Antibiotikatherapie bei operativen Intensivpatienten

The development of resistance by infective bacterial species is an incentive to reconsider the indications and administration of available antibiotics. Correct recognition of the indications and duration of therapy are particularly important for the use of highly potent substances in the intensive care situation. There has as yet been no clinical chemical parameter which is capable of specifically distinguishing a bacterial infection from a viral or non-infectious inflammatory reaction, but it now appears that procalcitonin (PCT) offers this possibility. The present study was intended to clarify whether PCT can be used to guide antibiotic therapy in surgical intensive care patients. A total of 110 patients in a surgical intensive care ward receiving antibiotic therapy after confirmed infection or a high grade suspicion of infection were enrolled in this study. In 57 of these patients a new decision was reached each day as to whether the antibiotic therapy should be continued after daily PCT determination and clinical assessment. The control group consisted of 53 patients with a standardized duration of antibiotic therapy over 8 days. Demographic and clinical data were comparable in both groups. However, in the PCT group the duration of antibiotic therapy was significantly shorter compared to controls (5.9+/-1.7 vs. 7.9+/-0.5 days, p<0.001) without unfavorable effects on clinical outcome.     

Strategies in the treatment of infections with antibiotics in intensive care medicine

The treatment of infections is one of the central elements in post-operative intensive care and contributes significantly to outcome. Measures of quality of antibiotic therapy include survival, duration of ICU or in-patient stay and rates of organ failure, antibiotic resistance or nosocomial infection. The pre-requisites for antibiotic prescribing in the intensive care unit are as follows: the treatment has to be started early, the antibiotic must be effective against probable causative organisms, the patient's risk factors for infection with multi-drug resistant organisms must be taken into account, local patterns of resistance must be known, an effective dosage must be used and the duration of therapy should be adjusted to the patient's risk factors and probable causative organisms. The multiplicity of factors which must be taken into account when determining timely empirical therapy and the fact that this must be possible at any time of the day, make local standard operating procedures for antibiotic prescribing imperative. These standards should reflect local resistance patterns and should be regularly reviewed. The aim of this educational article is to portray a selection of the pre-requisites and strategies available in the treatment of infections with antibiotics in intensive care medicine.     

Prokalzitoninbasierte Algorithmen

Sepsis is one of the most cost-intensive conditions of critically ill patients in intensive care medicine. Furthermore, sepsis is known to be the leading cause of morbidity and of mortality in intensive care patients. Early initiation of antibiotic therapy can significantly reduce mortality. The development of resistance of bacterial species against antibiotics is a compelling issue to reconsider indications and administration of antibiotic treatment. Adequate indications and duration of therapy are particularly important for the use of highly potent substances in the intensive care setting. Until recently no laboratory marker has been available to distinguish bacterial infections from viral or non-infectious inflammatory responses. However, procalcitonin (PCT) appears to be the first among a large array of inflammatory markers that offers this possibility. Regular procalcitonin measurements can significantly shorten the length of antibiotic therapy, show positive influence on antibiotic costs and have no adverse affects on patient outcome.     

Antibiotic-treated infections in intensive care patients in the UK

The purpose of this audit was to study reasons for starting antibiotic therapy, duration of antibiotic treatment, reasons for changing antibiotics and the agreement between clinical suspicion and microbiological results in intensive care practice. We conducted a multicentre observational audit of 316 patients. Data on demographic details, site, treatment and nature of infection were collected. The median duration of antibiotic therapy was 7 days. Infections were community-acquired in 160 patients (55%). Antibiotics were started on clinical suspicion of infection in 237 patients (75%). Pulmonary infections were the most common, representing 52% of all proven infections. Gram-negative organisms were the most common cause of proven infections (n = 90 (50%)). The antibiotic spectrum was narrowed in light of microbiology results in 78 patients (43%) and changed due to antibiotic resistance in 38 patients (21%). We conclude that the mean duration of treatment contrasts with existing published guidelines, highlighting the need for further studies on duration and efficacy of treatment in intensive care.     

Duration of antibiotic therapy for ventilator-associated pneumonia caused by non-fermentative gram-negative bacilli

BACKGROUND AND PURPOSE: Chastre et al. compared eight and 15 days of antibiotic therapy for ventilator-associated pneumonia (VAP), finding no difference in outcome with the exception of VAP caused by non-fermentative gram-negative bacilli (NFGNB), for which a higher recurrence rate was seen in the shorter-duration group (JAMA 2003;290:2588-2598). We recently examined our institutional experience with VAP caused by NFGNB to determine whether shorter courses of antibiotic therapy were associated with higher rates of recurrence. METHODS: Data collected on all patients completing treatment for VAP in a surgical/trauma intensive care unit from December 1996 to October 2004 were analyzed retrospectively for the relations between the duration of antibiotic therapy and recurrence and in-hospital mortality rates. RESULTS: Of the 452 episodes of VAP, 154 were associated with NFGNB. Twenty-seven patients were treated with 3-8 days (mean 6.4 +/- 0.3 days) of antibiotics, whereas 127 received nine or more days (mean 17.1 +/- 0.7 days) of therapy. The recurrence rate for infections treated with the shorter course was 22% vs. 34% for patients receiving nine or more days of antibiotics (p = 0.27). The mortality rates were 22% and 14%, respectively (p = 0.38). Similar trends were demonstrated for infections caused by other organisms. CONCLUSIONS: We did not find a higher recurrence rate in patients with VAP caused by NFGNB who received shorter courses of antibiotic therapy. On the contrary, those patients receiving shorter courses trended toward lower rates of recurrence. Pending further prospective trials addressing the duration of antibiotic treatment for patients with VAP caused by NFGNB, shorter courses of treatment, perhaps based on improvement in clinical parameters, may be warranted.     

Emergence of antibiotic resistance in infected pancreatic necrosis

BACKGROUND: Overall, the use of antibiotics in the treatment of patients with severe acute pancreatitis has increased owing to the use of antibiotic prophylaxis. HYPOTHESIS: The incidence of antibiotic-resistant (AB-R) bacteria in infected pancreatitis is related to prolonged antibiotic treatment and may affect outcome. DESIGN: Case series. SETTING: Fifty-six-bed intensive care unit of a tertiary care center. PATIENTS: Forty-six consecutive patients with infected pancreatic necrosis. MAIN OUTCOME MEASURES: Occurrence rate of AB-R organisms in pancreatic infection, overall duration of antibiotic treatment prior to infection, and mortality, defined as inhospital mortality. RESULTS: Infection with AB-R microorganisms was found in 24 (52%) of 46 patients. Primary infection was present in 7 patients; in 21 patients, nosocomial surinfection with AB-R organisms occurred. Patients with AB-R infections were treated with antibiotics for a longer period (24 vs 15 days, P<.05), while disease severity and the incidence of organ failure were not statistically significantly different. The intensive care unit stay was significantly longer in patients with AB-R infections (23 vs 31 days, P = .02). Mortality was not statistically significantly different in patients with AB-R infections (37% vs 28%, P = .23). CONCLUSIONS: The occurrence rate of infections with AB-R organisms in our patients with severe acute pancreatitis was high and was associated with a longer intensive care unit stay, but no increased mortality could be demonstrated. The duration of antibiotic treatment was increased in patients in whom AB-R infections developed.     

2型糖尿病患者胆道术后的胰岛素强化治疗

目的：探讨胰岛素强化治疗对2型糖尿病患者胆道术后的临床疗效。方法：72例胆道术后合并2型糖尿病患者随机分为强化治疗组和对照组各36例。强化治疗组给予强化胰岛素治疗,使血糖控制在4.4～6.1mmol/L;对照组给予常规胰岛素治疗,使血糖控制在10.0～11.1mmol/L。比较两组空腹血糖（FBG）、炎性指标及预后等。结果：强化治疗组FBG、体温、WBC明显低于对照组,抗生素使用天数、院内感染发生率、重症监护天数及术后并发症明显少于对照组,但低血糖发生率显著高于对照组,差异有统计学意义（P〈0.05）。结论：糖尿病患者胆道术后强化胰岛素治疗,可降低炎性反应,并减少抗生素用量及重症监护天数,降低术后并发症,但低血糖发生率较高。     

Acne today. What's new?

WELL-CONDUCTED TREATMENT: Acne is a common condition in adolescents and requires careful management both in terms of therapeutic care and psychological support. Treatment is long and requires strict compliance. A well-conducted treatment can be expected to provide major improvement in most patients. LOCAL CARE: Local care is often sufficient for retentional or discretely inflammatory acne. A retinoid and/or a benzoyl peroxide can be associated with a local antibiotic. SEVERE FORMS: An oral antibiotic regimen for at least 3 months is proposed in association with the local treatment (retinoid, benzoyl peroxide, local antibiotic) in case of severe acne. ISOTRETINOIN: In case of unsuccessful treatment for nodular or conglobata acne, isotretinoin can be proposed in an oral preparation. This highly teratogenic drug must not be prescribed for women of reproductive age unless a well proven contraception has been instituted for more than 1 month and maintained for the entire duration of the treatment and 1 month after discontinuation. The patient must be informed of the risk in case of pregnancy and consent to regular monitoring of beta hCG less than 3 days before treatment onset, every 2 months during treatment and 5 weeks after treatment withdrawal).     

Antibiotic therapy in Italy. Current data and proposals for the future

Data concerning antibiotic therapy in italian ICUs are presented. These data were not directly measured: they have been derived from a previous study on costs of intensive care treatments. 78% of 1065 patients received antibiotic therapy. Empirical therapy was started in 82% of septic patients. 93% of septic patients had at least one antibiogram. In 96% of cases, 2 or more antibiotics were given. 85% of surgical non septic patients received antibiotic prophylaxis for an average of 3.6 days, with a 3rd generation cephalosporin in the majority of cases. 60% of medical non septic patients received antibiotic prophylaxis for an average of 6.2 days, mostly with a 3rd generation cephalosporin. These data raise doubts about the proper use of prophylaxis. These data can be considered a useful starting point for the development of a program of surveillance of infections in Italian ICUs.     

Management of clostridial gas gangrene and the role of hyperbaric oxygen.

BACKGROUND AND AIMS: Clostridial gas gangrene is one of the most dreaded infections in surgery. The aim of this study was to investigate the efficacy of surgery, antibiotic treatment, surgical intensive care and especially the role of hyperbaric oxygen in the management of clostridial gas gangrene. MATERIAL AND METHODS: 53 patients, 42 of them submitted from other hospitals in Finland. After the diagnosis had been made the patients underwent surgical debridement, broad spectrum antibiotic therapy and a series of hyperbaric oxygen (HBO) treatments at 2.5 ATA pressure. The necrotic tissue was excised and incisions were made in the affected areas. Amputations were performed when necessary. RESULTS: Twelve patients died (22.6%). Hyperbaric oxygen therapy decreased the systemic toxicity and prevented further extension of the infection thereby improving the overall outcome of the patients. CONCLUSION: Hyperbaric oxygen therapy of gas gangrene seems to be life-, limb- and tissue saving. Early diagnosis remains essential. Patient survival can be improved if the disease is recognized early and appropriate therapy applied promptly. Surgical and antibiotic therapy as well as HBO treatment combined with surgical intensive care must be started as soon as possible.     

Use of aerosolized aminoglycosides in the treatment of Gram-negative ventilator-associated pneumonia

BACKGROUND AND PURPOSE : Ventilator-associated pneumonia (VAP) in the surgical intensive care unit (ICU) is associated with substantial morbidity and mortality. Affected patients are at higher risk for infection with multi-drug-resistant (MDR) pathogens, often necessitating therapeutic regimens of two parenteral antibiotics. Aerosolized antibiotics achieve high alveolar concentrations and have been reported anecdotally to have value in the treatment of VAP. This study examined the role of aerosolized aminoglycosides in the treatment of VAP in surgical ICU patients. METHODS: We reviewed retrospectively the medical records of 22 patients who received aerosolized aminoglycosides in conjunction with parenteral antibiotics for VAP in the surgical ICU. Sixteen patients received inhaled tobramycin, and six received inhaled amikacin. Demographic information and data on the length of stay (LOS), mortality rate, days of antibiotic therapy, days of mechanical ventilation, and recurrence of VAP were collected. Results of bronchoscopic and sputum cultures were reviewed to identify bacterial pathogens and antimicrobial susceptibilities. RESULTS: The average duration of mechanical ventilation was 31 +/- 12 days, the mean ICU LOS was 41 +/- 13 days, and the mean hospital LOS was 71 +/- 25 days. There were three deaths. The average duration of mechanical ventilation after initiation of aerosolized antibiotics was 4.3 days. Seven patients (40%) developed recurrent pneumonia with the same pathogen, but only one had a change in antibiotic susceptibility pattern. There were no renal or pulmonary complications of aminoglycoside treatment. CONCLUSIONS: Ventilator-associated pneumonia in critically ill patients is associated with substantial morbidity, longer ICU stays, and prolonged mechanical ventilation. Along with systemic therapy, aerosolized aminoglycosides are valuable adjuncts in select patients with minimal risk of antibiotic resistance.     

Therapie nosokomialer Infektionen in der chirurgischen Intensivmedizin

The timing of appropriate antibiotic therapy determines the prognosis of patients with severe nosocomial infections. In this context, “appropriate” means that the agent selected is effective against the pathogen and is used at the right dose for an adequately long course. While this calls for liberal prescribing policies for antibiotics, clinical data suggest that excessive use of broad-spectrum antibiotics leads to the emergence of multi-drug-resistant pathogens. The present article faces up to this dilemma, outlining strategies for antibiotic use in intensive care medicine, with special reference to ventilator-associated pneumonia and the growing problem of multi-drug-resistant pathogens. The intensivist can be helped to achieve an appropriate initial therapy without overuse of antibiotics by a thorough understanding of the local patterns of antibiotic resistance, consistent de-escalation of empiric therapy as soon as the results of microbiological diagnostic investigations are available and evidence-based limitation of the duration of therapy.     

Strategies in the prevention and management of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is a leading cause of morbidity and mortality in the intensive care unit. Prevention of VAP is possible through the use of several evidence-based strategies intended to minimize intubation, the duration of mechanical ventilation, and the risk of aspiration of oropharyngeal pathogens. Current data favor the quantitative analysis of lower respiratory tract cultures for the diagnosis of VAP, accompanied by the initiation of broad-spectrum empiric antimicrobial therapy based on patient risk factors for infection with multi-drug-resistant pathogens and data from unit-specific antibiograms. Eventual choice of antibiotic and duration of therapy are selected based on culture results and patient stability, with an emphasis on minimization of unnecessary antibiotic use.     

Ventilator-associated pneumonia and multiresistant bacteria

Ventilator-associated pneumonia remains the most serious nosocomial infection in critically ill patients. Providing appropriate antibiotic therapy promptly is crucial for successful treatment; whereas the diagnostic approach seems to play a minor role. The empirical antibiotic therapy should be guided by the risk for infections due to multiresistant bacteria. For patients at risk a combination therapy, considering local resistance data and formerly applied antibiotic substances, is recommended. Reevaluation and deescalation of antibiotic therapy based on microbiological culture results and discontinuation of antimicrobial treatment after one week is essential for the control of broadspectrum antibiotic use and antibiotic resistance.     

胰岛素严格控制血糖对脓毒症患者的影响及其机理的初步探讨

目的　探讨用胰岛素严格控制血糖对脓毒症患者预后和并发症的影响及其可能的机理。方法　将 5 5例脓毒症患者随机分为严格控制血糖组 (用胰岛素控制血糖在 4 4～ 6 1mmol/L)和常规治疗组 (血糖控制在 10 0～ 11 1mmol/L)。在入院后的 2 4h、3d、5d和 7d、10d、14d用流式细胞仪测定外周血单核细胞HLA DR的变化 ,并同时收集炎症反应指标 ,包括血肿瘤坏死因子α(TNF α)、白细胞介素 6 (IL 6 )和C 反应蛋白 (CRP) ,以及病情严重度 (APACHEⅡ评分、SOFA评分 )、感染并发症和预后等资料 ,在两组之间进行比较。结果　相对于常规治疗组 ,严格控制血糖组体温异常持续时间、发热时间以及呼吸机辅助呼吸时间均显著缩短 (P <0 0 5 ) ,同时住院期间的ΔSOFA也显著降低(P <0 0 5 )。在严格控制血糖组有 3例 (11% )患者并发了低血糖 ,经过及时治疗未出现明显的不良后果。在感染初期单核细胞表面HLA DR表达降低、血CRP浓度增加 ,随着病程的推移HLA DR表达逐渐恢复 ,血CRP也逐渐降低。严格控制血糖组HLA DR表达的恢复较常规治疗组更快 ,入院后 3d、5和 7d存在显著差异 (P <0 0 5 ) ;同时血CRP浓度的下降也有更明显的趋势 ,在入院后 10d有显著差异 (P <0 0 5 )。结论　用胰岛素严格控制血糖能加快感染患者恢复、增     

Procalcitonin (PCT)-guided algorithm reduces length of antibiotic treatment in surgical intensive care patients with severe sepsis: results of a prospective randomized study

Background  Adequate indication and duration of administration are central issues of modern antibiotic treatment in intensive care medicine. The biochemical variable procalcitonin (PCT) is known to indicate systemically relevant bacterial infections with high accuracy. In the present study, we aimed to investigate the clinical usefulness of PCT for guiding antibiotic treatment in surgical intensive care patients with severe sepsis. Patients and methods  Patients were randomly assigned to a PCT-guided or a control group requiring antibiotic treatment. All patients received a calculated antibiotic regimen according to the presumed microbiological spectrum. In the PCT-guided group, antibiotic treatment was discontinued if clinical signs of infection improved and the PCT value was either <1 ng/ml or decreased to <35% of the initial concentration within three consecutive days. In the control group, antibiotic treatment was directed by empirical rules. Results  The PCT-guided group (n = 14 patients) and the control group (n = 13 patients) did not differ in terms of biological variables, underlying diseases, and overall disease severity. PCT guidance led to a significant reduction of antibiotic treatment from 6.6 ± 1.1 days (mean ± SD) compared with 8.3 ± 0.7 days in control patients (p < 0.001) along with a reduction of antibiotic treatment costs of 17.8% (p < 0.01) without any adverse effects on outcome. Conclusions  Monitoring of PCT is a helpful tool for guiding antibiotic treatment in surgical intensive care patients with severe sepsis. This may contribute to an optimized antibiotic regimen with beneficial effects on microbial resistances and costs in intensive care medicine. S. Schroeder and M. Hochreiter equally contributed to the paper.     

Long-term suppression of infection in total joint arthroplasty

Optimal treatment for a chronic infected prosthesis is the removal of infected and necrotic tissue and all the components of the prosthesis with staged revision in conjunction with systemic antibiotics. If this is not possible because of the poor general condition of the patient, because of unacceptable functional results secondary to removal of the prosthesis, or because the patient refuses surgery in an attempt to salvage the infected prosthesis, a reasonable alternative is long-term oral suppressive antibiotic therapy for maintenance of a functioning prosthesis. Prompt recognition with rapid debridement and initiation of antibiotic therapy seems crucial. Our study confirms a favorable outcome of maintenance of functioning prostheses in 86.2% of patients after a mean followup of 5 years. All patients had initial debridement with 4 to 6 weeks of systemic antibiotic therapy. Advanced age did not seem to predict poor outcome. Joint location, duration of symptoms, and the time of onset of infection did not predict success or failure. The overall success rate for Staphylococcus aureus prosthetic joint infection was 69% after a mean followup of 5 years. The ideal regimen and optimal duration of oral suppressive therapy for a favorable outcome is not well-established and needs additional data with prospective multicenter studies.     

Septic shock due to community-acquired complicated intra-abdominal infection treated with ertapenem: outcome in 25 cases

OBJECTIVES: To assess the effectiveness of ertapenem in patients admitted to a surgical intensive care unit with septic shock due to community-acquired complicated intra-abdominal infection. PATIENTS AND METHODS: Patients undergoing emergency surgery for community-acquired complicated intra-abdominal infection were enrolled prospectively. All patients were given intravenous ertapenem at a rate of 1 g/24 h and the guidelines of the Surviving Sepsis Campaign were applied. Outcome measures were duration of antibiotic therapy, mean length of stay in the surgical intensive care unit (ICU), antibiotic failure, and death while in the surgical ICU. RESULTS: Twenty-five patients with a mean (SD) age of 74 (14) years were enrolled. The origin of infection was the colon in 56% of the cases; most patients (76%) had generalized peritonitis. The mean stay in the surgical ICU was 10 (7) days. The mean duration of antibiotic therapy was 5.8 (1.26) days. Antibiotic failure occurred in 12%. Mortality in the surgical ICU was 28%. CONCLUSIONS: Our findings suggest that patients with community-acquired intra-abdominal infection and septic shock have a good chance of survival when treated according to the guidelines of the Surviving Sepsis Campaign. Ertapenem seems to give good results when used in this setting.     

Postmenopausal osteoporosis treatment with antiresorptives: effects of discontinuation or long-term continuation on bone turnover and fracture risk--a perspective

Osteoporosis may be a lifelong condition. Robust data regarding the efficacy and safety of both long-term osteoporosis therapy and therapy discontinuation are therefore important. A paucity of clinical trial data regarding the long-term antifracture efficacy of osteoporosis therapies necessitates the use of surrogate endpoints in discussions surrounding long-term use and/or discontinuation. Long-term treatment (beyond 3-4 years) may produce further increases in bone mineral density (BMD) or BMD stability, depending on the specific treatment and the skeletal site. Bisphosphonates, when discontinued, are associated with a prolonged reduction in bone turnover markers (BTMs), with a very gradual increase to pretreatment levels within 3 to 60 months of treatment cessation, depending on the bisphosphonate used and the prior duration of therapy. In contrast, with nonbisphosphonate antiresorptive agents, such as estrogen and denosumab, BTMs rebound to above pretreatment values within months of discontinuation. The pattern of BTM change is generally mirrored by a more or less rapid decrease in BMD. Although the prolonged effect of some bisphosphonates on BTMs and BMD may contribute to residual benefit on bone strength, it may also raise safety concerns. Adequately powered postdiscontinuation fracture studies and conclusive evidence on maintenance or loss of fracture benefit is lacking for bisphosphonates. Similarly, the effects of rapid reversal of bone turnover upon discontinuation of denosumab on fracture risk remain unknown. Ideally, studies evaluating the effects of long-term treatment and treatment discontinuation should be designed to provide head-to-head "offset" data between bisphosphonates and nonbisphosphonate antiresorptive agents. In the absence of this, a clinical recommendation for physicians may be to periodically assess the benefits/risks of continuation versus discontinuation versus alternative management strategies.