Peroperative teicoplanin for prevention of gram-positive infections in neutropenic patients with indwelling central venous catheters: a randomized, controlled study

 A prospective, randomized, open study comparing two doses of teicoplanin with no therapy administered at the time of insertion of a central venous catheter was performed in patients with hematological malignancies and in patients scheduled to undergo allogeneic or autologous stem cell transplantation. The study was designed as a group sequential study. At predetermined intervals statistical analysis was performed for the main efficacy variable, which was the number of days to treatment failure. Sixty-five patients were randomized. Three patients were judged to be not evaluable. Baseline characteristics were identical in the two groups. No differences were found in overall infections, bacteremias, gram-positive infections, or local infections between the teicoplanin and control groups. Teicoplanin given at the time of insertion of central venous catheters did not reduce the risk of bacteremias or other line-associated infections.     

Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: a randomized controlled clinical trial

OBJECTIVE: Central venous catheters (CVC) are a major cause of nosocomial bloodstream infections. Catheters modified with miconazole and rifampicin that constantly and slowly release antimicrobial substances are assumed to be beneficial in reducing rates of colonization and catheter-related infections. DESIGN AND SETTING: Prospective controlled non-blinded randomized clinical trial in two German university hospitals. PATIENTS: 223 adult inpatients with CVC between October 2000 and February 2002. Baseline characteristics, APACHE II score and therapeutic interventions were comparable. INTERVENTION: Randomization to receive either a miconazole and rifampicin modified catheter (n=118) or a standard triple-lumen CVC (n=105). MEASUREMENTS, DEFINITIONS: Microbiological evaluation was done after CVC removal. A catheter was considered colonized if growth of > or =15 cfu was found by semi-quantitative roll-plate technique from a proximal or distal catheter segment. A catheter-related infection (CRI) was defined as a colonized catheter with local signs of inflammation. A catheter-related bloodstream infection (CR-BSI) was defined as a colonized catheter with isolation of the same organism from the patient's blood with accompanying clinical signs of infection. RESULTS: A colonization of CVC was observed in six patients (5.1%) with a modified catheter and 38 patients (36.2%) with a standard catheter (P < 0.001). Five patients in the modified group (4.2%) and 18 in the standard group (17.1%) developed CRI (P=0.002). One assumed CR-BSI was detected in the standard group, with none in the modified group. No adverse effects related to the modified catheters and no antimicrobial resistance were observed. CONCLUSION: CVC supersaturated with miconazole and rifampicin were associated with a significantly lower risk for catheter colonization and catheter-related infections compared to standard catheters.     

重症监护病房中心静脉导管相关感染的临床研究

[目的]了解重症监护病房中心静脉导管相关感染（CVC-RI）的原因。[方法]以回顾性调查方法对发生CVC-RI病人的一般情况、基础疾病、使用导管腔数、置管时间、置管部位、细菌学检查结果进行统计分析。[结果]CVC-RI与年龄、性别、基础疾病无关,但与置管时间、导管腔数有关。锁骨下静脉置管发生感染的比例最低。CVC-RI病原菌中革兰阳性菌、阴性菌和真菌发生感染的比例无统计学意义。[结论]应尽量选择在锁骨下静脉置管,控制置管时间和导管腔数,高度重视致病菌菌谱的变化。     

重症监护病房中心静脉导管相关感染的临床研究

[目的]了解重症监护病房中心静脉导管相关感染(CTC-Rl)的原因.[方法]以回顾性调查方法时发生CVC-Rl病人的一般情况、基础疾病、使用导管腔数、置管时间、置管部位、细菌学检查结果进行统计分析.[结果]CVC-RI与年龄、性别、基础疾病无关,但与置管时间、导管腔数有关.锁骨下静脉置管发生感染的比例最低.CVC-RI病原菌中革兰阳性菌、阴性菌和真菌发生感染的比例无统计学意义.[结论]应尽量选择在锁骨下静脉置管,控制置管时间和导管腔数,高度重视致病菌菌谱的变化.     

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.     

Rifampicin-impregnated central venous catheters: a meta-analysis of randomized controlled trials

BACKGROUND: The use of antimicrobial-impregnated central venous catheters (CVCs) for the prevention of CVC microbial colonization and catheter-related bloodstream infection (CRBSI) remains controversial. METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) evaluating CRBSI and colonization of CVCs impregnated with rifampicin-based antimicrobial combinations. Our main analysis compared the occurrence of CRBSI with rifampicin/minocycline-impregnated CVCs with that of non-rifampicin-impregnated CVCs. The PubMed and Cochrane Central Register of Controlled Trials databases were searched (until October 2006). RESULTS: Eight RCTs were included in the analysis. The main analysis (seven RCTs) demonstrated that rifampicin/minocycline-impregnated CVCs were associated with fewer CRBSIs compared with catheters not impregnated with rifampicin/minocycline (OR 0.23, 95% CI 0.14-0.40). The same was true regarding colonization (OR 0.46, 95% CI 0.31-0.69). Further analysis, comparing rifampicin-based CVCs with non-rifampicin-impregnated CVCs, demonstrated superiority of rifampicin-based CVCs in reducing colonization (OR 0.38, 95% CI 0.24-0.62) and CRBSI (OR 0.24, 95% CI 0.14-0.40). Similar results, suggesting superiority of rifampicin/minocycline-impregnated CVCs, were noted in a subgroup analysis of colonization and CRBSIs in which rifampicin/minocycline-impregnated CVCs were compared with simple, non-tunnelled, non-antimicrobially impregnated CVCs, a subgroup analysis that was performed by excluding low quality RCTs, and a subgroup analysis for colonization comprising studies in which the sonication technique was used. No serious adverse events and no difference in mortality between the two treatment groups were reported. No clear conclusions can be made regarding the impact of the use of rifampicin/minocycline-impregnated CVCs on the development of antimicrobial resistance based on the available data. CONCLUSIONS: The available evidence suggests that rifampicin/minocycline-impregnated CVCs are safe and effective in reducing the rate of catheter colonization and CRBSI. Further research should focus on the possible development of resistance and on pharmacoeconomic issues related to the use of rifampicin/minocycline-impregnated CVCs.     

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.     

Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients

OBJECTIVES: To evaluate a new silver-impregnated multi-lumen central venous catheter for reducing catheter-related colonization in intensive care patients. DESIGN: Multicenter, prospective, randomized, controlled clinical study. SETTING: Ten adult intensive care units (multidisciplinary, medical and surgical, university and nonuniversity hospitals) in eight institutions. PATIENTS: A total of 577 patients who required 617 multi-lumen central venous catheters between November 2002 and April 2004 were studied. INTERVENTIONS: Intensive care adult patients requiring multi-lumen central venous catheters expected to remain in place for >or=3 days were randomly assigned to undergo insertion of silver-impregnated catheters (silver group) or standard catheters (standard group). Catheter colonization was defined as the growth of >or=1,000 colony-forming units in culture of the intravascular tip of the catheter by the vortexing method. Diagnosis of catheter-related infection was performed by an independent and blinded expert committee. RESULTS: A total of 320 catheters were studied in the silver group and 297 in the standard group. Characteristics of the patients, insertion site, duration of catheterization (median, 11 vs. 10 days), and other risk factors for infection were similar in the two groups. Colonization of the catheter occurred in 47 (14.7%) vs. 36 (12.1%) catheters in the silver and the standard groups (p = .35), for an incidence of 11.2 and 9.4 per 1,000 catheter days, respectively. Catheter-related bloodstream infection was recorded in eight (2.5%) vs. eight (2.7%) catheters in the silver and the standard groups (p = .88), for an incidence of 1.9 and 2.1 per 1,000 catheter days, respectively. CONCLUSION: The use of silver-impregnated multi-lumen catheters in adult intensive care patients is not associated with a lower rate of colonization than the use of standard multi-lumen catheters.     

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.

     

重症监护病房患者深静脉血栓形成预防指南

重症监护病房(ICU)患者是深静脉血栓形成(DVT)的高发人群,在DVT的发生、预防和治疗等方面有着明显的特殊性.国内外对DVT的预防已有多个共识或指南,但目前尚缺少针对ICU患者DVT预防的指南.为此,中华医学会重症医学分会组织有关专家,经过广泛征求意见,采用循证医学的方法制定了本指南.     

Cefepime versus imipenem-cilastatin for treatment of nosocomial pneumonia in intensive care unit patients: a multicenter, evaluator-blind, prospective, randomized study

In a randomized, evaluator-blind, multicenter trial, we compared cefepime (2 g three times a day) with imipenem-cilastatin (500 mg four times a day) for the treatment of nosocomial pneumonia in 281 intensive care unit patients from 13 centers in six European countries. Of 209 patients eligible for per-protocol analysis of efficacy, favorable clinical responses were achieved in 76 of 108 (70%) patients treated with cefepime and 75 of 101 (74%) patients treated with imipenem-cilastatin. The 95% confidence interval (CI) for the difference between these response rates (-16 to 8%) failed to exclude the predefined lower limit for noninferiority of -15%. In addition, therapy of pneumonia caused by an organism producing an extended-spectrum beta-lactamase (ESBL) failed in 4 of 13 patients in the cefepime group but in none of 10 patients in the imipenem group. However, the clinical efficacies of both treatments appeared to be similar in a secondary intent-to-treat analysis (95% CI for difference, -9 to 14%) and a multivariate analysis (95% CI for odds ratio, 0.47 to 1.75). Furthermore, the all-cause 30-day mortality rates were 28 of 108 (26%) patients in the cefepime group and 19 of 101 (19%) patients in the imipenem group (P = 0.25). Rates of documented or presumed microbiological eradication of the causative organism were similar with cefepime (61%) and imipenem-cilastatin (54%) (95% CI, -23 to 8%). Primary or secondary resistance of Pseudomonas aeruginosa was detected in 19% of the patients treated with cefepime and 44% of the patients treated with imipenem-cilastatin (P = 0.05). Adverse events were reported in 71 of 138 (51%) and 62 of 141 (44%) patients eligible for safety analysis in the cefepime and imipenem groups, respectively (P = 0.23). Although the primary end point for this study does not exclude the possibility that cefepime was inferior to imipenem, some secondary analyses showed that the two regimens had comparable clinical and microbiological efficacies. Cefepime appeared to be less active against organisms producing an ESBL, but primary and secondary resistance to imipenem was more common for P. aeruginosa. Selection of a single agent for therapy of nosocomial pneumonia should be guided by local resistance patterns.     

A recruitment maneuver increases oxygenation after intubation of hypoxemic intensive care unit patients: a randomized controlled study

Introduction

Febrile neutropenia (FN) is common in cancer patients receiving myelotoxic therapy. The procedures to treat FN are well established in oncology, but it is unclear whether management is adequate in the emergency department (ED).

Methods

This prospective, multicentre, observational study was carried out in 47 French EDs for 6 months. Patients were adults presenting at the ED with FN after myelotoxic treatment for cancer. Severity of infection was defined according to Bone criteria for severe sepsis and septic shock (SS/SSh) and risk was determined according to Multinational Association of Supportive Care in Cancer (MASCC) criteria. The end point was the implementation of guidelines. Management of patients with SS/SSh required: (i) adequate intravenous (IV) antimicrobial therapy for the first 90 min (broad-spectrum beta-lactam with or without an aminoglycoside); (ii) fluid challenge (500 mL); (iii) lactate measurement; (iv) at least one blood culture; and (v) hospitalization. Management of patients without SS/SSh required: (1) no initiation of granulocyte - cell stimulating factor (G-CSF); (2) adequate IV antimicrobial therapy (broad-spectrum beta-lactam) and hospitalization if the patient was high-risk according to MASCC criteria; (3) adequate oral antimicrobial therapy (quinolone or amoxicillin/clavulanate or cephalosporin) and hospital discharge if the patient was low-risk.

Results

198 patients were enrolled; 89 patients had SS/SSh, of whom 19 received adequate antimicrobial therapy within 90 min and 42 received appropriate fluid challenge. Blood cultures were obtained from 87 and lactate concentration was measured in 29. Overall, only 6 (7%) patients with SS/SSh received adequate management. Among 108 patients without SS/SSh, 38 (35%) were high-risk and 70 (65%) low-risk. In the high-risk group, adequate antimicrobial therapy was given to 31 patients, G-CSF was initiated in 4 and 35 were hospitalized. In the low-risk group, 4 patients received adequate oral antimicrobial therapy, IV antimicrobial therapy was prescribed in 59, G-CSF was initiated in 12 and six patients were discharged. Adequate management was given to 26/38 (68%) high-risk and 1/70 low-risk patients. Factors associated with adequate management were absence of SS/SSh (P = 0.0009) and high-risk according to MASCC criteria (P < 0.0001).

Conclusions

In this French sample of cancer patients presenting to the ED with FN, management was often inadequate and severity was under-evaluated in the critically ill.     

Prevalence of infections in intensive care units in Mexico: a multicenter study

OBJECTIVE: To determine the 1-day prevalence of community-acquired, hospital-acquired, or intensive care unit (ICU)-acquired infections in Mexican ICUs. To identify associated risk factors, predominant infecting organisms, and mortality rates. DESIGN: A 1-day point-prevalence study. SETTING: A total of 254 adult ICUs in Mexico. PATIENTS: Adult patients hospitalized in the participating ICUs. RESULTS: A total of 895 patients were studied, of whom 521 patients (58.2%) were infected. Community-acquired infection occurred in 214 patients (23.9%), non-ICU nosocomial infection occurred in 99 patients (11.1%), and 208 patients had at least one ICU-acquired infection (23.2%; 1.45 episodes/patient). The most frequently reported ICU-acquired infections were pneumonia (39.7%), urinary tract infections (20.5%), wound infection (13.3%), and bacteremia (7.3%). The mortality rate for the ICU-acquired infections after 6 wks of follow-up was 25.5%. Multivariate regression analysis showed the following risk factors for ICU-acquired infections: neurologic failure as a primary cause of admission (odds ratio [OR], 1.697; 95% confidence interval [CI], 1.001-2.839); length of stay in ICU (OR, 1.119; 95% CI, 1.091-1.151); number of therapeutic and/or diagnostic interventions during the preceding week (OR, 1.118; 95% CI, 1.016-1.231); peripherally administered infusion of hyperosmolar solutions (OR, 6.93; 95% CI, 2.452-21.661); sedative usage in the preceding week (OR, 1.751; 95% CI, 1.183-2.602); history of an emergency surgery in the preceding month (OR, 1.875; 95% CI, 1.251-2.813). The administration of antimicrobial treatment if there was an infection decreased the risk of death (OR, 0.406; 95% CI, 0.204-0.755). CONCLUSIONS: Evidence of a high frequency of nosocomial infections was found, and potential risk factors for acquiring infections and mortality were identified. Mortality rates according to the hierarchy of the systemic inflammatory response syndrome in Latin American ICUs are reported.