Chromobacterium violaceum nosocomial pneumonia in two Japanese patients at an intensive care unit

Chromobacterium violaceum is sensitive to temperature and the infection is usually confined to tropical or subtropical regions. Since Japan has a warm climate, C. violaceum has been scarcely isolated from clinical specimens. With global warming, however, the geographical distribution of C. violaceum infection is likely to change. We report two cases of C. violaceum nosocomial pneumonia that occurred at an intensive care center in Japan. C. violaceum was first detected from a patient in the same center as a pathogenic organism of pneumonia. Later, the organism was isolated from sputum and a ventilator circuit tube of another patient in the center. The two patients were admitted to the center in nearby beds for several days. All of the pathogens were confirmed to be C. violaceum by the nucleic acid sequence of the 16S rRNA gene and were proven to be genetically identical organisms by pulsed field gel electrophoresis. Both patients were managed with well-humidified and heated oxygen using a venturi mask and ventilator to promote excretion of sputum. It was thought that the medical respiratory care devices that provide a humid and warm environment, an optimal condition for proliferation of C. violaceum, can contribute to C. violaceum infection in a hospital environment.     

糖皮质激素在重症医学科急性呼吸窘迫综合征中的应用

目的评价糖皮质激素(glucocorticoids,GCs)在重症监护室(intensive care unit,ICU)治疗急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)中的作用。方法回顾性分析本院入住ICU的ARDS患者的临床资料,并根据致病因素在肺损伤中的作用,将所入选患者分为肺内源性ARDS(primarily from pulmonary diseases,ARDSp)和肺外源性ARDS(primarily from extra-pulmonary diseases,ARDSexp);ARDSp患者62例,ARDSexp患者101例。根据GCs的使用量各分为3组,分析ARDSp及ARDSexp应用GCs和未应用GCs患者的病情改善和病死率。结果 ARDSp及ARDSexp患者各组急性生理与慢性健康评分(Acute Physiology and Chronic Health EvaluationⅡ,APACHE-Ⅱ)相当(P0.05)。GCs治疗30mg/d组与≥30mg/d组比较,病情改善时间和呼吸机治疗时间明显缩短(P0.01),病死率也略低(P0.05);GCs治疗30mg/d组与非GCs治疗组比较差异有统计学意义(P0.01);≥30mg/d组与非GCs治疗组比较差异无统计学意义(P0.05)。ARDS患者总体病死率23.3%(38/163),其中使用GCs治疗组病死率22.8%(34/149),未使用GCs治疗组病死率28.6%(4/14)(P0.05)。结论低剂量(30mg/d)、早期应用(24h内)、长期疗程(7d)的GCs,可及时遏制炎性介质的"瀑布样效应",在一定程度上缩短病程,降低病死率。     

Mortality rate attributable to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case-control study.

OBJECTIVE: To evaluate the mortality rate attributable to nosocomial ventilator-associated pneumonia in an intensive care unit. DESIGN: Prospective, matched, risk-adjusted cohort study. SETTING: A 18-bed adult medical-surgical intensive care unit in a 1,100-bed regional and teaching hospital in France. PATIENTS: From January 1, 1996, to April 30, 1999, 135 patients who developed nosocomial pneumonia were matched with 135 control patients without nosocomial pneumonia. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nosocomial pneumonia was identified on the basis of results of distal bronchial samples. The matching process was conducted according to the following primary criteria: cause of admission, indication for ventilatory support, immunologic status, cardiac status, probability of death (+/-5%), Glasgow Coma Scale score (+/-2 points), age (+/-7 yrs), and duration of exposure to risk. When possible, case and control patients were matched according to five secondary criteria: respiratory and alcoholism status before admission, diagnosis categories, surgical procedure or not, and gender. The mortality rates were compared between case and control patients by using the Kaplan-Meier estimate and the log-rank test. The influence of nosocomial pneumonia on mortality rate then was tested by adjusting for the secondary criteria and other possible confounding factors by using the Cox proportional-hazards model. The matching process was successful for 1,080 of 1,080 primary criteria. The crude intensive care unit mortality rate was higher in patients with nosocomial pneumonia than in control patients (41 vs. 14%; p <.0001). In actuarial survival analysis, the probability of intensive care unit death was higher in the case patients (odds ratio = 2.7, 95% confidence interval = 1.8-3.1, p =.028). After adjustment, the occurrence of nosocomial pneumonia remained an independent risk factor of death (odds ratio = 2.1, 95% confidence interval = 1.2-3.6, p =.008). Nosocomial pneumonia attributable to multiresistant microorganisms was significantly associated with death (odds ratio = 2.6, 95% confidence interval = 1.1-5.8, p =.02). The length of intensive care unit stay was higher in case than in control patients (31 +/- 19 vs. 26 +/- 17 days, p <.0001). CONCLUSIONS: Nosocomial pneumonia is independently associated with death in the intensive care unit. In addition, it increases the length of intensive care unit stay.     

N-acetylcysteine reduces respiratory burst but augments neutrophil phagocytosis in intensive care unit patients

OBJECTIVE: The antioxidant N-acetylcysteine (NAC) has been shown to attenuate septic tissue injury. To evaluate whether NAC affects host defense mechanisms in critically ill patients, thus predisposing to increased risk of infection, the current study focuses on neutrophil phagocytotic and burst activity after treatment with NAC. DESIGN: Prospective, randomized, clinical trial. SETTING: Twelve-bed operative intensive care unit in a university hospital. PATIENTS: Thirty patients diagnosed with sepsis/systemic inflammatory response syndrome, or multiple trauma. INTERVENTIONS: Patients were randomly assigned to receive either NAC (n = 15) for 4 days in increasing dosages (day 1: 6 g; day 2: 12 g; days 3 and 4: 18 g) or a mucolytic basis dosage of NAC (3 x 300 mg/day [control]; n = 15), respectively. MEASUREMENTS AND MAIN RESULTS: Blood samples were taken before NAC high-dose infusion (day 1), after increasing doses of NAC (days 3 and 5) and 4 days after the last high-dose treatment (day 8). Neutrophil oxidative burst activity after stimulation with Escherichia coli and polymorphonuclear phagocytosis were determined in a flow cytometric assay. Baseline values of polymorphonuclear functions were comparable in both groups. NAC high-dose treatment resulted in a significantly improved phagocytosis activity compared with control patients. In contrast to this, polymorphonuclear burst activity was significantly reduced in the NAC high-dose treated group on day 3. CONCLUSION: These findings suggest that infusion of NAC in high doses affects granulocyte functions in critically ill patients. Antimicrobial host defense requires the effective sequence of cell adhesion, phagocytosis, and bactericidal respiratory burst. The enhanced phagocytotic activity might be a compensatory mechanism in states of impaired respiratory burst to maintain tissue sterility. For certain mechanisms of disease, the effects observed might be favorable (e.g., ischemia/reperfusion, endothelial cell activation), for others (infection) this might be detrimental.     

A 25-year study of nosocomial bacteremia in an adult intensive care unit.

OBJECTIVE: To identify the organisms, their antibiotic susceptibility, and the associated focus on infection causing nosocomial bacteremia in patients in an adult intensive care unit (ICU) between 1971 and 1995. DESIGN: Prospective observational study. SETTING: A 12-bed general adult ICU in a 1,000-bed tertiary referral teaching hospital. PATIENTS: Four hundred eighty-six episodes of bacteremia involving 570 organisms in 425 patients. MEASUREMENTS AND MAIN RESULTS: Blood cultures taken from patients with suspected nosocomial infection were analyzed. Isolated organisms were identified, and their susceptibility to commonly used antibiotics was determined. Clinical details, including antibiotic treatment, were recorded for all patients. From 1986 to 1995, culture results of samples obtained from other sites were used to help identify the focus of infection causing bacteremia. All results were collected prospectively by clinical microbiologists. Between 1971 and 1990, the number of bacteremias and the relative frequency of isolation of individual organisms changed little, with Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Klebsiella species predominating. During 1991 to 1995, the number of bacteremias increased two-fold, largely attributable to increased isolation of Enterococcus species, coagulase-negative staphylococci, intrinsically antibiotic-resistant gram-negative organisms (particularly P. aeruginosa), and Candida species. The most commonly used antibiotics for the treatment of bacteremic patients throughout the 1970s were amoxicillin and gentamicin. After the introduction of cephalosporins in the early 1980s, their use increased progressively to equal that of gentamicin in the 1990s, whereas amoxicillin use decreased. Since the introduction of cephalosporins, increases in the antibiotic resistance of gram-negative organisms have been largely confined to an outbreak of gentamicin- and ceftazidime-resistant organisms caused by contaminated arterial pressure monitors during 1992 and 1993 and a two-fold increase in ceftazidime resistance of the Pseudomonas species. Gentamicin resistance of gram-negative aerobes remained unchanged (excluding the arterial pressure monitor outbreak), despite gentamicin being one of the most frequently prescribed antibiotics throughout the 25-yr period. Between 1986 and 1995, two thirds of all bacteremic organisms were cultured from intravascular catheters, which were designated as the focus of infection, 7% were secondary to gastrointestinal pathology, but only approximately 3% were secondary to wound, respiratory tract, or urinary tract infections. CONCLUSIONS: Bacteremias have become more frequent in the ICU, probably because of the increased use of intravascular catheters, which are the most frequent foci for bacteremic infection. The spectrum of organisms has changed, and this can be temporally related to the changes in the antibiotics prescribed. Gentamicin resistance of gram-negative organisms has not increased during a 25-yr period, despite being one of the most frequently prescribed antibiotics in the ICU.     

Hypophosphatemia in children hospitalized within an intensive care unit

The aims of this study were to estimate the occurrence of hypophosphatemia and to identify potential risk factors and outcome measures associated with this disturbance in children admitted to a pediatric intensive care unit. Data concerning 42 children admitted consecutively to 1 pediatric intensive care unit over a 1-year period were examined. Serum phosphorus levels were measured on the third day of admission, where levels below 3.8 mg/dL were considered indicative of hypophosphatemia. Hypophosphatemia was found in 32 children (76%), and there was a significant association between this disturbance and malnutrition (P = .04). Of the potential risk factors such as sepsis, diuretic/steroid therapy, starvation (over 3 days), and Pediatric Index of Mortality, none discriminated for hypophosphatemia. There were no associations between hypophosphatemia and mortality, length of stay in the pediatric intensive care unit, or time on mechanical lung ventilation. Hypophosphatemia was a common finding in critically ill children and was associated with malnutrition.     

Antimicrobial resistance in nosocomial bloodstream infection associated with pneumonia and the value of systematic surveillance cultures in an adult intensive care unit

OBJECTIVE: To study the occurrence of multiple-drug-resistant pathogens in nosocomial bloodstream infection associated with pneumonia. To evaluate prediction of multiple drug resistance by systematic surveillance cultures. DESIGN: A retrospective study of a prospectively gathered cohort. SETTING: Fifty-four-bed adult medical-surgical intensive care unit of a tertiary hospital. PATIENTS: One hundred twelve intensive care unit patients with nosocomial bloodstream infection associated with pneumonia from 1992 through 2001. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Concordance of blood cultures with prior surveillance culture was assessed. Surveillance cultures were taken routinely as thrice weekly urinary cultures and oral swabs, once weekly anal swabs, and thrice weekly tracheal aspirates in intubated patients. Tracheal surveillance cultures from 48 to 96 hrs before bloodstream infection and surveillance cultures from any site during the same intensive care unit episode but >or=48 hrs before bloodstream infection were evaluated separately. Forty-four bloodstream infections (39%) were caused by a multiple-drug-resistant pathogen. Multiple-drug-resistant pathogens were predicted by tracheal surveillance culture in 70% (concordant); in 15%, tracheal surveillance culture grew a multiple-drug-resistant pathogen not found in blood cultures (discordant). Multiple-drug-resistant pathogens were predicted by any surveillance culture in 88%, but these surveillance cultures grew additional multiple-drug-resistant pathogens not causing bloodstream infection in up to 46% of patients. In 86% of bloodstream infections, early (i.e., within 48 hrs) antibiotic therapy was appropriate. Patients were divided into four risk categories for multiple-drug-resistant bloodstream infection based on length of prior intensive care unit stay and prior antibiotic exposure. In patients with two risk factors, knowledge of surveillance cultures increased appropriateness of early antibiotic therapy from 75-79% to 90% (p<.05) while limiting use of broad-spectrum antibiotics such as antipseudomonal betalactams, fluoroquinolones, and carbapenems. CONCLUSIONS: In our intensive care unit, tracheal surveillance culture predicted multiple-drug-resistant etiology of bloodstream infection associated with pneumonia in 70% of patients but yielded discordant resistant pathogens in 15%. In the subgroup of patients with two risk factors for multiple-drug-resistant infection, incorporating results of surveillance cultures moderately contributed to adequacy of early antibiotic therapy while limiting antibiotic consumption.     

呼吸科重症监护病房医院获得性肺炎临床分析

目的探讨呼吸科重症监护病房(RICU)医院获得性肺炎(HAP)的发病情况、危险因素、病原菌分布、治疗结局。方法回顾分析2008年8月—2010年8月于南京军区南京总医院RICU住院期间发生HAP患者的临床资料。结果 RICU住院患者HAP发生率为17.3%,主要的危险因素包括高龄,长期住ICU,患有慢性阻塞性肺疾病、心脑血管疾病、糖尿病、恶性实体瘤等基础疾病,应用多种抗生素,留置鼻饲管、导尿管、气管插管、中心及外周静脉导管,应用质子泵抑制剂,并发多脏器功能衰竭等。病原菌主要为鲍曼不动杆菌、铜绿假单胞菌、金葡菌。总病死率为42.0%,抗感染治疗有效率54.0%。结论针对高危人群采取积极预防措施,治疗基础疾病、降低危险因素、改善病房环境,同时根据药敏试验结果采用多种抗生素联合应用是治疗成功的关键。     

Antimicrobial activity of tigecycline tested against nosocomial bacterial pathogens from patients hospitalized in the intensive care unit

The antimicrobial activity of tigecycline and selected antimicrobials was evaluated against bacterial pathogens isolated from patients hospitalized in intensive care units (ICUs) worldwide. A total of 9093 isolates were consecutively collected in >70 medical centers in North America (4157), South America (1830), Europe (3034), and the Asia-Australia (72) areas. The isolates were collected from the bloodstream (68.5%), respiratory tract (13.6%), skin/soft tissue (5.5%), and urinary tract (2.0%) infections in the 2000-2004 period, and susceptibility was tested by reference broth microdilution methods. The most frequently isolated pathogens were Staphylococcus aureus (32.1%), Enterococcus spp. (13.7%), coagulase-negative staphylococci (CoNS; 13.0%), Pseudomonas aeruginosa (8.4%), and Escherichia coli (7.9%). All Gram-positive pathogens (5665) were inhibited at < or =1 microg/mL of tigecycline. Resistance to oxacillin was detected in 43.5% of Staphylococcus aureus and in 85.0% of CoNS, and resistance to vancomycin was observed in 18.6% of enterococci. Tigecycline was very active against Enterobacteriaceae (1876 strains tested) with an MIC90 of < or =1 microg/mL, except for Serratia spp. (2 microg/mL). Extended-spectrum beta-lactamase (ESBL) phenotype was detected in 10% of E. coli and 31% of Klebsiella spp., whereas 28% of Enterobacter spp. were resistant to ceftazidime (AmpC enzyme production). These resistance phenotypes did not adversely affect tigecycline activity. Tigecycline and trimethoprim/sulfamethoxazole were the most active compounds against Stenotrophomonas maltophilia (MIC90, 2 and 1 microg/mL respectively). Tigecycline was also active against Acinetobacter spp. (MIC90, 1 microg/mL), but P. aeruginosa showed decreased susceptibility to tigecycline (MIC90, 16 microg/mL). In summary, isolates from ICU patients worldwide showed high rates of antimicrobial resistance. The most alarming problems detected were vancomycin resistance among enterococci, ESBL-mediated beta-lactam resistance and fluoroquinolone resistance among Enterobacteriaceae, and carbapenem resistance among P. aeruginosa and Acinetobacter spp. Tigecycline exhibited potent in vitro activity against most of clinically important pathogenic bacteria (except P. aeruginosa) isolated from ICU patients and may represent an excellent option for the treatment of infections in this clinical environment.     

重症监护病房患者下呼吸道院内感染细菌及其耐药性分析

目的探讨重症监护病房患者院内感染细菌分布特点及耐药情况。方法回顾性总结2004年5月至2006年6月本院重症监护病房103例院内感染(nosocomial infection,NP)患者的临床资料、感染病原菌谱及耐药性,并对相关因素进行分析。结果103例感染患者共分离出细菌117株,以G-杆菌为主(占68.4%),球菌比例较低(占21.4%)。G-杆菌中铜绿假单胞菌占第一位(31.6%),其次为大肠埃希氏菌(18.8%)、肺炎克雷伯菌(17.1%)。球菌主要为金黄色葡萄球菌,其中耐甲氧西林金黄色葡萄球菌(methicillin resistant staphylococcus aureus,MRSA)占46.2%。G 菌占35.2%,真菌占18.3%。结论ICU患者下呼吸道感染的病原菌以G-杆菌为主,病原菌显示多重耐药,G-杆菌对亚胺培南敏感性较好,而G 菌对万古霉素敏感应根据药敏选择抗菌素。     

青年急重症患者在急诊监护室住院体验的研究

目的深入了解青年急重症患者入住急诊监护室期间的体验,为进一步提高护理质量提供理论依据。方法采用质性研究中的现象学研究方法,对5名在急诊ICU住院时长超过15 d的青年急重症患者进行深度访谈,并对访谈内容进行分析。结果访谈结果共提炼出5个主题:舒适感被破坏、安全感严重缺失、对与亲友分离感到焦虑、自理能力的改变带来巨大心理落差、对自我及生命的反思。结论急诊ICU的住院经历给青年急重症患者带来许多负面体验,进一步了解这些负面体验的不同层次,有助于为医护人员更好地护理青年急重症患者提供指导和方向。     

Prone position in adult respiratory distress syndrome: nursing care

The use of prone position in patients with Adult Respiratory Distress Syndrome is becoming a more and more habitual therapeutic measure in the units of Intensive Care, for what to have appropriate Nursing protocols will improve our professional performances. This article seeks to modernize knowledge by means of the practical experience and the bibliographical revision about Adult Respiratory Distress Syndrome, of the prone position and its effects on the organism, as well as the prone technique and the Nursing cares of the patients in prone position. It is propounded a detailed technique in steps, to carry out the prone position in a sure way, an itemized revision on the posture of the patient's maintenance in prone position and a Nursing cares protocol for the patients located in this posture.     

呼吸重症监护病房院内获得性肺炎病原学特点及多因素Logistic回归分析

目的探讨呼吸重症监护病房（RICU）院内获得性肺炎（HAP）病原学特点及多因素Logistic回归分析。 方法选择安徽医科大学第二附属医院于2018年3月至2021年8月入住RICU病房患者160例,并发HAP患者54例。分离培养HAP患者病原菌,采用微生物鉴定系统分离鉴定病原菌;采用纸片法进行药敏试验。采用单因素分析影响HAP相关因素;采用多因素Logistic回归分析影响HAP独立危险因素。 结果HAP感染患者54例中,分离病原菌81株,其中革兰氏阴性菌62株,革兰氏阳性菌6株,真菌13株。肺炎克雷伯杆菌对头孢他啶（85.19%）和头孢唑啉（77.78%）耐药率较高;铜绿假单胞菌对头孢他啶（94.74%）和头孢哌酮/舒巴坦（78.95%）耐药率较高。经单因素分析显示,HAP组与无HAP组性别、体质量指数、吸烟史和高血压史比较差异无统计学意义（P＞0.05）;HAP组与无HAP组年龄、糖尿病史、机械通气时间、口腔清洁状况、白蛋白水平、合并肺内疾病、住院时间和广谱抗生素应用比较差异具有统计学意义（P＜0.05）。将上述单因素分析具有统计学差异的纳入多因素Logistic回归分析显示,年龄＞70岁、机械通气时间＞7 d、糖尿病史、口腔清洁状况、白蛋白＜30 g/L、合并肺内疾病、住院时间和广谱抗生素应用为影响RICU的HAP患者独立危险因素。 结论RICU的HAP患者病原菌以革兰氏阴性菌为主,其中年龄、机械通气时间、糖尿病史、口腔清洁状况、白蛋白水平、合并肺内疾病、住院时间和广谱抗生素应用为影响RICU的HAP患者独立危险因素。