Oral nystatin prophylaxis of Candida spp. colonization in ventilated critically ill patients

Objective Colonization of multiple body sites is a leading risk factor for Candida spp. infection in intensive care unit (ICU) patients. We evaluated whether oral nystatin prophylaxis reduces Candida spp. colonization in ventilated ICU patients.Design and setting Prospective, randomized, open-label study with blinded assessment of the objective primary evaluation criterion in the medical-surgical ICU of a teaching hospital.Patients The study included 98 consecutive patients mechanically ventilated for at least 48 h (mean age 58±19 years; mean SAPS II 40±11), assigned to either treatment group (n=51) or control group (n=47). Study groups were comparable for age, SAPS II, reason for admission, and immune status.Interventions Patients were randomized to receive oral nystatin (treatment group; 3×10⁶ U per day) or no nystatin (control group). Multiple body sites (trachea, stomach, rectum, urine, groin, and blood) were tested for Candida spp. on admission and then every 3 days by mycologists blinded to group assignment, and the colonization index was determined.Results Colonization by Candida spp. developed in 25% of controls but in none of the treated patients. In multivariate analysis, the absence of nystatin prophylaxis and ICU length of stay were independently associated with Candida spp. colonization. No invasive candidiasis was diagnosed in either study group.Conclusions Oral nystatin prophylaxis efficiently prevented Candida spp. colonization in ICU patients at low risk of developing invasive candidiasis. Further studies are needed to determine whether this strategy remains efficient in reducing Candida spp. infections in higher risk ICU patients.This article is discussed in the editorial available at:     

Candida spp. colonization significance in critically ill medical patients: a prospective study

Objective Multiple-site colonization with Candida species is commonly recognized as a major risk factor for invasive fungal infection in critically ill patients. The fungal colonization density could be of predictive value for the diagnosis of systemic candidiasis in high-risk surgical patients. Little is known about it in the medical ICU setting.Design and setting Prospective observational study in the eight-bed medical intensive care unit of a teaching hospital.Subjects 92 consecutive nonneutropenic patients hospitalized for more than 7 days.Measurements and results The colonization index (ratio of the number of culture-positive surveillance sites for Candida spp. to the number of sites cultured) was calculated weekly upon ICU admission until death or discharge. The 0.50 threshold was reached in 36 (39.1%) patients, almost exclusively in those with detectable fungal colonization upon ICU admission. The duration of broad-spectrum antibiotic therapy was found to be the main factor that independently promoted fungal growth as measured through the colonization index.Conclusions Candida spp. multiple-site colonization is frequently met among the critically ill medical patients. Broad-spectrum antibiotic therapy was found to promote fungal growth in patients with prior colonization. Since most of the invasive candidiasis in the ICU setting are thought to be subsequent to colonization in high-risk patients, reducing antibiotic use could be useful in preventing fungal infections.     

The clinical significance of Candida colonization of respiratory tract secretions in critically ill patients

PURPOSE: Clinical uncertainty exists regarding the significance of colonization confined to respiratory tract secretions with Candida sp in critically ill patients. Our objectives were to describe such colonization, its associated risk factors, and to examine the clinical outcomes in patients with a clinical suspicion of ventilator-associated pneumonia with isolated Candida colonization compared to those without. MATERIALS AND METHODS: In a retrospective analysis of the Canadian ventilator-associated pneumonia study, patients were divided into 2 groups according to the isolated presence or absence of Candida in the respiratory tract enrollment culture. We compared length of mechanical ventilation, intensive care unit and hospital stay, and mortality outcomes between groups. We used multiple logistic regression analysis to determine factors independently associated with Candida colonization and hospital mortality. RESULTS: Of the 639 eligible patients, 114 (17.8%) were colonized with Candida in the enrollment culture. A multivariate analysis identified female sex (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.02-2.65), number of comorbidities (OR, 1.35; 95% CI, 1.08-1.71), worsening or persistent infiltrate at randomization (OR, 1.92; 95% CI, 1.09-1.38), antibiotics started within 3 days of randomization (OR, 3.16; 95% CI, 1.71-5.83), and on antibiotics at randomization but all started more than 3 days before randomization (OR, 3.04; 95% CI, 1.68-5.50) as variables associated with Candida respiratory tract colonization. A significant increase in median hospital stay (59.9 vs 38.6 days, P = .006) and hospital mortality (34.2% vs 21.0%, P = .003) was observed in patients with Candida colonization. In a multivariate model, Candida colonization of the respiratory tract was independently associated with hospital mortality (OR, 2.47; 95% CI, 1.39-4.37). CONCLUSION: Respiratory tract Candida colonization is associated with worse clinical outcomes and is independently associated with increased hospital mortality. However, it is unclear whether Candida colonization is causally related to poor outcomes or whether it is a marker for increased morbidity and mortality.     

完善后的预警评分分析法对急诊潜在危重症患者的预测效果

目的探讨完善后的预警评分（MEWS）分析法预测急诊潜在危重症患者的可行性研究。方法对急诊科与抢救室298例患者进行MEWS评分法评测,对MEWS不同分值的急诊心肺复苏、重症监护室与专科普通病房所收住的患者、门诊治疗、出院〈1个月、出院≥1个月、转上级医院、死亡的构成比进行分析,并对所有患者进行预后追访。结果MEWS不同分值患者接受不同处置方式的概率比较差异有统计学意义（）（2=258．697,P〈0．001）;预后情况比较差异有统计学意义（X^2=115．938,P〈0．001）;患者病情与MEWS的分值成正相关（r=0．848,P〈0．001）。结论MEWS于急诊潜在危重症患者的预测上具有可行性,可作为急诊评估专用系统进行推广。     

Biomarker-based strategy for early discontinuation of empirical antifungal treatment in critically ill patients: a randomized controlled trial

Purpose

The aim of this study was to determine the impact of a biomarker-based strategy on early discontinuation of empirical antifungal treatment.

Methods

Prospective randomized controlled single-center unblinded study, performed in a mixed ICU. A total of 110 patients were randomly assigned to a strategy in which empirical antifungal treatment duration was determined by (1,3)-β-d-glucan, mannan, and anti-mannan serum assays, performed on day 0 and day 4; or to a routine care strategy, based on international guidelines, which recommend 14 days of treatment. In the biomarker group, early stop recommendation was determined using an algorithm based on the results of biomarkers. The primary outcome was the percentage of survivors discontinuing empirical antifungal treatment early, defined as a discontinuation strictly before day 7.

Results

A total of 109 patients were analyzed (one patient withdraw consent). Empirical antifungal treatment was discontinued early in 29 out of 54 patients in the biomarker strategy group, compared with one patient out of 55 in the routine strategy group [54% vs 2%, p < 0.001, OR (95% CI) 62.6 (8.1–486)]. Total duration of antifungal treatment was significantly shorter in the biomarker strategy compared with routine strategy [median (IQR) 6 (4–13) vs 13 (12–14) days, p < 0.0001). No significant difference was found in the percentage of patients with subsequent proven invasive Candida infection, mechanical ventilation-free days, length of ICU stay, cost, and ICU mortality between the two study groups.

Conclusions

The use of a biomarker-based strategy increased the percentage of early discontinuation of empirical antifungal treatment among critically ill patients with suspected invasive Candida infection. These results confirm previous findings suggesting that early discontinuation of empirical antifungal treatment had no negative impact on outcome. However, further studies are needed to confirm the safety of this strategy. This trial was registered at ClinicalTrials.gov, NCT02154178.

     

危重病人床边评估指引在ICU中的应用

[目的]探讨危重病人床边评估指引在重症监护病房(ICU)中的应用效果.[方法]制订危重病人床边评估指引,规范护士对危重病人的评估顺序,掌握评估时机,提高护理体检技能.[结果]实施危重病人床边评估指引2年后,护理文书书写合格率、基础护理合格率、危重病人抢救成功率明显提高,不良事件发生率明显降低.[结论]应用危重病人床边评估指引可有效提高ICU临床护理质量.     

念珠菌痰培养阳性是危重病患者实施经验性抗真菌治疗的指征吗

目的 通过对ICU中念珠菌痰培养阳性危重病患者的回顾分析,评估经验性抗真菌治疗对预后的影响.方法回顾分析2004-04～2007-03浙江大学医学院附属第一医院ICU病区所有单纯性念珠菌痰培养阳性患者抗真菌治疗对其预后、住ICU时间、总住院时间及住院费用的影响.结果三年间ICU入院4192人次,痰培养念珠菌阳性患者且无其他部位念珠菌培养阳性患者98例.同一时期ICU送检痰培养标本10333份,培养阳性7587株,其中念珠菌1376株.在1376株念珠菌中,白色念珠菌897株(65.2%),光滑念珠菌206株(15.0%),热带念珠菌187株(13.6%),克柔念珠菌35株(2.5%),近平滑念珠菌28株(2.0%),无名念珠菌10株(0.7%),季也蒙念珠菌5株(0.4%),葡萄牙念珠菌5株(0.4%).死亡40例,病死率40.8%.其中行抗真菌治疗68例,未行抗真菌治疗30例.两组预后比较差异无统计学意义(P＝0.817),但两组住院时间(P＝0.013)、住ICU时间(P＝0.046)、住院费用(P＝0.034)比较差异有统计学意义.结论念珠菌痰培养阳性的危重病患者实施抗真菌治疗对预后改善不明显,相反可能延长住院时间、住ICU时间,增加住院费用.因此,念珠菌痰培养阳性不应成为危重病患者实施抗真菌治疗的指征.     

Outcome scoring systems for short-term prognosis in critically ill cirrhotic patients

Cirrhotic patients admitted to intensive care units (ICUs) have high mortality rates. This study evaluated specific predictors and scoring systems for hospital and 6-month mortality in critically ill cirrhotic patients. This investigation is a prospective clinical study performed in a 10-bed specialized hepatogastroenterology ICU in a tertiary care university hospital in Taiwan. Two hundred two consecutive cirrhotic patients admitted to the ICU during a 2-year period were enrolled in this study. Demographic, clinical, and laboratory variables recorded on the first day of ICU admission and scoring systems applied were prospectively recorded for post hoc analysis for predicting survival. The overall hospital mortality was 59.9%, and the 6-month mortality rate was 70.8%. The main causes of cirrhosis were hepatitis B (29%), hepatitis C (22%), and alcoholism (20%). The major cause of ICU admission was upper gastrointestinal bleeding (36%). Multiple logistic regression analysis revealed that the Acute Kidney Injury Network (AKIN) score at the 48th hour of ICU admission and the Sequential Organ Failure Assessment (SOFA) as well as the Model for End-Stage Liver Disease scores on the first day of ICU admission were independent risk factors for hospital mortality. The SOFA score had the best discriminatory power (0.872 ± 0.036), whereas the AKIN had the best Youden index (0.57) and the highest correctness of prediction (79%). Cumulative survival rates at the 6-month follow-up after hospital discharge differed significantly (P < 0.05) for AKIN stage 0 vs. stages 1, 2, and 3, and for AKIN stage 1 vs. stage 3. The AKIN, SOFA, and Model for End-stage Liver Disease (MELD) scores showed well discriminative power in predicting hospital mortality in this group of patients. The AKIN scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.     

Assessment of a modified 4T scoring system for heparin-induced thrombocytopenia in critically ill patients

Purpose

The purpose of the study is to determine if a modified 4T (m4T) scoring system, which omits clinical evaluation of other thrombocytopenic etiologies, is different from the 4T scoring system's probability to predict a positive heparin-induced thrombocytopenia (HIT) laboratory test in the intensive care unit.

Materials and methods

This is a single-centered retrospective analysis of critically ill adults who had an enzyme-linked immunosorbent assay antiplatelet factor 4 antibody (ELISA anti-PF4 Ab) ordered. Patients were identified as HIT positive (optical density, ≥ 0.40) or HIT negative (optical density, < 0.40) based on the ELISA anti-PF4 Ab. Both 4T and m4T scores were calculated, and the diagnostic accuracy was compared using paired receiver operating characteristic curves.

Results

A total of 1487 adult intensive care unit patients with an ELISA anti-PF4 Ab ordered between January 2007 and December 2009 were eligible for study enrollment. Application of exclusion criteria and random selection yielded a total of 232 patients included for analysis (58 HIT-positive and 174 HIT-negative patients). The area under the curve for the 4T and m4T scores were 0.683 (95% confidence interval, 0.604-0.762) and 0.680 (95% confidence interval, 0.600-0.759), respectively (P = .065).

Conclusion

This study does not show a difference in the probability of the m4T and 4T scoring systems to predict a positive ELISA anti-PF4 Ab test in the critically ill patient population. Further prospective studies are needed to validate the m4T scoring system.     

Lung ultrasound in critically ill patients: comparison with bedside chest radiography

Purpose  

To compare the diagnostic performance of lung ultrasound and bedside chest radiography (CXR) for the detection of various pathologic abnormalities in unselected critically ill patients, using thoracic computed tomography (CT) as a gold standard.     

How to select an antifungal agent in critically ill patients

Fungal infections are common in critically ill patients and are associated with increased morbidity and mortality. Candida spp are the most commonly isolated fungal pathogens. The last 2 decades have seen an increased incidence of fungal infections in critical illness and the emergence of new pathogenic fungal species and also the development of more effective (better bioavailability) and safer (less toxicity, fewer drug interactions) drugs. The distinction between colonization and infection can be difficult, and problems diagnosing infection may delay initiation of antifungal treatment. A number of factors have been identified that can help to distinguish patients at high risk for fungal infection. The antifungal agents that are most frequently used in the intensive care unit are the first- and second-generation azoles and the echinocandins; amphotericin B derivatives (mainly the liposomal agents) are less widely used because of adverse effects. The choice of antifungal agent in critically ill patients will depend on the aim of therapy (prophylaxis, pre-emptive, empiric, definitive), as well as on local epidemiology and specific properties of the drug (antifungal spectrum, efficacy, toxicity, pharmacokinetic/pharmacodynamic properties, cost). In this article we will review all these aspects and propose an algorithm to guide selection of antifungal agents in critically ill patients.     

Accuracy of bedside capillary blood glucose measurements in critically ill patients

OBJECTIVE: To compare the accuracy of fingerstick with laboratory venous plasma glucose measurements (laboratory glucose) in medical ICU patients and to determine the factors which interfere with the accuracy of fingerstick measurements. PARTICIPANTS: The study included 80 consecutive patients aged 58+/-7 years, BMI 29.5+/-9.0, and APACHE II score 15+/-6 (277 simultaneous paired measurements). MEASUREMENTS: This prospective observational study compared fingerstick measurements to simultaneously sampled laboratory glucose once a day in patients in our medical ICU (twice daily if on an insulin infusion). Data recorded included patient demographics, admission diagnoses, APACHE II score, BMI, daily hematocrit, arterial blood gasses, chemistry results, concomitant medications (including vasopressors and corticosteroids), and upper extremity edema. Accuracy was defined as the percentage of paired values not in accord (>15 mg dl(-1)/ 0.83 mmol(-1)l(-1) difference for laboratory values <75 mg dl(-1)/4.12 mmol(-1)l(-1) and >20% difference for laboratory values >or=75 mg/dl). Outliers (blood glucose difference >100 mg dl(-1)/5.56 mmol(-1) l(-1)) were excluded from the correlation and distribution analyses. RESULTS: Mean fingerstick glucose was 129+/-45 mg/dl (7.2+/-2.5 mmol/l) and mean laboratory glucose 123+/-44 mg/dl (6.8+/-2.4 mmol/l). The correlation coefficient between the two values was 0.9110 (Clinical and Laboratory Standards Institute threshold 0.9751). The mean difference (bias) between the two methods was 8.6+/-18.6 mg/dl (0.48+/-1.0 mmol/l) and limits of agreement +45.8 and -28.6 mg/dl (+2.5 and -1.6 mmol/l). Fifty-three (19%) paired measurements in 22 patients were not in accord (CLSI threshold 相似文献   

Helping at the bedside: spouses' preferences for helping critically ill patients

Spouses of patients in intensive care units (ICU) need to be close and helpful to ill partners. According to adult attachment theory, emotional responses may be related to preferences for closeness and helpfulness, and according to control theory optimism also may influence spouses' emotional responses. Spouses' goals and helping behaviors were assessed in 88 spouses of ICU patients. Using a repeated-measures design, the relationships of closeness, helpfulness, and optimism to emotional outcomes were assessed. Preferences for closeness and helpfulness were strongly related, and together with optimism, predicted spouses' mood at some point of the illness trajectory. Spouses who were over-involved with partners' care requirements were at greater risk for emotional distress. Results suggest that closeness and helpfulness are integrated concepts, and that attachment dimensions of a relationship and optimism are useful for understanding spouses' emotional responses to critical illness.     

Corticosteroid treatment in critically ill patients with severe influenza pneumonia: a propensity score matching study

Purpose

To determine clinical predictors associated with corticosteroid administration and its association with ICU mortality in critically ill patients with severe influenza pneumonia.

Methods

Secondary analysis of a prospective cohort study of critically ill patients with confirmed influenza pneumonia admitted to 148 ICUs in Spain between June 2009 and April 2014. Patients who received corticosteroid treatment for causes other than viral pneumonia (e.g., refractory septic shock and asthma or chronic obstructive pulmonary disease [COPD] exacerbation) were excluded. Patients with corticosteroid therapy were compared with those without corticosteroid therapy. We use a propensity score (PS) matching analysis to reduce confounding factors. The primary outcome was ICU mortality. Cox proportional hazards and competing risks analysis was performed to assess the impact of corticosteroids on ICU mortality.

Results

A total of 1846 patients with primary influenza pneumonia were enrolled. Corticosteroids were administered in 604 (32.7%) patients, with methylprednisolone the most frequently used corticosteroid (578/604 [95.7%]). The median daily dose was equivalent to 80 mg of methylprednisolone (IQR 60–120) for a median duration of 7 days (IQR 5–10). Asthma, COPD, hematological disease, and the need for mechanical ventilation were independently associated with corticosteroid use. Crude ICU mortality was higher in patients who received corticosteroids (27.5%) than in patients who did not receive corticosteroids (18.8%, p?<?0.001). After PS matching, corticosteroid use was associated with ICU mortality in the Cox (HR?=?1.32 [95% CI 1.08–1.60], p?<?0.006) and competing risks analysis (SHR?=?1.37 [95% CI 1.12–1.68], p?=?0.001).

Conclusion

Administration of corticosteroids in patients with severe influenza pneumonia is associated with increased ICU mortality, and these agents should not be used as co-adjuvant therapy.