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Biomedical subjects

J Rello

Publications and source records attributed to J Rello.

At least 91 records · Page 5Linked to original sources
PubMed1993

Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia.

OBJECTIVE: To define the influence of prior antibiotic use on the etiology and mortality of ventilator-associated pneumonia (VAP). SETTING: A university hospital medical-surgical ICU. DESIGN: Prospective clinical study. METHODS: Over a 35-month period, we prospectively studied 129 consecutive episodes of VAP. Etiologic diagnosis was established using a protected specimen brush and quantitative culture techniques. We examined prognostic factors by univariate and multivariate analyses using a statistical software package (SPSS). RESULTS: The rate of VAP caused by Gram-positive cocci or Haemophilus influenzae was statistically lower (p < 0.05) in the patients who had received antibiotics previously, while the rate of VAP caused by Pseudomonas aeruginosa was statistically higher (p < 0.01). Patients died of causes directly related to the infection in 18 (14.0 percent) episodes, P aeruginosa being isolated in 9 of these fatal cases. Indeed, we found that 27.7 percent (15/54) of patients who had received prior antimicrobial therapy before the onset of pneumonia died, compared with only 4.0 percent (3/75) of those who did not. In the univariate analysis, the variables significantly associated with attributable mortality were age older than 45 years, use of corticosteroids, presence of shock, hospital day of VAP over 9, antecedent COPD, and a prior antibiotic use. A step-forward logistic regression analysis defined only prior antibiotic use (p < 0.0001, OR = 9.2) as significantly influencing the risk of death from VAP. The same result was obtained when severity was included in the model. However, prior antibiotic use entirely dropped out as a significant risk factor when the etiologic agent was included in the regression equation. CONCLUSIONS: Distribution of infecting microorganisms responsible for VAP differs in patients who received prior antimicrobial therapy, and this factor determines a higher mortality rate. We suggest a restrictive antibiotic policy in mechanically ventilated patients with the purpose of reducing the risk of death from VAP.

Anti-Bacterial Agents↗
PubMed1992

Nosocomial respiratory tract infections in multiple trauma patients. Influence of level of consciousness with implications for therapy.

A prospective study of 161 multiple trauma patients was carried out to determine the incidence, the causative agents, and the outcome of nosocomial respiratory tract infections in this highly selected population. Thirty-eight (23.6 percent) patients developed a nosocomial pneumonia (NP). In addition, there were four superinfections in three patients, representing an incidence of 26 percent (42 of 161). Incidence of NP was significantly greater among comatose patients (42.2 vs 13.3 percent, p less than 0.05). Furthermore, purulent tracheobronchitis was diagnosed in six patients. The causative agent of NP was identified in 36 (85.7 percent) episodes by means of fiberoptic bronchoscopies with protected specimen brush sampling. Staphylococcus aureus (55.8 percent) was the predominant pathogen isolated in multiple trauma patients in coma (Glasgow coma score [GCS] below 9 during a period greater than 24 h), while aerobic Gram-negative bacilli were responsible for the majority of cases in the remaining population studied. The overall mortality rate was 19.8 percent, but only five deaths were related to NP. We conclude that nosocomial respiratory tract infections are a frequent problem in multiple trauma patients, especially in those with GCS below 9, although this complication is associated with a relatively low mortality. Among patients with GCS below 9, S aureus was a frequent finding; consequently, antimicrobial therapy in this population needs to be different than that for the remaining multiple trauma patients with NP.

Bacteria↗
PubMed1992

Pneumonia due to Haemophilus influenzae among mechanically ventilated patients. Incidence, outcome, and risk factors.

Incidence and potential risk factors for pneumonia due to Haemophilus influenzae in adults treated with mechanical ventilation in a medical-surgical ICU were investigated. Diagnosis was established in 91 episodes and H influenzae was isolated in 20 of them. Mean onset of ventilator-associated pneumonia (VAP) due to H influenzae was 10.8 days after intubation. Six patients with H influenzae VAP died in the ICU. Of 13 risk factors for developing VAP due to H influenzae, an absence of prior antibiotic treatment was the only variable which had statistical significance (p < 0.001). In these mechanically ventilated patients, Haemophilus influenzae was a common causative agent for VAP, frequently associated with Gram-positive cocci. Episodes of H influenzae VAP were associated with a lower mortality compared with other etiologies. The epidemiologic and clinical findings indicate that patients without a prior antimicrobial treatment have increased susceptibility to infections of the airway by H influenzae.

Adolescent↗
PubMed1992

[Septic shock: epidemiology and prognosis].

As part of an infection control program in ICU, we studied prospectively 1500 consecutive patients admitted to a medical and surgical ICU from January 1988 to July 1990. Over this period of time, 69 patients developed septic shock, and 38 of them died (55.1%). Primary source of infection was the lower respiratory tract or intraabdominal in more than 50% of cases, and were related to a high mortality rate, however SS arising from a biliary tract infection is associated with a mortality rate below 20%. In the univariate analysis, nosocomial origin (p = 0.0001), creatinine serum level > 175 mumol/l (p = 0.005), multiple organ failure in the first 24 hours after shock started (p = 0.02), underlying cancer disease (p = 0.02) or liver cirrhosis (p = 0.03) were associated with a statistically significant higher risk for dying. No differences were found regarding age, sex, admission date, coma, recent surgery, prior cardiac arrest, diabetes, organ transplantation, corticosteroid therapy, cancer chemotherapy, absence of fever, bacteriology of the infection and appropriate antibiotic therapy. The multivariate analysis further identified that creatinine serum level > 175 mumol/l (p = 0.004), underlying cancer disease (p = 0.005), liver cirrhosis (p = 0.02) and nosocomial-acquired infection (p = 0.02) were independently associated to a higher risk for dying. These data allows the identification of factors related to a worst outcome. The high mortality rates recorded for septic shock still recommends the rapid transfer of the patient to an ICU as well as the use of aggressive therapy in all cases.

Cross Infection↗
PubMed1992

Nosocomial pneumonia in critically ill comatose patients: need for a differential therapeutic approach.

The purpose of this prospective clinical study was to determine the incidence, bacteriology and outcome of lower respiratory tract infections developed among 208 consecutive, critically ill comatose patients, hospitalized in a university hospital, medical-surgical intensive care unit, over a three year period. Nosocomial pneumonia developed in 53 (25%) patients after a mean of 8.1 days (range 3-31 days). Furthermore, there were five superinfections, raising the mean incidence to 28%. One patient developed secondary bacteraemia, and another two had septic shock. Fifteen (28%) patients from the pneumonia group died, and six of these deaths were considered to be directly related to nosocomial pneumonia. Identification of the causative agent, using the protected specimen brush technique, was possible in 42 episodes; in 10 (24%) of these cases more than one microorganism was isolated. Gram-positive cocci represented 53% of isolates, and Staphylococcus aureus accounted for 78% of all Gram-positive cocci, being the most frequent microorganism in this population. In conclusion, nosocomial pneumonia is a common complication of critically ill comatose patients. Its characteristic aetiological spectrum in this population should affect antibiotic prescription. Consequently, we suggest including antimicrobial drugs which are active against S. aureus in the empirical regimen until aetiological diagnosis is established.

Anti-Bacterial Agents↗
PubMed1991

[Protected bronchoalveolar lavage: a new endoscopic method in the diagnosis of bacterial pneumonia].

BACKGROUND: The identification of causative microoganisms in severe pneumonias is a usually difficult problem. Protected brushing (PB) has a good specificity but a limited sensitivity. Conventional bronchoalveolar lavage (BAL-C) has an excellent sensitivity but a doubtful specificity. The investigation of a new technique such as the protected bronchoalveolar lavage (BAL-P) appears as logical, as it should combine the advantages of PB and BAL-C without their drawbacks. METHODS: In 15 patients without bacterial or fungal infections and in 23 with bacterial or fungal pneumonia, quantitative cultures were carried out in the samples obtained with PB, BAL-P and BAL-C. PB and BAL-C were performed with the usual technique. BAL-P was performed through the internal catheter of a telescoped double catheter with reabsorbable distal cap within the fibroscope channel. 40 ml of saline were instillated for the lavage. RESULTS: With BAL-P sensitivity was 95% and specificity 89%. These were, respectively, 55% and 94% with PB, and 95% and 42% with BAL-C. The technique of BAL-P was more complex an longer than that of PB. CONCLUSIONS: If these results are confirmed in further studies, BAL-P might become a method of choice for the bacterial pneumonias where now PB is indicated. However, in patients with hypersecretion or when bronchoscopy should be rapidly carried out, PB is technically more feasible.

Bacterial Infections↗
PubMed1991

Incidence, etiology, and outcome of nosocomial pneumonia in mechanically ventilated patients.

This study assessed the incidence, etiology, and consequences of ventilator-associated pneumonia in 1,000 consecutive patients admitted in a medical-surgical intensive care unit (ICU). A total of 264 patients were submitted to mechanical ventilation (MV) for more than 48 hours. Fifty-eight (21.9 percent) patients developed a bacterial pneumonia after a mean of 7.9 days (range, 2 to 40 days) of MV. In addition, they were ten superinfections in nine patients, raising the mean incidence to 25.7 percent. Five patients developed secondary bacteremia, and another five had septic shock. Identification of the causative agent of pneumonia was possible in 47 episodes by means of highly specific techniques (telescoping plugged catheter, blood cultures, and/or necropsy). Thirteen (27.6 percent) of these cases were polymicrobial. The predominant pathogens isolated in the first episode of pneumonia were Gram-negative bacilli (62.6 percent), but a high incidence of Staphylococcus aureus infection (23.2 percent) was detected. Gram-negative bacilli represented 66.6 percent of the total organisms isolated in superinfections. The mortality rate in the pneumonia group was 42 percent; this percentage is similar to mortality rate among MV patients without pneumonia (37 percent). We conclude that nosocomial pneumonia is a frequent complication of MV in the medical-surgical ICU. Ventilator-associated pneumonia does not appear to increase fatality in critically ill patients with a high mortality rate (38 percent); however, it significantly prolongs the length of stay in the ICU for survivors.

Bacteria↗
PubMed1991

Laboratory diagnosis of catheter-related bacteremia.

Semiquantitative culture of the external surface of catheter tips has become the currently most used method to detect catheter colonisation and catheter-related bacteremia; however, this method may fail to detect significant colonisation of the internal lumen of catheters, and several quantitative methods have been described for this purpose. Although 15 and 1000 CFU are used to define positive catheters, the sensitivity and specificity are not yet well known, and the definitive cut-off level for a positive result remains to be established. We studied prospectively 91 intravascular catheter tips removed because a catheter-related infection was suspected. The result of external and internal cultures with different cut-off levels, alone or combined, were correlated with clinical data in 22 bacteremic episodes which occurred in these patients, 12 of which were catheter-related. The semiquantitative culture of the external surface alone with a cut-off level of 25 CFU provided the best means of detecting catheter-related bacteremia. This method has 100% sensitivity and 81.1% specificity. We conclude that semiquantitative culture technique of the catheter tip alone is sufficient and this method should be employed for diagnosing catheter-related bacteremia in unselected populations.

Bacteremia↗
PubMed1991

Evaluation of different catheter parts for identification of pulmonary artery catheter colonisation.

A prospective study was conducted over 18 months to evaluate the accuracy of the semiquantitative culture technique performed from different catheter parts for detection of catheter colonisation in critically ill patients with pulmonary artery catheters. Semiquantitative culture of the tip catheter segment alone detected 66% of catheter colonisations. Semiquantitative culture of the other intravascular catheter segments (atrial or intradermal) provided similar yield. A combination of intradermal and atrial or tip catheter segment cultures provided the best means of detecting catheter colonisation.

Bacteria↗
PubMed1991

[Value of studying the extraluminal and intraluminal surfaces in the detection of catheter colonization].

612 catheters have been prospectively investigated. In all of them, both the external and the internal surfaces were cultured, the former with the semiquantitative technique of Maki and the latter with the semiquantitative technique of Liñares. 102 of the 469 central venous catheters (22%), 21 of 70 catheters used for parenteral nutrition (30%), and 19 of the 73 arterial catheters (26%) were positive with one or both techniques. The external surface was positive in 95% of central venous catheters, in 90% of the parenteral nutrition catheters, and in 95% of the arterial catheters, whereas the internal surface was positive in only 59%, 62% and 42%, respectively. The routine study of the internal surface of the catheters does not appear as justified. In our opinion, the microbiological study of catheters should be individualized depending on the relative importance of the skin or the connections in a particular catheter type. The quantitative study of the intraluminal surface should only be carried out in those catheters where connections represent a significant pathogenetical route. These catheters constitute only a small proportion of those that we receive for culture in the Microbiology Laboratory; therefore, this approach represents a considerable simplification of our daily routine.

Bacteria↗