Clinical significance of Candida colonization of intravascular catheters in the absence of documented candidemia

In order to assess the significance of Candida colonization of intravascular catheters (IVC) in patients without documented candidemia, we retrospectively reviewed all Candida-positive IVC tip cultures over a 4-year period. Cases were defined as those with a culture yielding ≥15 colony-forming units of Candida spp. that either did not have blood cultures (BC) taken or had concomitant BC negative for Candida. Patients were followed up until death or 8 months after discharge. Risk factors for poor outcome following IVC removal (death, candidemia, or Candida-related complication) were analyzed. We analyzed a total of 40 patients. Overall mortality was 40.0%, with no death directly attributed to Candida infection. Twenty-two patients received antifungal therapy at the time of IVC removal. Only 1 patient developed a metastatic complication (chorioretinitis) attributable to transient candidemia (2.5% of the global cohort and 3.7% among those with concomitant BC). There were no cases of subsequent candidemia. In the multivariate analysis, the use of antifungal therapy did not show any impact on the risk of poor outcome. The risk of invasive disease in patients with isolated IVC colonization by Candida seems to be low. Nevertheless, the initiation of systemic antifungal therapy should be carefully considered in such context.     

Clinical features of patients with acute organophosphate poisoning requiring intensive care

OBJECTIVES: To describe the clinical features of organophosphate poisoning (OPP), to evaluate the Acute Physiology and Chronic Health Evaluation (APACHE) II score as an alternative index for measuring OPP severity, and to assess cholinesterase levels for predicting successful weaning from mechanical ventilation (MV). DESIGN AND SETTING: Retrospective medical record review in a medical intensive care unit of an acute general hospital. PATIENTS: Twenty-three adults with OPP between 1995 and 1999. All cases were due to malathion poisoning. Muscarinic features were the predominant clinical manifestations (83%), followed by central nervous system (78%) and nicotinic manifestations (17%). RESULTS: MV was required by 74% of patients because of bronchial secretions (83%), altered conscious level (78%), pneumonia (78%), and flaccid paralysis (57%). Five patients (22%) had features of intermediate syndrome. ICU mortality was 13% and the mean ICU stay was 9.1 +/- 6.0 days. The mean APACHE II score was 17.4 +/- 7.4 and it correlated with mortality, severity of OPP, length of MV, and cholinesterase level. An APACHE II score of 26 or higher was predictive of mortality, with 95% sensitivity and 100% specificity. Threshold levels of serum and red blood cell cholinesterase for successful weaning from MV were 2,900 U/l and 7,500 U/l, respectively. CONCLUSIONS: The APACHE II score may be used as an alternative index of severity in patients with OPP; a score of 26 or higher is a good predictor of mortality. Cholinesterase levels are useful in predicting successful weaning of patients from MV.     

Peripherally inserted central catheters in the intensive care unit

We report the success rate and complications of peripherally inserted central catheters (PICCs) in patients hospitalized in an intensive care unit (ICU). We performed a cohort study in the ICU of a large tertiary care, university-affiliated community hospital. All ICU patients for whom their attending physicians requested a PICC service consultation were included. Main outcome measurements included (1) the success rate for initial PICC placement, (2) the placement complication rate, and (3) the overall success and complication rate. Of the 91 consecutive attempts at PICC placement, 89 (97.8%) were successful: of the 89 successful placements, 25 (28%) required cutdown procedures. There were 20 complications of initial placement and 8 delayed complications, which occurred in 19 PICCs. Complications included recatheterization after first attempt was unsuccessful (10), catheter malposition (7), palpitations or catheter clotting (3 each), heavy bleeding or mechanical phlebitis (2 each), and arterial puncture (1). The overall success rate for completion of therapy using the PICC was 74.7%. The most frequent reasons for failure to complete therapy were catheter dislodgment in 8 patients and "infection" in 9 patients. Of these 9 patients with "infections," 8 catheters were discontinued due to potential infection, and only 1 was removed due to confirmed infection. The confirmed infection rate was 6/10,000 patient days. The PICC appears to be a reasonable alternative to other approaches to peripheral and central venous access. The initial and overall success rates from this preliminary study justify further evaluation of the PICC in critically ill patients.     

Peripherally inserted central catheters are equivalent to centrally inserted catheters in intensive care unit patients for central venous pressure monitoring

To determine the equivalency of pressure measurements from peripherally inserted central catheters (PICCs) versus centrally inserted central venous catheters (CVCs) in vitro as well as in vivo. The in vitro study was performed in a clinical laboratory. Static pressure measurements from PICCs and CVCs were obtained in vitro over a physiologic range of 5–25 mmHg. Triple and dual lumen PICCs were directly compared to CVC controls. Dynamic pressure waveforms were recorded to simulate physiologic intravascular pressure variation. The in vivo study was executed in the medical intensive care unit (MICU) of a tertiary-level academic medical center. Data was collected from ten adult patients with both a PICC and a CVC in place for on-going clinical care. Measurements of central venous pressure (CVP) were recorded simultaneously from PICCs and CVCs. Duplicate measurements were taken after a stable waveform was recorded. For the in vitro study, a total of 540 pressure measurements were recorded. The average bias determined by Bland–Altman plot was 0 mmHg for the 5Fr PICC and 0.071 mmHg for the 6Fr PICC. The correlation coefficient for both catheters was 1.0 (P < 0.001). Dynamic pressure waveforms revealed equivalent amplitude. During the in vivo trial, 70 CVP measurements were collected. The paired CVP measurements were found to be highly reliable across subjects (r = 0.99, P < 0.0001). No significance in the average difference in CVP measurement (PICC–CVC) was determined by the Wilcoxon Signed Rank test (S = 1, P = 0.93). In conclusion, PICCs are equivalent to CVCs when measuring static and dynamic pressure in vitro and CVP in ICU patients.     

Atrial fibrillation in trauma patients requiring intensive care

Objectives To evaluate the incidence and risk factors of atrial fibrillation (AF) in trauma patients. Design and setting Prospective observational study in a surgical intensive care unit (ICU). Patients All trauma patients admitted in the surgical ICU except those who had AF at admission. Measurements and results AF occurred in 16/293 patients (5.5%). AF patients were older, had a higher number of regions traumatized, and received more fluid therapy, transfusion products, and catecholamines. They more frequently experienced systemic inflammatory response syndrome, sepsis, shock, and acute renal failure and had higher scores of severity (Simplified Acute Physiology Score, SAPS II; Injury Severity Score). ICU length of stay and resources use were also increased. ICU and hospital mortality rates were twice higher in AF patients whereas standardized mortality ratio (observed/expected mortality by SAPS II) was similar in the two groups. We found five independent risk factors of developing AF: catecholamine use (OR = 5.7, 95% CI 1.7–19.1), SAPS II of 30 or higher (OR = 11.6, 95% CI 1.3–103.0), three or more regions traumatized (OR = 6.2, 95% CI 1.8–21.4), age 40 years or higher (OR = 6.3, CI 1.4–28.7), and systemic inflammatory response syndrome (OR = 4.4, 95% CI 1.2–16.1). Conclusions In addition to age and catecholamine use, inflammation and severity of injury may be involved in the development of AF in trauma patients. Our results suggest that AF could rather be a marker of a higher severity of illness without major effect on mortality. This article is discussed in the editorial available at: .     

The microbial colonization due to medical devices in intensive care patients with special emphasis on Candida albicans

Incidence of microbial colonization related to medical devices was prospectively studied in 101 consecutive patients treated in intensive care unit ICU. Following endotracheal intubation 50% of patients had positive bacterial culture in the trachea within 24 hours irrespective of the use of antibiotics. Positive urine cultures occurred in 33% of patients with indwelling urinary catheters. Colonization of the trachea and the urinary tract with Candida albicans usually followed a few days after the bacterial colonization. However, septic Candida albicans infections seem to be rare in intensive care patients in spite of abundant colonization in the mucous membranes. Simultaneous growth of Candida albicans in the trachea and the urinary tract was associated with poor prognosis.     

Peripherally inserted central catheters are associated with lower risk of bloodstream infection compared with central venous catheters in paediatric intensive care patients: a propensity-adjusted analysis

Purpose

Central line-associated bloodstream infection (CLABSI) is an important cause of complications in paediatric intensive care units (PICUs). Peripherally inserted central catheters (PICCs) could be an alternative to central venous catheters (CVCs) and the effect of PICCs compared with CVCs on CLABSI prevention is unknown in PICUs. Therefore, we aimed to evaluate whether PICCs were associated with a protective effect for CLABSI when compared to CVCs in critically ill children.

Methods

We have carried out a retrospective multicentre study in four PICUs in São Paulo, Brazil. We included patients aged 0–14 years, who needed a CVC or PICC during a PICU stay from January 2013 to December 2015. Our primary endpoint was CLABSI up to 30 days after catheter placement. We defined CLABSI based on the Center for Disease Control and Prevention’s National Healthcare Safety Networks (NHSN) 2015 surveillance definitions. To account for potential confounders, we used propensity scores with inverse probability weighting.

Results

A total of 1660 devices (922 PICCs and 738 CVCs) in 1255 children were included. The overall CLABSI incidence was 2.28 (95% CI 1.70–3.07)/1000 catheter-days. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR 2.20, 95% CI 1.05–4.61; p = 0.037) compared with PICCs. In a sensitivity analysis, CVCs remained associated with higher risk of CLABSI (adjHR 2.18, 95% CI 1.02–4.64; p = 0.044) after adding place of insertion and use of parenteral nutrition to the model as a time-dependent variable.

Conclusions

PICC should be an alternative to CVC in the paediatric intensive care setting for CLABSI prevention.

     

Clinical and economic burden of bloodstream infections in critical care patients with central venous catheters

PurposeBloodstream infections (BSIs) complicate the management of intensive care unit (ICU) patients. We assessed the clinical and economic impact of BSI among patients of a managed care provider group who had a central venous catheter (CVC) placed in the ICU.MethodsWe considered hospitalizations occurring between January 1, 2011, and September 30, 2014, that involved an ICU stay during which a CVC was placed. Comparisons were made between episodes where the patient did vs did not develop BSI after CVC insertion. Length of stay, costs of index hospitalization, and total costs over the 180 days after discharge were compared using linear mixed models. Inhospital mortality and 30-day readmission rates were compared using negative binomial regression models.ResultsDevelopment of BSI was associated with longer hospital stay (+ 7 days), more than 3-fold increase in risk of inhospital death, and an additional $129 000 in costs for the index hospitalization. No statistically significant differences in 30-day readmission rates or costs of care over the 180-day period after discharge from the index admission were observed.ConclusionBloodstream infections after CVC placement in ICU patients are associated with significant increases in costs of care and risk of death during the index hospitalization but no differences in readmissions or costs after discharge.     

Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit.

OBJECTIVE: To identify clinical predictors for tracheostomy among patients requiring mechanical ventilation in the intensive care unit (ICU) setting and to describe the outcomes of patients receiving a tracheostomy. DESIGN: Prospective cohort study. SETTING: Intensive care units of Barnes-Jewish Hospital, an urban teaching hospital. PATIENTS: 521 patients requiring mechanical ventilation in an ICU for >12 hours. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND MAIN RESULTS: The main variables studied were hospital mortality, duration of mechanical ventilation, length of stay in the ICU and the hospital, and acquired organ-system derangements. Fifty-one (9.8%) patients received a tracheostomy. The hospital mortality of patients with a tracheostomy was statistically less than the hospital mortality of patients not receiving a tracheostomy (13.7% vs. 26.4%; p = .048), despite having a similar severity of illness at the time of admission to the ICU (Acute Physiology and Chronic Health Evaluation [APACHE] II scores, 19.2 +/- 6.1 vs. 17.8 +/- 7.2; p = .173). Patients receiving a tracheostomy had significantly longer durations of mechanical ventilation (19.5 +/- 15.7 days vs. 4.1 +/- 5.3 days; p < .001) and hospitalization (30.9 +/- 18.1 days vs. 12.8 +/- 10.1 days; p < .001) compared with patients not receiving a tracheostomy. Similarly, the average duration of intensive care was significantly longer among the hospital nonsurvivors receiving a tracheostomy (n = 7) compared with the hospital nonsurvivors without a tracheostomy (n = 124; 30.9 +/- 16.3 days vs. 7.9 +/- 7.3 days; p < .001). Multiple logistic regression analysis demonstrated that the development of nosocomial pneumonia (adjusted odds ratio [AOR], 4.72; 95% confidence interval [CI], 3.24-6.87; p < .001), the administration of aerosol treatments (AOR, 3.00; 95% CI, 2.184.13; p < .001), having a witnessed aspiration event (AOR, 3.79; 95% CI, 2.30-6.24; p = .008), and requiring reintubation (AOR, 2.21; 95% CI, 1.54-3.18; p = .028) were variables independently associated with patients undergoing tracheostomy and receiving prolonged ventilatory support. Among the 44 survivors receiving a tracheostomy in the ICU, 38 (86.4%) were alive 30 days after hospital discharge and 31 (70.5%) were living at home. CONCLUSIONS: Despite having longer lengths of stay in the ICU and hospital, patients with respiratory failure who received a tracheostomy had favorable outcomes compared with patients who did not receive a tracheostomy. These data suggest that physicians are capable of selecting critically ill patients who most likely will benefit from placement of a tracheostomy. Additionally, specific clinical variables were identified as risk factors for prolonged ventilatory assistance and the need for tracheostomy.     

导管交接表在ICU安全管理中的应用

目的探讨导管班情交接表在重症监护室导管安全管理中的应用方法及效果。方法 2011年1⁵月住院患者219例为对照组,采用传统模式床边交接班法;2011年65月住院患者219例为对照组,采用传统模式床边交接班法;2011年6¹0月住院患者223例为试验组,使用导管班情交接表进行床边交接。比较两组导管不良事件发生情况和护士对患者导管情况的掌握程度。结果试验组发生导管不良事件率低于对照组(P<0.01)。使用导管班情交接表后护士对于导管掌握情况有所提高(P<0.01)。结论使用导管班情交接表可以帮助护士进行导管的安全管理,有效减少导管不良事件的发生。     

Clinical practices concerning central venous catheters in haematological patients

PurposeCentral venous catheters (CVCs) are frequently used in patients with a haematological malignancy in order to administer chemotherapy, stem cell infusions, blood products, medication, parenteral hyperalimentation as well as for blood sampling.Reported complications consist of mechanical complications during the insertion and long-term complications such as CVC-related thrombosis and infections. CVC-related thrombosis and infections are frequently occurring complications and may cause significant morbidity in patients with haematological malignancies. CVC-related infections and thrombosis should not be considered as a result of modern care or fait accompli and must be one of the priority targets of a multidisciplinary approach emphasizing quality-of-care improvement.MethodsWe conducted a survey among 23 Dutch and Belgian haematological centres to assess the local views and clinical practices concerning central venous catheters in haematological patients.Results and conclusionsThe local protocols and policies differ greatly among the centres probably reflecting wide differentiations in practice across Europe. It also shows lack of evidence concerning CVC-related thrombosis and infections which may cause morbidity in haematological patients. Further research has to be stimulated and development of clinical practice guidelines should be promoted.     

Hospital care of major burns

The burn patient initially requires many of the same measures as any other trauma patient. Both depth and surface extent of the burn injury should be evaluated. Evaluation for smoke inhalation is important, since this is prevalent and life-threatening among burn victims. A treatment plan begins with a realistic appraisal of the probability of survival. Once goals of management have been established, treatment is aimed at both physiologic and aesthetic rehabilitation.     

老年内科ICU中心静脉内导管相关感染的调查

目的 观察老年ICU中心静脉内导管相关感染(CRI)发生率的临床特征. 方法调查了老年内科ICU内66例患者143例次中心静脉留置导管情况.结果 共31例患者发生CRI 46例次,累积感染率为28.57/千导管日,发生感染的中位时间为8.5d;CRI发生率与基础疾病无关,是否卧床、置管部位不同、导管腔道数不同及是否进行血液滤过治疗者CRI发生率的差异有统计学意义(P<0.05).导管培养阳性率为43.18%,导管血培养阳性率为31.82%. 结论老年内科ICU内CRI感染发生率较其他科室更高,置管部位、置管腔道数及是否正经历增加接触导管的各种操作(如血液滤过)等不同,CRI的感染风险也不一样.     

Efficacy of silver-coating central venous catheters in reducing bacterial colonization

OBJECTIVE: To compare silver-coated and uncoated central venous catheters regarding bacterial colonization. To assess the relative contribution of catheter hub and skin colonization to catheter tip colonization. DESIGN: Prospective, randomized clinical trial. SETTING: Intensive care unit in a university hospital. PATIENTS: Patients after cardiac surgery who required a central venous double-lumen catheter (DLC). INTERVENTIONS: Sixty-seven adult patients were prospectively randomized to receive either a silver-coated (S group, n = 34) or an uncoated control (C group, n = 33) DLC. Blood cultures were drawn at catheter removal, and removed catheters were analyzed with quantitative cultures. Typing of microorganisms included DNA fingerprinting. MEASUREMENTS AND MAIN RESULTS: Catheters were removed if no longer necessary and aseptically divided into three segments: segment A, the catheter tip; segment B, an intermediate section; and segment C, the subcutaneous portion. Bacterial catheter colonization was quantitatively measured using sonication to detach adherent bacteria from the catheter segments in the broth and subsequent culture of an aliquot. Selected isolates of coagulase-negative staphylococci and other bacteria from catheter segments were examined by means of pulsed-field gel electrophoresis (PFGE) after macrorestriction digestion of bacterial DNA to study colonization pathogenesis. Quantitatively lower bacterial colonization could be demonstrated on the silver-coated catheters (200 +/- 550 colony forming units [CFUs]/cm catheter segment; mean +/- SD). The difference in the control catheters (1120 +/- 5350 CFUs/cm catheter segment; mean +/- SD) was not, however, significant (p = .25). The frequency of colonization of at least one catheter segment was 52.9% for the silver-coated catheters and 57.6% for the control catheters (p= .44), without any significant differences in the colonization of corresponding catheter segments. The rate of significant catheter colonization (i.e., > or = 10(3) CFUs/cm catheter by quantitative catheter culture or > or = 10(3) CFUs/mL by luminal flush) was nine in the silver group and seven in the control group, a difference that failed to reach significance (p = .41). Two patients in both groups developed catheter-related bacteremia. Pattern analysis after PFGE demonstrated that about 70% of the isolates found on the catheter tip were identical with those on the skin at the insertion site, whereas about 75% were identical with those recovered from the hub. In 29% of colonized catheters, identical bacteria were found on the hub and the skin at the insertion site. CONCLUSIONS: Silver-coating of DLCs did not significantly reduce bacterial catheter colonization compared with the control catheters. PFGE analysis of coagulase-negative staphylococci and other bacteria demonstrated various pathogenic routes of catheter-related colonization, whereby the microorganisms of the skin flora around the insertion site must be regarded as the main source of catheter-related infections.