez-Montauti J, Sierra M, Horcajada JP, Sorli L, Gómez J, Gené A, Urrea M, Valerio M, Díaz-Martín A, Puchades F, Mularoni A. Initial Use of Echinocandins Does Not Negatively Influence Outcome in Candida parapsilosis Bloodstream Infection: A Propensity Score Analysis. Clin Infect Dis 2014; 58:1413-21. [DOI: 10.1093/cid/ciu158] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Calbo E, Zaragoza R. [Ceftaroline fosamil in community-acquired and nosocomial pneumonia]. Enferm Infecc Microbiol Clin 2014; 32 Suppl 2:38-43. [PMID: 24702978 DOI: 10.1016/s0213-005x(14)70157-0] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Community-acquired pneumonia (CAP) is a common infection in developed countries and causes a large number of hospital admissions and deaths. In recent years, the incidence of this disease has increased, caused by progressive population aging. Following the introduction of the conjugate vaccine against Streptococcus pneumoniae, there have been significant epidemiological changes that require close monitoring because of the possible emergence of new patterns of resistance. This article aims to review the role of ceftaroline fosamil, a new parenteral cephalosporin with antibacterial activity against Gram-negative and Gram-positive pathogens, in the treatment of pneumonia. Several in vitro and in vivo studies have shown the efficacy of ceftaroline fosamil against penicillin-resistant S. pneumoniae and methicillin-resistant Staphylococcus aureus (MRSA). Additionally, ceftaroline has shown similar efficacy and safety to ceftriaxone in the treatment of community-acquired pneumonia with severe prognosis (prognostic severity index III and IV) in two phase III clinical trials. Although a non-inferiority design was used for these clinical trials, some data suggest a superior efficacy of ceftaroline, with earlier clinical response and higher cure rate in infections caused by S. pneumoniae, making this drug particularly interesting for critically-ill patients admitted to the intensive care unit. Ceftaroline may also be considered for empirical and directed treatment of MRSA pneumonia.
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Affiliation(s)
- Esther Calbo
- Servicio de Medicina Interna, Unidad de Enfermedades Infecciosas, Hospital Universitario Mutua de Terrassa, Terrassa, Barcelona, España; Universidad Internacional de Catalunya, Valencia, España.
| | - Rafael Zaragoza
- Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, España; Coordinador del Programa Interdisciplinar de Atención en la Sepsis Grave, Hospital Universitario Dr. Peset, Valencia, España
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Solé Violan J, Ferrer Agüero J, Sádaba B, Sancho S, Zaragoza R, Luque P, Nieto M, López M, García F, Hernández C, Azanza J. Pharmacokinetics of meropenem during continuous renal replacement therapy in critically ill patients. Crit Care 2014. [PMCID: PMC4069441 DOI: 10.1186/cc13593] [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: 11/11/2022] Open
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47
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Pemán J, Zaragoza R, Salavert M. [Prevention and control of nosocomial and health-care facilities associated infections caused by species of Candida and other yeasts]. Rev Esp Quimioter 2013; 26:298-311. [PMID: 24399344] [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: 06/03/2023]
Abstract
Knowledge of the epidemiology of invasive fungal diseases caused by yeasts (Candida spp., especially) in health care settings allows the establishment of the levels necessary for its prevention. A first step is to identify groups of patients at high risk of nosocomial invasive fungal infections, establish accurate risk factors, observing the periods of greatest risk, and analyze the epidemiological profile in genera and species as well as the patterns of antifungal resistance. Secondly, mechanisms to avoid persistent exposure to potential fungal pathogens must be programed, protecting areas and recommending measures such as the control of the quality of the air and water, inside and outside the hospital, and other products or substances able to cause outbreaks. Finally, apart from the correct implementation of these measures, in selected patients at very high risk, the use of antifungal prophylaxis should be considered following the guidelines published.
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Affiliation(s)
- Javier Pemán
- Miguel Salavert Lletí. Unidad de Enfermedades Infecciosas; Hospital Universitario y Politécnico La Fe, Boulevar sur s/n; 46026; Valencia, Spain.
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Puig-Asensio M, Padilla B, Garnacho-Montero J, Zaragoza O, Aguado JM, Zaragoza R, Montejo M, Muñoz P, Ruiz-Camps I, Cuenca-Estrella M, Almirante B. Epidemiology and predictive factors for early and late mortality in Candida bloodstream infections: a population-based surveillance in Spain. Clin Microbiol Infect 2013; 20:O245-54. [PMID: 24125548 DOI: 10.1111/1469-0691.12380] [Citation(s) in RCA: 210] [Impact Index Per Article: 19.1] [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: 06/27/2013] [Revised: 08/21/2013] [Accepted: 08/24/2013] [Indexed: 12/24/2022]
Abstract
A prospective, multicentre, population-based surveillance programme for Candida bloodstream infections was implemented in five metropolitan areas of Spain to determine its incidence and the prevalence of antifungal resistance, and to identify predictors of death. Between May 2010 and April 2011, Candida isolates were centralized to a reference laboratory for species identification by DNA sequencing and for susceptibility testing by EUCAST reference procedure. Prognostic factors associated with early (0-7 days) and late (8-30 days) death were analysed using logistic regression modelling. We detected 773 episodes: annual incidence of 8.1 cases/100 000 inhabitants, 0.89/1000 admissions and 1.36/10 000 patient-days. Highest incidence was found in infants younger than 1 year (96.4/100 000 inhabitants). Candida albicans was the predominant species (45.4%), followed by Candida parapsilosis (24.9%), Candida glabrata (13.4%) and Candida tropicalis (7.7%). Overall, 79% of Candida isolates were susceptible to fluconazole. Cumulative mortality at 7 and 30 days after the first episode of candidaemia was 12.8% and 30.6%, respectively. Multivariate analysis showed that therapeutic measures within the first 48 h may improve early mortality: antifungal treatment (OR 0.51, 95% CI 0.27-0.95) and central venous catheter removal (OR 0.43, 95% CI 0.21-0.87). Predictors of late death included host factors (e.g. patients' comorbid status and signs of organ dysfunction), primary source (OR 1.63, 95% CI 1.03-2.61), and severe sepsis or septic shock (OR 1.77, 95% CI 1.05-3.00). In Spain, the proportion of Candida isolates non-susceptible to fluconazole is higher than in previous reports. Early mortality may be improved with strict adherence to guidelines.
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Affiliation(s)
- M Puig-Asensio
- Infectious Diseases Department, Medicine Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Pemán J, Zaragoza R. Combined use of nonculture-based lab techniques in the diagnosis and management of critically ill patients with invasive fungal infections. Expert Rev Anti Infect Ther 2013; 10:1321-30. [PMID: 23241189 DOI: 10.1586/eri.12.128] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Invasive fungal infections are associated with high morbidity and mortality in critically ill patients due, in part, to diagnostic difficulties in the early stages. Nonculture-based techniques such as (1,3)-β-d-glucan, galactomannan, mannan and antimannan antibodies, Candida albicans germ tube-specific antibodies or fungal DNA are required for earlier diagnosis, prognostic information and monitoring outcome. A decision-tree algorithm based on the combination of nonculture-based techniques is suggested to optimize the diagnosis and evolution of critically ill patients at risk of invasive mycoses. The use of (1,3)-β-d-glucan and blood cultures twice a week is proposed; if positive, treatment initiation is recommended alongside the performance of the nonculture-based microbiological tool depending on suspected mycoses and the availability of techniques.
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Affiliation(s)
- Javier Pemán
- Servicio de Microbiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
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Abstract
The management of invasive fungal infections in critically ill patients, from diagnosis to selection of the therapeutic protocol, is often a challenge. Early diagnosis and treatment are associated with a better prognosis, but apart from cases with positive cultures from blood or fluid/tissue biopsy, diagnosis is neither sensitive nor specific, and there is a need for specific markers in these diseases. Serodiagnostic assays such as mannan antigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, and molecular techniques for the detection of fungal-specific DNA have been developed with promising results in critical care settings. One of the main features in diagnosis is the evaluation of risk factors for infection, which will identify patients in need of preemptive or empirical treatment. Clinical scores were built from those risk factors. The combination of prediction rules and non-culture microbiological tools could be currently be the key to improving the diagnosis and prognosis of invasive fungal infections in critically ill patients.
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Affiliation(s)
- Javier Pemán
- Servicio de Microbiología, Hospital Universitario y Politécnico La Fe, Valencia, España.
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