[Guidelines for the empirical antibiotic treatment of intraabdominal infections].
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Abdomen, Acute↗
Biomedical subjects
M Palomar
Publications and source records attributed to M Palomar.
Economic impact of Candida colonization and Candida infection in the critically ill patient.
The objective of the study presented here was to assess the economic impact of Candida colonization and Candida infection in critically ill patients admitted to intensive care units (ICUs). For this purpose, a prospective, cohort, observational, and multicenter study was designed. A total of 1,765 patients over the age of 18 years who were admitted for at least 7 days to 73 medical-surgical ICUs in 70 Spanish hospitals between May 1998 and January 1999 were studied. From day 7 of ICU admission to ICU discharge, samples of tracheal aspirates, pharyngeal exudates, gastric aspirates and urine were collected every week for culture. Prolonged length of stay was associated with severity of illness, Candida colonization or infection, infection by other fungi, antifungal therapy, treatment with more than one antifungal agent, and toxicity associated with this therapy. Compared to non-colonized, non-infected patients (n=720), patients with Candida colonization (n=880) had an extended ICU stay of 6.2 days (OR, 1.69; 95%CI, 1.53-1.87; P<0.001) and an extended hospital stay of 8.6 days (OR, 1.27; 95%CI, 1.16-1.40; P<0.001). The corresponding figures for patients with Candida infection (n=105) were 12.7 days for ICU stay (OR, 2.13; 95%CI, 1.72-2.64; P<0.001) and 15.5 days for hospital stay (OR, 1.23; 95%CI, 0.99-1.52; P=0.060). Candida colonization resulted in an additional 8,000 EUR in direct costs and Candida infection almost 16,000 EUR. Both Candida colonization and Candida infection had an important economic impact in terms of cost increases due to longer stays in both the ICU and in the hospital.
Adolescent↗
Levofloxacin in the treatment of pneumonia in intensive care unit patients.
In this study, we analyzed 302 patients with pneumonia admitted to the Intensive Care Unit (ICU) who were treated with levofloxacin (LFX) either as monotherapy or combined therapy. Pneumonia was classified as community-acquired in 220 (73%) patients, extra-ICU nosocomial-acquired in 43 (14%), and intra-ICU nosocomial-acquired in 39 (13%) patients. Treatment with LFX was used empirically in 85.7% of the cases. Initial doses of LFX were 500 mg every 24 h in 48.5% of the cases and 500 mg every 12 hours in 48.3%. Treatment was maintained for a mean (SD) of 12.6 (21.9) days. Treatment began as monotherapy in 116 (38.4%) patients and as combination therapy in 186 (61.6%). The factors that influenced the choice of combined treatment were septic shock (odds ratio [OR] 3.03; 95% confidence interval [CI] 1.50-6.12) and the presence of two or more extrinsic factors (OR 1.83; 95% CI 1.04-3.23), while young age was a variable associated with monotherapy (OR 0.98; 95% CI 0.96-0.99). An etiological diagnosis was made in 61.6% of the cases. LFX administration was changed from the intravenous route to oral administration in 85 (28.6%) patients. Satisfactory clinical response (cure and improvement) was achieved in 69.4% of the community-acquired pneumonia, in 55.8% of the extra-ICU nosocomial infection, and in 78.3% of the intra-ICU nosocomial infection. The overall mortality rate was 31.5%. Variables associated with death during ICU stay were combined therapy (OR 3.07; 95% CI 1.23-7.65), septic shock (OR 3.49; 95% CI 1.30-9.39), or therapeutic failure (OR 32.6; 95% CI 13.5-78.9). A total of 15% of the patients experienced adverse effects possibly or probably related the antibiotic given.
Adult↗
[Levofloxacin in patients in the ICU. Factors influencing the choice of dose and its use in combined therapy].
This study aimed to identify factors that influence the selection of different approaches to prescribing levofloxacin (e.g., monotherapy vs. combined therapy, 12-h vs. 24-h interval) and the effect on mortality in the ICU. An observational, prospective, multicenter study was conducted. A logistic regression analysis was performed to identify factors associated with the prescription of levofloxacin in combined therapy and at a dose of 500 mg every 12 hours. In addition, a logistic regression analysis was conducted to determine the impact of the different prescribing methods on mortality in the ICU. The most frequently administered initial dose was 500 mg/24 h (48.5%) and 500 mg/12 h (48.3%). No factors were found to influence the choice of daily dose. A total of 49.7% of levofloxacin prescriptions were in combined therapy. Factors influencing the decision to prescribe a combined regimen included diagnosis of extra-ICU nosocomial infection (OR: 1.97; 95% CI: 1.13-3.42); severe sepsis (OR: 2.56; 95% CI: 1.66-3.94); septic shock (OR: 6.22; 95% CI: 3.54-10.9); and identification of the causative pathogen (OR: 1.99: 95% CI: 1.34-2.95). The mortality rate was 21.4% and the related factors were septic shock (OR: 3.09; 95% CI: 1.38-6.91); treatment failure (OR: 23.4; 95% CI: 12.3-44.6); and combined therapy (OR: 2.36; 95% CI: 1.21-4.59). The selection of the initial dose of levofloxacin was not influenced by any factor, as long as the antibiotic was given in combined therapy in patients in whom the cause of the infection had been identified, in patients with greater systemic response, and in nosocomial infection outside the ICU. The selection of combined therapy was associated with a worse prognosis.
Anti-Infective Agents↗
[Risk and prognostic factors of Pseudomonas aeruginosa bacteremia in critically ill patients].
BACKGROUND: To determine risk and prognostic factors in patients admitted to the intensive care unit (ICU) in which an episode of bacteremia caused by Pseudomonas aeruginosa has been diagnosed. PATIENTS AND METHOD: Cohort, observational, prospective, multicenter study. Patients admitted to 30 ICUs in Spain in whom one or more pathogens were isolated from blood cultures were included. RESULTS: In a total of 16,216 patients admitted to the participating ICUs during the study period, 949 episodes of bacteremia were diagnosed In 77 cases (8.11%), P. aeruginosa was the causative pathogen, with an infection rate of 4.7 episodes per 1000 patients. Independent risk factors associated with P. aeruginosa bacteremia were as follows: respiratory infection focus (OR 3.92; 95% IC 2.33-6.59; p </= 0.0001), previous use of antibiotics (OR 2.13; 95% IC 1.18-3.81; p </= 0.0078), arterial catheter (OR 4.09; 95% IC 2.26-7.38; p </= 0.0001), and previous longer ICU stay (days) (OR 1.02; 95% IC 1.003-1.033; p = 0.0274). Crude mortality rate in patients with bacteremia caused by P. aeruginosa was 50.6% (39/77), whereas mortality rate of bacteremia caused by other pathogens was 38.6% (337/872) (p = 0.039). This difference was also found for attributed mortality (31.2% [24/77] vs. 20.4% [178/872], (p = 0.027). In the multivariate analysis adjusted by respiratory infection focus, previous ICU stay, and age, crude mortality (OR 1.55; 95% CI 0.96-2.51; p = 0.071) and attributed mortality (OR 1.63; 95% CI 0.96-2.78; p = 0.0709) of P. aeruginosa bacteremia were higher than in bacteremia caused by other pathogens. In the multivariate analysis, risk factors significantly associated with crude mortality were respiratory infection focus (OR 4.13; 95% IC 1.15-14.76; p = 0.0293) and severe sepsis or septic shock (OR 4.96; 95% IC 1.23-20.09; p = 0.0248). CONCLUSIONS: Bacteremia caused by P. aeruginosa admitted to the ICU have a higher crude and attributed mortality than bacteremias caused by other pathogens. Prognosis is associated with the presence of severe sepsis or septic shock and respiratory infection focus.
Anti-Bacterial Agents↗
Efficacy and tolerability of piperacillin/tazobactam versus ceftazidime in association with amikacin for treating nosocomial pneumonia in intensive care patients: a prospective randomized multicenter trial.
OBJECTIVE: To compare clinical and bacteriological efficacy as well as tolerability of two regimens of broad-spectrum antibiotics (ceftazidime versus piperacillin/tazobactam) combined with amikacin in the treatment of nosocomial pneumonia in intensive care patients. DESIGN: Open label, prospective, multicenter, and randomized phase III clinical trial. SETTING: Medical or surgical intensive care units (ICUs) of nine acute-care teaching hospitals in Spain. PATIENTS AND PARTICIPANTS: One hundred and twenty-four ICU patients with nosocomial pneumonia and requiring mechanical ventilation were included. They were randomized to receive amikacin (15 mg/day divided into two doses) combined with either piperacillin (4 g every 6 h) and tazobactam (0.5 g every 6 h) (n = 88) or ceftazidime (2 g every 8 h) (n = 36). MEASUREMENTS AND RESULTS: The causative pathogen was determined in 60.2% of patients in the group of amikacin plus piperacillin/tazobactam and in 76.9% in the group of amikacin plus ceftazidime. A total of 94 bacterial organisms were isolated among which gram-negative bacilli predominated, Pseudomonas aeruginosa being the most frequent. Clinical response at the end of antibiotic therapy was considered satisfactory (cure and/or improvement) in 63.9% of patients in the amikacin plus piperacillin/tazobactam group and in 61.5% in the amikacin plus ceftazidime (odds ratio 1.1; 95% confidence interval 0.44-2.75). Eradication or presumptive eradication rates for each pathogen and for either gram-negative or gram-positive bacteria were similar in both antibiotic combinations (odds ratio 1.2; 95% confidence interval 0.39-3.66). A total of 21 adverse effects (23.9%) occurred in the amikacin plus piperacillin and tazobactam group and six (16.7%) in the amikacin plus ceftazidime group, thrombocytosis, renal dysfunction, and hepatic cytolysis being the most common. The efficacy and tolerability of the two therapeutic regimens were similar not only in the whole study population, but also in the subset of P. aeruginosa-related pneumonia (odds ratio 1; 95% confidence interval 0.08-13.37). CONCLUSIONS: Amikacin associated with either ceftazidime or piperacillin and tazobactam has shown comparable efficacy and tolerability in the treatment of ICU patients with nosocomial pneumonia.
Aged↗
[Cefotaxime, twenty years later. Observational study in critically ill patients].
OBJECTIVE: Afer twenty years of commercial availability of cefotaxime, the objective of this study was to know the reasons and modes of use, administration dosage as well as its effectiveness and tolerance in critically ill patients admitted to Intensive Care Units (ICU) in our country. DESIGN: Open, prospective, observational, multicenter study. SUBJECTS: All patients who had cefotaxime administered in monotherapy or in combination with other antibiotics were included as cases in this study. RESULTS: A total of 624 patients were included in 44 ICUs (average 14 cases). Cefotaxime was indicated for therapy of 274 community-acquired infections (43.9%), 194 prophylaxis (31.1%), and 156 nosocomial infections (25.0%). Both community-acquired pneumonia (149, 34.7%) and mechanical ventilation associated pneumonia (62, 14.4%) predominated, followed by trachebronchitis (60, 13.9%) and central nervous system infections (42, 9.8%). Over half of infections (222, 51.6%) presented as systemic inflammatory response syndrome (SIRS), 133 (30.9%) as severe sepsis, and 75 (17.4%) as septic shock. In 374 (87.0%) out of the 430 cases of infection treatment, cefotaxime wan prescribed on an empirical basis and in 150 of them (40.1%) a further confirmation of the causative agent was obtained. In 120 (27.9%) cases, cefotaxime was administered as monotherapy and in the remaining cases in association with one or more antibiotics.The use of cefotaxime as prophylaxis was evaluated as failure in 31 (16.0%) of the cases, whereas in treatment it was considered as failure in 98 (22.8%) of the 430 cases, 51 community-acquired infections, 27 (27.3%) of ICU-acquired infections, and 20 (35.1%) nosocomial infections acquired outside the ICU. In 127 (29.5%) of the 430 infection treatments the initial treatment was changed. The reasons for the change included clinical failure (36, 28.3%), recovery of an uncovered pathogen with the antibiotic (40, 31.5%), emergence of multi-resistant pathogens (28, 22.0%), to decrease the therapeutic spectrum (7, 5.5%), and other reasons (16). Cefotoxime was also changed in 21 (6.0%) of the 194 cases in which it was used as prophylaxis. In 32 (5.1%) patients 37 adverse effects were noted which were associated with a possible or likely use of cefotaxime. Most notably, diarrhoea in 15 (2.4%) occasions and skin rash in 6 cases (1.0%). CONCLUSIONS: Cefotaxime is still one of the therapies of choice for community-acquired and nosocomial infections as well as in different prophylactic modes. It is mostly used on an empirical basis and associated with other antibiotics. Clinical and microbiological efficiency is high whereas adverse effects related to its use have been scarce.
Antibiotic Prophylaxis↗
Management of antimicrobial use in the intensive care unit.
Indications for the use of antimicrobials in critically ill patients are similar to those for other hospitalised patients. However, the selection of agents depends on the particular characteristics of patients in the intensive care unit (ICU), the form of presentation of infection, the type of infection and the bacteriological features of the causative pathogens. The use of antimicrobials in patients admitted to medical-surgical ICUs varies between 33 and 53%. The selection of empirical antimicrobials to be included in treatment protocols of the most common infections depends on the strong interrelationship between patient characteristics, predominant pathogens in each focus. and antimicrobials used for treatment. Epidemiological studies carried out in the past have identified the microorganisms most frequently responsible for community-acquired and nosocomial infections in patients admitted to ICUs. Susceptibility to antimicrobial agents may be different between each geographical area, between each hospital and even within the same hospital service. In addition, susceptibility patterns may change temporarily in relation to the use of particular antimicrobials or in association with other unknown factors so that assessment of endemic antimicrobial resistance patterns is very useful in order to tailor the antimicrobial regimens of therapeutic protocols. Antimicrobial use should not be a routine procedure. The clinical course of the patient (an indicator of effectiveness) should be closely monitored as well as the possible appearance of adverse effects and/or multiresistant pathogens. Controls are based on the assessment of plasma drug concentrations and microbiological surveillance to detect the presence of multiresistant strains or new antibacterial-resistant pathogens. Prevention of the development of multiresistant pathogens is the main goal of the ICU antimicrobial policy. Although a series of general strategies to reduce the presence of multiresistant pathogens have been proposed, the implementation of these recommendations in ICUs requires the cooperation of a member of the intensive care team.
Anti-Infective Agents↗
Treatment of severe nosocomial pneumonia: a prospective randomised comparison of intravenous ciprofloxacin with imipenem/cilastatin.
BACKGROUND: A prospective multicentre study was undertaken to compare the efficacy of intravenous ciprofloxacin or imipenem in the treatment of severe nosocomial pneumonia requiring mechanical ventilation. METHODS: Patients with a clinical suspicion of pneumonia were randomised to receive either ciprofloxacin (800-1200 mg/day) or imipenem (2-4 g/day) in doses adjusted for renal function and specimens of the lower respiratory tract were taken. Patients were included in the study when specimens showed significant growth for potentially pathogenic microorganisms in quantitative bacterial cultures (n = 75, ciprofloxacin 41/75 (55%); imipenem 34/75 (45%)). The clinical and bacteriological success rates were the primary and secondary efficacy variables. An intent-to-treat analysis was performed for all randomised patients who received at least one dose of the study medication (n = 149, ciprofloxacin 72/149 (48%), imipenem 77/149 (52%)). RESULTS: The success rates were generally good, but neither the clinical success rates (ciprofloxacin, 29/41 (71%), imipenem, 27/34 (79%); 95% CI -10.8 to 28.1; p = 0.435) nor the bacteriological response rate (ciprofloxacin, 20/41 (49%), imipenem, 17/34 (50%); 95% CI -21.5 to 23.9; p = 1.0) were significantly different between the study arms. Pseudomonas aeruginosa was recovered in 26/75 patients (35%) and clinical (ciprofloxacin, 10/14 (71%), imipenem, 8/12 (67%); 95% CI -40.4 to 30.9; p = 1.0) and bacteriological response rates (ciprofloxacin, 7/14 (50%), imipenem, 3/12 (25%), 95% CI -60.9 to 10.9, p = 0.247) were not significantly different in this subgroup of patients. Resistance of Pseudomonas aeruginosa developed in 5/26 cases (19%), 1/14 (7%) to ciprofloxacin and 4/12 (33%) to imipenem (p = 0.147), and the mortality was 12/75 (16%) with no difference between treatment groups (ciprofloxacin, 8/41(24%), imipenem 4/34 (17%); p = 0.362). The clinical response was evaluable in 109/149 patients (73%) in the intent-to-treat analysis and was successful in 74/109 patients (68%). The clinical response rates were also not significantly different in the intent-to-treat analysis (ciprofloxacin, 34/52 (65%), imipenem, 40/57 (70%); 95% CI -12.8 to 22.3; p = 0.746). CONCLUSIONS: Treatment with either ciprofloxacin or imipenem was effective in a selected group of patients with microbiologically confirmed, severe nosocomial pneumonia requiring mechanical ventilation. Although no differences between the study medication could be documented in this trial, smaller differences between treatment arms may have been missed because of sample size limitations.
Adult↗
[Guidelines for empirical antibiotic treatment of intraabdominal infections. Spanish Society of Chemotherapy].
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Abdomen↗
[Guidelines for empirical antibiotic treatment of intraabdominal infections]
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Journal Article↗
[Indications for admission to the intensive care service of adult patients with severe infections].
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Acquired Immunodeficiency Syndrome↗
Electroconvulsive therapy for status epilepticus.
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Combined Modality Therapy↗
Endoscopic evolution of laryngeal injuries caused by translaryngeal intubation.
Despite improvements in tube design and materials, the longer survival rates of critically ill patients make laryngeal and tracheal lesions still common following prolonged translaryngeal intubation. The time of intubation is almost the only factor employed in deciding whether or not tracheotomy has to be performed. Some patients will not develop laryngeal lesions afer long intubation periods, whereas some already have clinical symptoms after short periods of time. If the conditions of the larynx and trachea could be assessed before irreversible complications take place, then timing of tracheotomy could be individualized to avoid laryngeal stenosis as well as unnecessary tracheostomies. We present the preliminary results of an endoscopic study of the early laryngeal changes that take place during translaryngeal intubation. The method of exploration is explained and tissue changes seen and their evolution after extubation are described, emphasizing those that could have a predictive value.
Adolescent↗
[Postoperative infections in critically ill patients].
Patients subjected to surgery often develop nosocomial infections, among which the intra-abdominal ones stand out as being a common cause of septicemia, multi-organ failure, and death of the critical patients. Advances have been made in the study of the physiopathology by studying the mediators which are responsible for the systemic inflammatory response, the microbiology (changes in the pathogen type and in the antimicrobial sensitivity), and for the clinical picture (cholecystitis, tertiary peritonitis). Abdominal ultra-sound and computerized axial tomography have contributed greatly to the diagnosis of these infections. The new treatment techniques are discussed, both of the drainage of the septic focus (percutaneous or surgical), as of the antimicrobial treatment and the supportive measures. The diagnostic and therapeutic advances have modified the prognosis of these patients, although this continues to be poor when there is development of the multi-organ failure syndrome.
Bacterial Infections↗
[Treatment of status epilepticus].
The management of status epilepticus (SE) is very complex due to the variability of its clinical features. This paper aims to achieve an schematic basis for a consensus in the treatment of these patients. Thus we need the clinical forms of SE grouped according to the differences in treatment. We also need to divided the development of every type of SE into stages in order to adjust the correct application of general measures and antiepileptic drugs. In patients prone to suffering recurrent seizures it is important to prevent risk factors. We can sometimes identify a premonitory phase during which the clinical deterioration presages SE; in these cases immediate treatment at home can prevent the evolution into true SE. Once SE has developed up to stage of early SE or stablished SE, the treatment must be carried out in emergency department. If seizures have not responded, the stage of refractory SE is reached and Intensive Care Unit facilities are mandatory. We devote special attention to conic-clonic SE but the other clinical forms of SE are categorized according to the differences in treatment.
Anticonvulsants↗
Fatal chemical pneumonitis due to cadmium fumes.
Acute exposure to high concentrations of cadmium fumes may cause acute chemical pneumonitis with a possibly fatal outcome. The etiologic diagnosis of acute cadmium intoxication from inhaled fumes may be difficult and can be confused with other forms of acute respiratory failure. We report on a case of a fit 53 year-old man who was exposed to cadmium fumes after flame-cutting an alloy containing around 10% of cadmium for a period of 60-75 minutes. He developed severe chemical pneumonitis and died 19 days after exposure.
Cadmium↗
Pattern of tracheal colonization during mechanical ventilation.
The relationship between gastric (GC) and tracheal (TC) colonization and the development of ventilator-associated pneumonia (VAP) remains controversial. TC, GC, and pharyngeal (PC) colonization were studied serially in 80 patients with mechanical ventilation (MV) to ascertain the routes and onset of TC. Simultaneous sample from pharynx, stomach, and trachea were obtained throughout the MV period. Quantitative cultures were performed. Seventy-two patients (90%) had TC at some time during MV. Only 19 patients presented TC after PC or GC by the same microorganisms. Indigenous gram-negative and gram-positive microorganisms colonized mainly the trachea from the start of or during MV without previous PC or GC (p < 0.05). Pseudomonas were the microorganisms causing TC principally during MV without previous PC or GC (p < 0.005). Enterobacteria produced TC without a preferential route. Of the 12 patients who developed VAP, the microorganisms responsible had already colonized the trachea in 10 patients. Only 10 of the 21 microorganisms isolated in VAP had previously colonized the pharynx or stomach. In summary, although some microorganisms have preferential routes for producing TC, the microorganisms isolated frequently change during MV. TC precedes VAP in most patients, but only a minority develop a VAP; therefore, together with TC other factors must be involved in VAP development.
Adult↗