Medical imaging and timely diagnosis of invasive pulmonary aspergillosis.
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Aspergillosis↗
Biomedical subjects
Koenraad H Vandewoude
Publications and source records attributed to Koenraad H Vandewoude.
Invasive devices: no need? No use!
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Cross Infection↗
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.
Anti-Bacterial Agents↗
Invasive aspergillosis in immunocompetent patients.
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Aspergillosis↗
Clinical relevance of Aspergillus isolation from respiratory tract samples in critically ill patients.
INTRODUCTION: The diagnosis of invasive pulmonary aspergillosis, according to the criteria as defined by the European Organisation for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG), is difficult to establish in critically ill patients. The aim of this study is to address the clinical significance of isolation of Aspergillus spp. from lower respiratory tract samples in critically ill patients on the basis of medical and radiological files using an adapted diagnostic algorithm to discriminate proven and probable invasive pulmonary aspergillosis from Aspergillus colonisation. METHODS: Using a historical cohort (January 1997 to December 2003), all critically ill patients with respiratory tract samples positive for Aspergillus were studied. In comparison to the EORTC/MSG criteria, a different appreciation was given to radiological features and microbiological data, including semiquantitative cultures and direct microscopic examination of broncho-alveolar lavage samples. RESULTS: Over a 7 year period, 172 patients were identified with a positive culture. Of these, 83 patients were classified as invasive aspergillosis. In 50 of these patients (60%), no high risk predisposing conditions (neutropenia, hematologic cancer and stem cell or bone marrow transplantation) were found. Typical radiological imaging (halo and air-crescent sign) occurred in only 5% of patients. In 26 patients, histological examination either by ante-mortem lung biopsy (n = 10) or necropsy (n = 16) was performed, allowing a rough estimation of the predictive value of the diagnostic algorithm. In all patients with histology, all cases of clinical probable pulmonary aspergillosis were confirmed (n = 17). Conversely, all cases classified as colonisation had negative histology (n = 9). CONCLUSION: A respiratory tract sample positive for Aspergillus spp. in the critically ill should always prompt further diagnostic assessment, even in the absence of the typical hematological and immunological host risk factors. In a minority of patients, the value of the clinical diagnostic algorithm was confirmed by histological findings, supporting its predictive value. The proposed diagnostic algorithm needs prospective validation.
Aged↗
Outcome in severely ill patients with hematological malignancies who received intravenous chemotherapy in the intensive care unit.
OBJECTIVE: To assess the outcome in severely ill patients with hematological malignancies who receive intravenous chemotherapy in an intensive care unit (ICU) for a life-threatening malignancy-related complication. DESIGN: Retrospective observational study of prospectively collected data. PATIENTS: All 37 critically ill patients with hematological malignancies who received intravenous chemotherapy in the ICU between January 1997 and March 2005 (mean age 46+/-19 years; mean APACHE II 23+/-7). MEASUREMENTS AND RESULTS: Thirty-seven (69%) patients received chemotherapy because of extensive disease with organ involvement (54%), extensive disease without organ involvement (19%), severe disseminated intravascular coagulation (11%), and other reasons (16%). In 41% there was concomitant infection when chemotherapy was initiated, in 86% a high-grade malignancy, and 30% relapsing disease. Twenty-three (62%) patients received mechanical ventilation at the moment of or soon after initiation of chemotherapy for a median duration of 5 days (1-67), and 24% underwent renal replacement therapy during ICU stay. Only ventilation was associated with in-hospital mortality (odds ratio 9.3). ICU, in-hospital, and 6-month mortality rates in nonventilated vs. ventilated patients were 7% and 48%, 14% and 61%, and 54% and 74%, respectively. CONCLUSIONS: Starting chemotherapy in the ICU for a life-threatening malignancy related complication can be lifesaving even when infection or organ failure is present.
Adolescent↗
Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections.
BACKGROUND: Central venous catheters are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk, potentially leading to increased mortality and costs. We evaluate clinical and economic outcomes associated with nosocomial central venous catheter-related bloodstream infection (CR-BSI) in intensive care unit (ICU) patients. METHODS: A retrospective (1992-2002), pairwise-matched (ratio of case patients to control subjects, 1:2 or 1:1), risk-adjusted cohort study was performed at a 54-bed general ICU at a university hospital. ICU patients with microbiologically documented CR-BSI (n = 176) were matched with control subjects (n = 315) on the basis of disease severity, diagnostic category, and length of ICU stay (equivalent or longer) before the onset of CR-BSI in the index case patient. Clinical outcome was principally evaluated by in-hospital mortality. Economic outcome was evaluated on the basis of duration of mechanical ventilation, length of ICU and hospital stays, and total hospital costs, as derived from the patient's hospital invoices. RESULTS: The attributable mortality rate for CR-BSI was estimated to be 1.8% (95% confidence interval, -6.4% to 10.0%); in-hospital mortality rates for patients with CR-BSI and matched control subjects were 27.8% and 26.0%, respectively. CR-BSI was associated with significant excesses in duration of mechanical ventilation, duration of ICU and hospital stays, and a significant increase in total hospital cost. Linear regression analysis with adjustment for duration of hospitalization and clinical covariates, revealed that CR-BSI is independently associated with higher costs. CONCLUSIONS: In ICU patients, CR-BSI does not result in increased mortality. It is, however, associated with a significant economic burden, emphasizing the importance of continuous efforts in prevention.
Adult↗
Outcome and changes over time in survival following severe burns from 1985 to 2004.
OBJECTIVE: To investigate outcome in severely burned patients over a 20-year period and to evaluate survival over time. DESIGN AND SETTING: Historical cohort in a six-bed burn unit of a 1060-bed university hospital. PATIENTS: 1385 patients admitted to the burn unit over a 20-year period. MEASUREMENTS AND RESULTS: Outcome was evaluated in relation to the presence of three major risk factors for death: age 60 years or over, total burned surface area 40% or more, and the presence of inhalation injury. Overall mortality was 7.1%. When zero, one, two, or three risk factors were present, mortality was respectively 0.5%, 9.9%, 48.0%, and 90.5%. Over the study period the average proportional total burned surface area decreased as did mortality. The survival benefit was significant among patient groups with one or two risk factors present. Multivariate regression analysis adjusting for risk factors for death confirmed that survival improved over time (odds ratio 0.73 per 5-year period). CONCLUSIONS: Global mortality following burns is low, and nearly all patients who die had at least one risk factor present. In the presence of three risk factors the prognosis following burns is particularly compromised. Taking into account that our patients over the past 20 years have been progressively less extensively burned and hence have a lesser at risk for death, survival following severe burns has continued to improve.
Adolescent↗
Documented and clinically suspected bacterial infection precipitating intensive care unit admission in patients with hematological malignancies: impact on outcome.
OBJECTIVE: To assess the impact of documented and clinically suspected bacterial infection precipitating ICU admission on in-hospital mortality in patients with hematological malignancies. DESIGN AND SETTING: Prospective observational study in a 14-bed medical ICU at a tertiary university hospital. PATIENTS: A total of 172 consecutive patients with hematological malignancies admitted to the ICU for a life-threatening complication over a 4-year period were categorized into three main groups according to their admission diagnosis (documented bacterial infection, clinically suspected bacterial infection, nonbacterial complications) by an independent panel of three physicians blinded to the patient's outcome and C-reactive protein levels. RESULTS: In-hospital and 6-months mortality rates in documented bacterial infection (n=42), clinically suspected bacterial infection (n=40) vs. nonbacterial complications (n=90) were 50.0% and 42.5% vs. 65.6% (p=0.09 and 0.02) and 56.1% and 48.7% vs. 72.1% (p=0.11 and 0.02), respectively. Median baseline C-reactive protein levels in the first two groups were 23 mg/dl and 21.5 mg/dl vs. 10.7 mg/dl (p<0.001 and p=0.001) respectively. After adjustment for the severity of critical and underlying hematological illness and the duration of hospitalization before admission documented (OR 0.20; 95% CI 0.06-0.62, p=0.006) and clinically suspected bacterial infection (OR 0.18; 95% CI 0.06-0.53, p=0.002) were associated with a more favorable outcome than nonbacterial complications. CONCLUSIONS: Severely ill patients with hematological malignancies admitted to the ICU because of documented or clinically suspected bacterial infection have a better outcome than those admitted with nonbacterial complications. These patients should receive advanced life-supporting therapy for an appropriate period of time.
Adult↗
Outcome in critically ill medical patients treated with renal replacement therapy for acute renal failure: comparison between patients with and those without haematological malignancies.
BACKGROUND: Starting renal replacement therapy (RRT) for acute renal failure in critically ill patients with haematological malignancies is controversial because of the poor outcome and high costs. The aim of this study was to compare the outcome between critically ill medical patients with and without haematological malignancies who received RRT for acute renal failure. METHODS: We retrospectively collected data on all consecutive patients who received RRT for acute renal failure at the Medical Intensive Care Unit (ICU) of a University Hospital between 1997 and 2002, and assessed the impact of the presence of a haematological malignancy on the survival within 6 months after ICU admission by Cox proportional hazard models. RESULTS: Fifty of the 222 (22.5%) consecutive patients with haematological malignancies admitted to the ICU over the study period received RRT for acute renal failure compared with 248 of the 4293 (5.8%) patients without haematological malignancies (P<0.001). Among patients who received RRT, those with haematological malignancies had higher crude ICU (79.6 vs 55.7%, P=0.002) and in-hospital (83.7 vs 66.1%, P=0.016) mortality rates, and a higher mortality at 6 months (86 vs 72%, P=0.018) by Kaplan-Meier estimates compared with those without haematological malignancies. However, after adjustment for the severity of illness and the duration of hospitalization before ICU admission, haematological malignancy by itself was no longer associated with a higher risk of death (hazard ratio 1.04; 95% confidence interval, 0.73-1.54, P=0.78). CONCLUSIONS: Medical ICU patients with haematological malignancies have a higher rate of occurrence of acute renal failure treated with RRT and a higher mortality, compared with those without haematological malignancies. However, the presence of a haematological malignancy by itself is not a reason to withhold RRT in medical ICU patients with acute renal failure.
Acute Kidney Injury↗
Outcome in noninvasively and invasively ventilated hematologic patients with acute respiratory failure.
STUDY OBJECTIVES: The survival rate of patients with a hematologic malignancy requiring mechanical ventilation (MV) in the ICU has improved over the last few decades. The objective of this study was to identify the factors affecting the in-hospital mortality of these particular patients, and to assess whether the use of noninvasive positive pressure ventilation (NPPV) was protective in our study population. DESIGN: We retrospectively collected variables in 166 consecutive patients with hematologic malignancies who had acute respiratory failure (ARF) requiring MV, and identified factors obtained within 24 h of ICU admission affecting in-hospital mortality in univariate and multivariate stepwise logistic regression analyses. The effect of NPPV on mortality was assessed using a pair-wise matched exposed-unexposed analysis. RESULTS: The mean simplified acute physiology score (SAPS) II was 58.9. The in-hospital mortality rate was 71%. In a multivariate logistic regression analysis, the in-hospital mortality rate was predicted by increasing severity of illness, as measured by SAPS II (odds ratio [OR] per point of increase, 1.07; 95% confidence interval [CI], 1.04 to 1.11) and a diagnosis of acute myelogenous leukemia (OR, 2.73; 95% CI, 1.05 to 7.11). Female sex (OR, 0.36; 95% CI, 0.16 to 0.82), endotracheal intubation (ETI) within 24 h of ICU admission (OR, 0.29; 95% CI, 0.11 to 0.78), and recent bacteremia (defined as blood cultures positive for bacteria < 48h before or < 24h after ICU admission) [OR, 0.22; 95% CI, 0.08 to 0.61] were associated with a lower mortality rate. Twenty-seven patients who received NPPV were matched for SAPS II (+/- 3) with 52 patients who required immediate ETI on a 1:2 basis. The crude in-hospital mortality rate was 65.4% in both groups. CONCLUSION: Although the in-hospital mortality rate in hematologic patients who develop ARF remains high, the reluctance to intubate and start treatment with invasive MV in this population is unjustified, especially when bacteremia has precipitated ICU admission.
Acute Disease↗
Estimates of attributable mortality of systemic candida infection in the ICU.
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Antifungal Agents↗
Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication.
OBJECTIVES: To assess the outcome and to identify early prognostic indicators in a global population of patients with hematologic malignancy admitted to the intensive care unit for a life-threatening complication. DESIGN: Retrospective observational study. SETTING: Medical intensive care unit at a tertiary university hospital. PATIENTS: A total of 124 consecutive critically ill patients with a hematologic malignancy admitted to the intensive care unit during a 3.5-yr period. MEASUREMENTS We collected variables at admission and during admission and identified predictors of in-hospital mortality by stepwise logistic regression analysis. MAIN RESULTS: Mean Acute Physiology and Chronic Health Evaluation II score was 26 +/- 7.7. Sixty-one percent had a high-grade malignancy, and 27% had active disease. Thirty-five percent were leukopenic (leukocyte count, <1.0 x 10(9)/L) at admission. Respiratory failure (48%), sepsis (18.5%), and neurologic impairment (17%) were the major reasons for admission at the intensive care unit. Seventy-one percent of the patients required ventilatory support for a median duration of 6 (3-17) days, 46% received vasopressors at admission, and 26.6% needed renal replacement therapy during their intensive care unit stay. A recent bacteremia precipitating intensive care unit admission was found in 21.8% of the patients. Crude intensive care unit, in-hospital, and 6-month mortality rates were 42%, 54%, and 66%, respectively. Four variables were independently associated with outcome in a multivariate logistic regression analysis: leukopenia (odds ratio, 2.9; 95% confidence interval, 1.1-7.7), vasopressors (odds ratio, 3.74; 95% confidence interval, 1.4-9.8), and urea of >0.75 g/L (>12 mmol/L) (odds ratio, 9.4; 95% confidence interval, 4.2-26) at admission were associated with poor outcome, whereas recent bacteremia (odds ratio, 0.17; 95% confidence interval, 0.05-0.58) was associated with better prognosis. Using these variables, we arbitrarily categorized our population into three groups for survival analysis: a low-risk group (low urea with or without either leukopenia or vasopressors, n = 60), an intermediate-risk group (high urea or a combination of leukopenia and vasopressors, n = 34), and a high-risk group (high urea in combination with leukopenia or vasopressors, n = 27). Patients with a bacteremia prompting intensive care unit admission were allocated to a one-step-lower risk group. Survival probabilities at 30 days and 6 months were 75% and 55% in the first group, 35% and 21% in the second group, and 4% and 0%, respectively, in the third group ( <.001). CONCLUSION: The general reluctance to admit patients with a hematologic malignancy to the intensive care unit, even with severe critical illness, is unjustified. However, we identified four early predictors of outcome that may be of value in deciding in which patients advanced or prolonged support should not be continued.
Adult↗
Evaluation of outcome in critically ill patients with nosocomial enterobacter bacteremia: results of a matched cohort study.
STUDY OBJECTIVE: To evaluate the clinical impact of nosocomial Enterobacter bacteremia in critically ill patients. DESIGN: Retrospective (January 1992 to December 2000) matched cohort study. SETTING: Fifty-four-bed ICU (including medical, surgical, cardiosurgical ICU, and burns unit) from a university hospital. PATIENTS: Sixty-seven ICU patients with Enterobacter bacteremia (case patients) and 134 control patients. INTERVENTION: Matching of control patients (1:2 ratio) was on the basis of the APACHE (acute physiology and chronic health evaluation) II system. As expected, mortality can be derived from this severity-of-disease classification system; this matching procedure results in an equal expected mortality rate for patients with Enterobacter bacteremia and control patients. RESULTS: The overall rate of appropriate antibiotic therapy in patients with Enterobacter bacteremia was high (96%) and initiated soon after the onset of the bacteremia (0.5 +/- 0.9 days). Patients with Enterobacter bacteremia had more hemodynamic instability (p = 0.015), longer ICU stay (p < 0.001), and ventilator dependence (p < 0.001). No differences between case and control patients were found in age (52 years vs 53 years, p = 0.831), prevalence of acute renal failure (16% vs 16%, p = 0.892), and acute respiratory failure (93% vs 84%, respectively; p = 0.079). In-hospital mortality rates for case and control patients were not different (34% vs 39%, respectively; p = 0.536). CONCLUSION: After accurate adjustment for severity of underlying disease and acute illness, no difference was found between ICU patients with Enterobacter bacteremia and matched control patients. In the presence of fast and appropriate antibiotic therapy, Enterobacter bacteremia does not adversely affect the outcome in ICU patients.
APACHE↗
Outcome and attributable mortality in critically Ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus.
BACKGROUND: Staphylococcus aureus bacteremia carries high mortality rates. The clinical impact of methicillin resistance remains controversial: outcome comparisons between patients with bacteremia involving methicillin-susceptible (MSSA) and methicillin-resistant (MRSA) S aureus are difficult to perform because of important differences in severity of illness. METHODS: A retrospective cohort analysis and 2 independent case-control analyses were performed to determine and compare outcomes and attributable mortality rates of MSSA (n = 38) and MRSA bacteremia (n = 47) in critically ill patients. For the case-control studies, matching (1:2 ratio) was based on the APACHE (Acute Physiology and Chronic Health Evaluation) II classification: APACHE II score (+/-1 point) and diagnostic category. RESULTS: Patients with MRSA bacteremia had more acute renal failure and hemodynamic instability than patients with MSSA bacteremia. They had a longer intensive care unit stay and ventilator dependency. Patients with MRSA bacteremia had a higher 30-day mortality rate (53.2% vs 18.4%) and in-hospital mortality rate (63.8% vs 23.7%) (P<.05). Multivariate survival analysis demonstrated acute renal failure, length of mechanical ventilation, age, and methicillin resistance to be independently associated with mortality (P<.05). The attributable mortality rate for MSSA bacteremia was 1.3%: mortality rates for cases and controls were respectively 23.7% and 22.4% (P =.94). The attributable mortality rate for MRSA bacteremia was 23.4%: mortality rates for cases and controls were respectively 63.8% and 40.4% (P =.02). The difference (22.1%) between both attributable mortality rates was significant (95% confidence interval, 8.8%-35.3%). CONCLUSION: In critically ill patients, after accurate adjustment for disease severity and acute illness, we found MRSA bacteremia to have a higher attributable mortality than MSSA bacteremia.
Acute Kidney Injury↗
Effects of nosocomial candidemia on outcomes of critically ill patients.
PURPOSE: To determine whether nosocomial candidemia is associated with increased mortality in intensive care unit (ICU) patients. SUBJECTS AND METHODS: We performed a retrospective (1992 to 2000) cohort study of 73 ICU patients with candidemia and 146 matched controls. Controls were matched based on disease severity as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (+/- 1 point), diagnostic category, and length of ICU stay before onset of candidemia. RESULTS: In comparison with the control group, patients with candidemia developed more acute respiratory failure (97% [n = 71] vs. 88% [n = 129], P = 0.03) during their ICU stay. They were mechanically ventilated for a longer period (29 +/- 26 days vs. 19 +/- 19 days, P<0.01) and had a longer stay in the ICU (36 +/- 33 days vs. 25 +/- 23 days, P = 0.02) as well as in the hospital (77 +/- 81 days vs. 64 +/- 69 days, P = 0.04). There was no difference in in-hospital mortality between the groups (48% [n = 35] vs. 43% [n = 62], P = 0.44), a difference of 5% (95% confidence interval [CI]: -8% to 19%). In a multivariate analysis, older age (hazard ratio [HR] = 1.13 per 10 years; 95% CI: 1.04 to 1.23; P = 0.004), acute renal failure (HR = 1.4; 95% CI: 1.1 to 2.0; P = 0.02), and unfavorable APACHE II scores (HR = 1.10 per 5 points; 95% CI: 1.00 to 1.20; P = 0.05) were independent predictors of mortality. Candidemia was not associated with mortality in a model that adjusted for these factors (HR = 0.9; 95% CI: 0.7 to 1.2; P = 0.53). CONCLUSION: Nosocomial candidemia does not adversely affect the outcome in ICU patients in whom mortality is attributable to age, the severity of underlying disease, and acute illness.
APACHE↗