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The epidemiology of severe infections is changing worldwide. As a result of many complex factors not limited to globalization of economies and increased travel, intensivists are increasingly challenged to manage patients with unusual etiologies and increased resistance profiles with the associated risk of treatment failure. While a comprehensive review of this area is beyond the scope of this series, this article aims to highlight some selected recent publications examining severe tropical viral diseases, early diagnosis of infection, and means to optimize therapies for infected patients admitted to the ICU.

The management of peritonitis in critically ill patients is becoming increasingly complex due to their changing characteristics and the growing prevalence of multidrug-resistant (MDR) bacteria. A multidisciplinary panel summarizes the latest advances in the therapeutic management of these critically ill patients. Appendicitis, cholecystitis and bowel perforation represent the majority of all community-acquired infections, while most cases of healthcare-associated infections occur following suture leaks and/or bowel perforation. The micro-organisms involved include a spectrum of Gram-positive and Gram-negative bacteria, as well as anaerobes and fungi. Healthcare-associated infections are associated with an increased likelihood of MDR pathogens. The key elements for success are early and optimal source control and adequate surgery and appropriate antibiotic therapy. Drainage, debridement, abdominal cleansing, irrigation, and control of the source of contamination are the major steps to ensure source control. In life-threatening situations, a "damage control" approach is the safest way to gain time and achieve stability. The initial empirical antiinfective therapy should be prescribed rapidly and must target all of the micro-organisms likely to be involved, including MDR bacteria and fungi, on the basis of the suspected risk factors. Dosage adjustment needs to be based on pharmacokinetic parameters. Supportive care includes pain management, optimization of ventilation, haemodynamic and fluid monitoring, improvement of renal function, nutrition and anticoagulation. The majority of patients with peritonitis develop complications, including worsening of pre-existing organ dysfunction, surgical complications and healthcare-associated infections. The probability of postoperative complications must be taken into account in the decision-making process prior to surgery.

Purpose: Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for patients with acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate associations between ventilatory settings during ECMO for refractory hypoxemia and outcome in ARDS patients. Methods: In this individual patient data meta-analysis of observational studies in adult ARDS patients receiving ECMO for refractory hypoxemia, a time-dependent frailty model was used to determine which ventilator settings in the first 3 days of ECMO had an independent association with in-hospital mortality. Results: Nine studies including 545 patients were included. Initiation of ECMO was accompanied by significant decreases in tidal volume size, positive end-expiratory pressure (PEEP), plateau pressure, and driving pressure (plateau pressure − PEEP) levels, and respiratory rate and minute ventilation, and resulted in higher PaO2/FiO2, higher arterial pH and lower PaCO2 levels. Higher age, male gender and lower body mass index were independently associated with mortality. Driving pressure was the only ventilatory parameter during ECMO that showed an independent association with in-hospital mortality [adjusted HR, 1.06 (95 % CI, 1.03–1.10)]. Conclusion: In this series of ARDS patients receiving ECMO for refractory hypoxemia, driving pressure during ECMO was the only ventilator setting that showed an independent association with in-hospital mortality. © 2016, Springer-Verlag Berlin Heidelberg and ESICM.

Purpose Microbiological diagnosis (MD) of infections remains insufficient. The resulting empirical antimicrobial therapy leads to multidrug resistance and inappropriate treatments. We therefore evaluated the cost-effectiveness of direct molecular detection of pathogens in blood for patients with severe sepsis (SES), febrile neutropenia (FN) and suspected infective endocarditis (SIE). Methods Patients were enrolled in a multicentre, open-label, cluster-randomised crossover trial conducted during two consecutive periods, randomly assigned as control period (CP; standard diagnostic workup) or intervention period (IP; additional testing with LightCycler®SeptiFast). Multilevel models used to account for clustering were stratified by clinical setting (SES, FN, SIE). Results A total of 1416 patients (907 SES, 440 FN, 69 SIE) were evaluated for the primary endpoint (rate of blood MD). For SES patients, the MD rate was higher during IP than during CP [42.6% (198/465) vs. 28.1% (125/442), odds ratio (OR) 1.89, 95% confidence interval (CI) 1.43–2.50; P

Dear Editor, Extracorporeal membrane oxygenation (ECMO) has a significant impact on intensive care unit (ICU) patient costs. Human resources are a major cost driver for ECMO in severe acute respiratory distress syndrome (ARDS) [1]. However, recent developments in ECMO technology has allowed safe patient management by a single caregiver [2–4]. In the present report, we analyze the direct ICU costs of patients with influenza A (H1N1)-related ARDS supported with miniaturized ECMO systems and managed by a single caregiver. We performed an observational study of all patients (n = 10) with H1N1-associated ARDS treated with ECMO in Hospital S. Joao (Porto, Portugal), between November 2009 and April 2011. The clinical data and ECMO treatment details of this ICU patient cohort have been described in a previous report [5]. Patients were admitted in medical ICUs and managed by a single caregiver using miniaturized ECMO circuits (Rotaflow Centrifugal Pump plus Quadrox PLS and CARDIOHELP; Maquet Cardiopulmonary AG). In our single caregiver model, the ICU nurse primarily managed the ECMO patient under the coordination of 24/7 inhouse ICU physicians, with the backup of an on-call ECMO specialist. Our multidisciplinary ECMO specialist team (ICU physicians, ICU nurses, and cardiovascular perfusionists) is responsible for managing equipment and supplies, circuit preparation, patient transportation, troubleshooting, daily rounds, education, and service administration. Per patient ICU direct costs were analyzed retrospectively from clinical records and hospital databases using both top-down and bottom-up approaches. Bottom-up analysis was performed for all drugs, transfusion requirements, laboratory and imagiology exams. Regarding disposable items, bottom-up analysis was possible for ECMO-specific disposables and for renal replacement therapies. Costs with human resources were assessed using the top-down approach. Specific ECMO costs were also individualized for each ICU episode: (1) disposables devices; (2) laboratory tests; (3) transfusion requirements; and (4) drugs. The Ethics Committee of the Hospital S. Joao approved this study and waived the need for patients’ informed consent. Variables are reported as median and interquartile ranges, if not otherwise indicated. The cost drivers of H1N1-related ARDS patients treated with miniaturized ECMO are presented in Table 1. ECMO support corresponded to 63.6 (62.5–88.5) % of the ICU length of stay (LOS). The ICU LOS positively correlated (r = 0.97; p \ 0.001) with ICU patient costs [42,721 (33,358–56,801) €], but not with specific ECMO costs [r = 0.17; p = 0.63; 7,516 (5,599–7,736) €]. ECMO-specific costs represented 17.6 (13.1–18.1) % of the total ICU direct costs, mostly ECMO disposable devices [94.8 (87.1–96.1) %]. Daily ICU costs with antibiotics, sedation, analgesia and neuromuscular blockade, fluids and nutrition, vasoactive drugs, anticoagulation medications, and other unspecific drugs were higher during the period of ECMO support compared with the period without ECMO support. In conclusion, the use of miniaturized ECMO had a small impact on direct ICU costs in our cohort of H1N1-related severe ARDS patients managed by a single caregiver and did not correlate with the ICU LOS. Knowledge of the incremental costs associated with miniaturized ECMO will contribute to the clarification of its cost-effectiveness in severe ARDS.

The recent increase in drug-resistant micro-organisms complicates the management of hospital-acquired bloodstream infections (HA-BSIs). We investigated the epidemiology of HA-BSI and evaluated the impact of drug resistance on outcomes of critically ill patients, controlling for patient characteristics and infection management. A prospective, multicentre non-representative cohort study was conducted in 162 intensive care units (ICUs) in 24 countries. We included 1,156 patients [mean ± standard deviation (SD) age, 59.5 ± 17.7 years; 65 % males; mean ± SD Simplified Acute Physiology Score (SAPS) II score, 50 ± 17] with HA-BSIs, of which 76 % were ICU-acquired. Median time to diagnosis was 14 [interquartile range (IQR), 7–26] days after hospital admission. Polymicrobial infections accounted for 12 % of cases. Among monomicrobial infections, 58.3 % were gram-negative, 32.8 % gram-positive, 7.8 % fungal and 1.2 % due to strict anaerobes. Overall, 629 (47.8 %) isolates were multidrug-resistant (MDR), including 270 (20.5 %) extensively resistant (XDR), and 5 (0.4 %) pan-drug-resistant (PDR). Micro-organism distribution and MDR occurrence varied significantly (p