Search

Introduction and objectives Mortality remains high in cardiogenic shock (CS), especially in refractory CS involving the use of mechanical circulatory support (MCS) devices. The aim of this study was to analyze the results of a care program for patients in CS after the creation of a multidisciplinary team in our center and a regional network of hospitals in our area. Methods Observational and retrospective study of patients attended in this program from September 2014 to January 2019. We included patients in refractory CS who required MCS and those who, because of their age and absence of comorbidities, were candidates for advanced therapies. The primary endpoint was survival to discharge. Results A total of 130 patients were included (69 local and 61 transferred patients). The mean age was 52 ± 15 years (72% men). The most frequent causes of CS were acute decompensated heart failure (29%), acute myocardial infarction (26%), and postcardiotomy CS (25%). MCS was used in 105 patients (81%), mostly extracorporeal membrane oxygenation (58%). Survival to discharge was 57% (74 of 130 patients). The most frequent destinations were myocardial recovery and heart transplant. Independent predictors of in-hospital mortality were SAPS II score, lactate level, acute myocardial infarction etiology, and vasoactive-inotropic score. Conclusions The creation of multidisciplinary teams for patients with mainly refractory CS and a regional network is feasible and allows survival to discharge in more than a half of attended patients with CS.

RESUMEN Objetivo Evaluar la utilidad del índice CD64 en granulocitos como marcador de infección en pacientes con fiebre postoperatoria. Métodos Estudio observacional prospectivo de una cohorte de pacientes con fiebre postoperatoria (2º-21º día tras la intervención) recogida durante 14 meses. Obtención de muestras sanguíneas durante las primeras 24 horas tras el pico febril para determinar el índice CD64 (ratio de la intensidad de fluorescencia, medido por citometría de flujo, en los granulocitos del paciente respecto a los controles sanos), procalcitonina y proteína C reactiva (PCR). Resultados Durante el período de estudio se incluyeron 50 pacientes, 28 pacientes (56%) con infección y 22 pacientes (44%) sin evidencia de infección. La PCR, procalcitonina y el índice CD64 mostraron valores significativamente más elevados en el grupo de pacientes que padecieron infección. El índice CD64 demostró tener una sensibilidad del 88,9%, con una especificidad de 65,2%. El valor predictivo positivo (VPP) fue 75% y el valor predictivo negativo (VPN) de 83,3%, con un área bajo la curva (ABC) de 0,805 (IC 95% 0,68-0,93). La procalcitonina, presentó una sensibilidad de 53,9% y especificidad de 86,4%, con VPN y VPP de 82,4% y 61,3% respectivamente, con ABC de 0,752 (IC 95% 0,61- 0,89). En cuanto a la PCR mostró una sensibilidad del 100%, con especificidad de 4,4% con un área bajo la curva de 0,676 (IC 95% 0,52- 0,83). Conclusiones La cuantificación del índice CD64 en pacientes que desarrollan fiebre en el postoperatorio precoz resulta de utilidad para distinguir fenómenos inflamatorios postquirúrgicos de episodios de infección establecida.

This study aimed to assess the efficacy of ceftolozane-tazobactam (C/T) for treating infections due to Pseudomonas aeruginosa (P. aeruginosa) in critically ill patients.A multicenter, retrospective and observational study was conducted in critically ill patients receiving different C/T dosages and antibiotic combinations for P. aeruginosa infections. Demographic data, localisation and severity of infection, clinical and microbiological outcome, and mortality were evaluated.Ninety-five patients received C/T for P. aeruginosa serious infections. The main infections were nosocomial pneumonia (56.2%), intra-abdominal infection (10.5%), tracheobronchitis (8.4%), and urinary tract infection (6.3%). Most infections were complicated with sepsis (49.5%) or septic shock (45.3%), and bacteraemia (10.5%). Forty-six episodes were treated with high-dose C/T (3 g every 8 hours) and 38 episodes were treated with standard dosage (1.5 g every 8 hours). Almost half (44.2%) of the patients were treated with C/T monotherapy, and the remaining group received combination therapy with other antibiotics. Sixty-eight (71.6%) patients presented a favourable clinical response. Microbiological eradication was documented in 42.1% (40/95) of the episodes. The global ICU mortality was 36.5%. Univariate analysis showed that 30-day mortality was significantly associated (P0.05) with Charlson Index at ICU admission and the need of life-supporting therapies.C/T appeared to be an effective therapy for severe infections due to P. aeruginosa in critically ill patients. Mortality was mainly related to the severity of the infection. No benefit was observed with high-dose C/T or combination therapy with other antibiotics.

In this outbreak, 12 patients in intensive care units acquired a Chryseobacterium indologenes infection. Cultures from sinkholes and air samples were positive for C. indologenes. After removing wash basins, no new cases appeared. Sinkholes, potentially contaminated, can act as a reservoir for C. indologenes and other microorganisms. Thus, patients and equipment should be protected from sink splashes to avoid contamination.

Background Infections and primary graft dysfunction are devastating complications in the immediate postoperative period following lung transplantation. Nowadays, reliable diagnostic tools are not available. Biomarkers could improve early infection diagnosis. Methods Multicentre prospective observational study that included all centres authorized to perform lung transplantation in Spain. Lung infection and/or primary graft dysfunction presentation during study period (first postoperative week) was determined. Biomarkers were measured on ICU admission and daily till ICU discharge or for the following 6 consecutive postoperative days. Results We included 233 patients. Median PCT levels were significantly lower in patients with no infection than in patients with Infection on all follow up days. PCT levels were similar for PGD grades 1 and 2 and increased significantly in grade 3. CRP levels were similar in all groups, and no significant differences were observed at any study time point. In the absence of PGD grade 3, PCT levels above median (0.50 ng/ml on admission or 1.17 ng/ml on day 1) were significantly associated with more than two- and three-fold increase in the risk of infection (adjusted Odds Ratio 2.37, 95% confidence interval 1.06 to 5.30 and 3.44, 95% confidence interval 1.52 to 7.78, respectively). Conclusions In the absence of severe primary graft dysfunction, procalcitonin can be useful in detecting infections during the first postoperative week. PGD grade 3 significantly increases PCT levels and interferes with the capacity of PCT as a marker of infection. PCT was superior to CRP in the diagnosis of infection during the study period.

Echinocandins are first-line therapy in critically ill patients with invasive Candida infection (ICI). This study describes our experience with micafungin at Surgical Critical Care Units (SCCUs).A multicenter, observational, retrospective study was performed (12 SCCUs) by reviewing all adult patients receiving 100 mg/24h micafungin for ≥72h during ad-mission (April 2011-July 2013). Patients were divided by ICI category (possible, probable + proven), 24h-SOFA (7, ≥7) and outcome.72 patients were included (29 possible, 13 probable, 30 proven ICI). Forty patients (55.6%) presented SOFA ≥7. Up to 78.0% patients were admitted after urgent surgery (64.3% with SOFA7 vs. 90.3% with SOFA ≥7, p=0.016), and 84.7% presented septic shock. In 66.7% the site of infection was intraabdominal. Forty-nine isolates were recovered (51.0% C. albicans). Treatment was empirical (59.7%), microbiologically directed (19.4%), rescue therapy (15.3%), or anticipated therapy and prophylaxis (2.8% each). Empirical treatment was more frequent (p0.001) in possible versus probable + proven ICI (86.2% vs. 41.9%). Treatment (median) was longer (p=0.002) in probable + proven versus possible ICI (13.0 vs. 8.0 days). Favorable response was 86.1%, without differences by group. Age, blood Candida isolation, rescue therapy, final MELD value and %MELD variation were significantly higher in patients with non-favorable response. In the multivariate analysis (R2=0.246, p0.001) non-favorable response was associated with positive %MELD variations (OR=15.445, 95%CI= 2.529-94.308, p=0.003) and blood Candida isolation (OR=11.409, 95%CI=1.843-70.634, p=0.009).High favorable response was obtained, with blood Candida isolation associated with non-favorable response, in this series with high percentage of patients with intraabdominal ICI, septic shock and microbiological criteria for ICI.

Lung-graft loss is a potential problem for the majority of lung-transplant recipients. Retransplantation could be a treatment option, despite significant morbidity and mortality due to infectious complications. The epidemiology, clinical presentation and early treatment are still the basis of the overall approach to the fungal invasive infection after repeated transplant.This is the case of a 29 year-old woman who underwent a left lung retransplantation due to bronchiolitis obliterans syndrome and developed Candida albicans invasive disease. She received the usual prophylaxis with nebulized liposomal amphotericin B and was also treated with anidulafungin. She received corticosteroid therapy and plasma exchange as acute lung transplant rejection was suspected with subsequent progressive deterioration and death. In the culture of blood samples yeasts were isolated, later identified as C. albicans resistant to fluconazole, caspofungin and micafungin (MCI 128 μg/ml, 8 μg/ml, 4 μg/ml, respectively) and susceptible to anidulafungin and amphotericin B (MCI 0.25 μg/ml, 0.5 μg/ml, respectively).The empirical management of acute transplant rejection with corticosteroid boluses and plasma exchange can help to spread the underlying and undiagnosed fungal infection. It is considered that an increase in the regular dose of anidulafungin is necessary after plasma exchange. To date, fungal echinocandin resistance did not seem to be a major cause for concern in the treatment of patients with invasive mycoses. However, there is increasing evidence of natural and acquired resistance resulting in life-threatening infections and clinical failure.