[Show abstract][Hide abstract] ABSTRACT: Clin Microbiol Infect 2011; 17: 1798–1803
Bloodstream infections (BSIs) caused by Klebsiella pneumoniae carbapenemases (KPC)-producing K. pneumoniae (KPC-KP) are associated with high mortality rates. We investigated outcomes, risk factors for mortality and impact of appropriate antimicrobial treatment in patients with BSIs caused by molecularly confirmed KPC-KP. All consecutive patients with KPC-KP BSIs between May 2008 and May 2010 were included in the study and followed-up until their discharge or death. Potential risk factors for infection mortality were examined by a case-control study. Case-patients were those who died from the BSI and control-patients those who survived. Appropriate antimicrobial therapy was defined as treatment with in vitro active antimicrobials for at least 48 h. A total of 53 patients were identified. Overall mortality was 52.8% and infection mortality was 34%. Appropriate antimicrobial therapy was administered to 35 patients; mortality due to infection occurred in 20%. All 20 patients that received combination schemes had favourable infection outcome; in contrast, seven of 15 patients given appropriate monotherapy died (p 0.001). In univariate analysis, risk factors for mortality were age (p <0.001), APACHE II score at admission and infection onset (p <0.001) and severe sepsis (p <0.001), while appropriate antimicrobial treatment (p 0.003), combinations of active antimicrobials (p 0.001), catheter-related bacteraemia (p 0.04), prior surgery (p 0.014) and other therapeutic interventions (p 0.015) were significantly associated with survival. Independent predictors of mortality were age, APACHE II score at infection onset and inappropriate antimicrobial treatment. Among them, appropriate treatment is the only modifiable independent predictor of infection outcome.
[Show abstract][Hide abstract] ABSTRACT: Intensive care may prolong the dying process in patients who have been unresponsive to the treatment already provided. Limitation of life-sustaining therapy, by either withholding or withdrawing support, is an ethically acceptable and common worldwide practice. The purpose of the present study was to examine the frequency, types, and rationale of limiting life support in Greek intensive care units (ICUs), the clinical and demographic parameters associated with it, and the participation of relatives in decision making.
This was a prospective observational study conducted in eight Greek multidisciplinary ICUs. We studied all consecutive ICU patients who died, excluding those who stayed in the ICU less than 48 hours or were brain dead.
Three hundred six patients composed the study population, with a mean age of 64 years and a mean APACHE II score on admission of 21. Of study patients, 41% received full support, including unsuccessful cardiopulmonary resuscitation (CPR); 48% died after withholding of CPR; 8%, after withholding of other treatment modalities besides CPR; and 3%, after withdrawal of treatment. Patients in whom therapy was limited had a longer ICU (P < 0.01) and hospital (P = 0.01) length of stay, a lower Glasgow Coma Scale score (GCS) on admission (P < 0.01), a higher APACHE II score 24 hours before death (P < 0.01), and were more likely to be admitted with a neurologic diagnosis (P < 0.01). Patients who received full support were more likely to be admitted with either a cardiovascular (P = 0.02) or trauma diagnosis (P = 0.05) and to be surgical rather than medical (P = 0.05). The main factors that influenced the physician's decision were, when providing full support, reversibility of illness and prognostic uncertainty, whereas, when limiting therapy, unresponsiveness to treatment already offered, prognosis of underlying chronic disease, and prognosis of acute disorder. Relatives' participation in decision making occurred in 20% of cases and was more frequent when a decision to provide full support was made (P < 0.01). Advance directives were rare (1%).
Limitation of life-sustaining treatment is a common phenomenon in the Greek ICUs studied. However, in a large majority of cases, it is equivalent to the withholding of CPR alone. Withholding of other therapies besides CPR and withdrawal of support are infrequent. Medical paternalism predominates in decision making.
[Show abstract][Hide abstract] ABSTRACT: We report the first two cases of community-acquired necrotizing pneumonia and bacteremia complicated by acute respiratory distress syndrome (ARDS) due to Panton-Valantine leukocidin-producing methicillin-resistant Staphylococcus aureus (MRSA-PVL) in Greece, together with a short literature review. Diagnosis was made by culture and broad spectrum PCR of respiratory secretions and blood. One patient received appropriate therapy and recovered fully. The other one died rapidly due to septic shock and life-threatening hemoptysis. Clinicians should be suspicious of community-acquired pneumonia due to MRSA-PVL strain, because rigorous microbiological diagnosis, early and appropriate therapy is essential for favorable outcome.
[Show abstract][Hide abstract] ABSTRACT: Aspergillus tracheobronchitis is an uncommon clinical form of invasive aspergillosis with fungal infection limited entirely or predominantly to the tracheobronchial tree. We report a case of Aspergillus fumigatus bronchitis, diagnosed by fiberoptic bronchoscopy, with fungal growth completely occluding the left main bronchus leading to lung collapse and acute respiratory failure in a 60-year-old male with erythroleukemia and profound granulocytopenia.
[Show abstract][Hide abstract] ABSTRACT: Objective: To investigate a possible additive effect of combined nitric oxide (NO) and almitrine bismesylate (ALM) on pulmonary ventilation-perfusion
(▪�VA/▪�Q) ratio.�Design: Prospective, controlled animal study.�Setting: Animal research facility of a university hospital.�Interventions: Three conditions were studied in ten female pigs with experimental acute lung injury (ALI) induced by repeated lung lavage:
1) 10 ppm NO, 2) 10 ppm NO with 1 μg/kg per min ALM, 3) 1 μg/kg per min ALM. For each condition, gas exchange, hemodynamics
and▪�VA/▪�Qdistributions were analyzed using the multiple inert gas elimination technique (MIGET).�Measurement and results: With NO + ALM, arterial oxygen partial pressure (PaO2) increased from 63 � 18 mmHg to 202 � 97 mmHg while intrapulmonary shunt decreased from 50 � 15 % to 26 � 12 % and blood
flow to regions with a normal▪�VA/▪�Qratio increased from 49 � 16 % to 72 � 15 %. These changes were significant when compared to untreated ALI (p p p Conclusions: We conclude that NO + ALM results in an additive improvement of pulmonary gas exchange in an experimental model of ALI by
diverting additional blood flow from non-ventilated lung regions towards those with normal▪�VA/▪�Qrelationships.
Intensive Care Medicine 03/2000; 26(2):252. DOI:10.1007/s001340050058 · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Ventilator-associated pneumonia (VAP) is one of the most common causes of morbidity and mortality in intensive care unit patients. However, the diagnosis is quite difficult. Gram stain (GS) of bronchoalveolar lavage (BAL) sample is a time-saving diagnostic method for VAP. However, its clinical significance has not been adequately investigated. The aim of this study was to determine its sensitivity and specificity for VAP diagnosis. We prospectively performed GS and quantitative bacterial cultures (QBC) of BAL samples, obtained through fiberoptic bronchoscope, in 75 consecutive postoperative and/or multiple trauma patients with suspected VAP. We considered BAL-GS as positive for VAP diagnosis when (i) polymorphonuclear neutrophils were > 25 per optic field at a magnification x 100 (p.o.f x 100); (ii) squamous epithelial cells were < 1% p.o.f x 100; and (iii) one or more microorganisms were seen p.o.f. at a magnification x 1,000 (p.o.f. x 1,000). VAP was diagnosed with criteria similar to those used in previous studies. Pneumonia was the final diagnosis in 22/75 (29%) patients. The BAL-GS was positive in 17/22 patients with VAP and in 7/53 patients without VAP. Accordingly, the sensitivity of BAL-GS for VAP diagnosis was 77%, the specificity 87%, the positive predictive value 71% and the negative predictive value 90%. Our data suggest that BAL-GS has good sensitivity and high specificity for VAP diagnosis. It could therefore constitute a useful complementary tool in the task of early diagnosis and treatment of VAP.
[Show abstract][Hide abstract] ABSTRACT: Pneumocystis carinii pneumonia (PCP) usually occurs in immunocompromised patients, and it is a life-threatening infection. We report the case of a human immunodeficiency virus (HIV)-seronegative patient with untreated rheumatoid arthritis (RA), who developed fatal PCP related to uncommon CD4+ T-lymphocytopenia. Although extremely rare and of uncertain aetiology, suppression of cellular immunity and subsequent opportunistic infections should be suspected in such patients.
European Respiratory Journal 06/1997; 10(5):1184-6. DOI:10.1183/09031936.97.10051184 · 7.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In an attempt to improve our ability to diagnose the cause of ventilator-associated pneumonia (VAP), we explore the usefulness of the conditional evaluation of bronchoalveolar lavage (BAL) samples from the involved and non-involved areas in patients with suspected unilateral lobar VAP (UL-VAP).
University teaching hospital intensive care unit.
We studied 19 consecutive patients with suspected UL-VAP.
Nine of the 12 patients (47%) developed UL-VAP. There was a significant difference between the involved and non-involved areas in UL-VAP patients (P < 0.001) in respect of the quantitative bacterial cultures (QBCs) of BAL samples for each micro-organism, whereas there was no difference in patients without UL-VAP. When we applied the criterion of usual BAL (one micro-organism in concentrations > 10(5) colony-forming units per millilitre) for UL-VAP diagnosis, the sensitivity was 100%, the specificity 70%, the positive predictive value 75%, and the negative predictive value 100%. When we used the conditional evaluation of the BAL results for UL-VAP diagnosis, in the involved and non-involved areas, the sensitivity was 78%, the specificity 90%, the positive predictive value 87.5% and the negative predictive value 82%. A statistically significant difference was found when we compared the difference in QBCs between the BAL samples for each micro-organism, between the involved and non-involved areas in patients with and without VAP (P < 0.001).
These data suggest that utilisation of the conditional evaluation of the QBCs of BAL samples improves significantly our ability to diagnose the cause of UL-VAP.
South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 05/1997; 87(5 Suppl):643-8. · 1.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the effect of tracheal gas insufflation (TGI) in spontaneously breathing, intubated patients with chronic obstructive pulmonary disease (COPD) undergoing weaning from the mechanical ventilation.
A prospective study in humans.
Polyvalent intensive care unit (14-bed ICU) in a 700-bed general university hospital.
Twelve patients with chronic obstructive pulmonary disease (COPD) who required intubation and mechanical ventilation were studied. All patients met standard criteria for weaning from mechanical ventilation. Seven patients (group 1) had been transorally intubated during episodes of acute respiratory failure. Five patients, all men (group 2), had previously undergone tracheostomy and had a transtracheal tube in place.
Intratracheal, humidified, O2-mixture insufflation (TGI) was given via a catheter placed in distal or proximal position. Gas delivered through the intratracheal catheter was blended to match the fractional of inspired gas through the endotracheal tube. Continuous flows of 3 and 6 l/min in randomized order were used in each catheter position. Prior to data collection at each stage, an equilibration period of at least 30 min was observed, and thereafter blood gases were analyzed every 5 min. A new steady state was assumed to have been established when values of both PaCO2 and V CO2 changed by less than 5% between adjacent measurements. The last values of blood gases were taken as representative. The new steady state was confirmed within 35-50 min. Baseline measurements with zero Vcath were made at the beginning and end of the experiment.
This study shows that VT, MV, PaCO2, and VD/VT are reduced in a flow-dependent manner when gas is delivered through an oral-tracheal tube (group 1). The distal catheter position was more effective than the proximal one. In contrast, when gas was delivered through tracheostomy (group 2), TGI was ineffective in the proximal position and less effective than in group 1 in distal position.
Under the experimental conditions, tracheal gas insufflation decreased dead space, increased alveolar ventilation and possibly reduced work of breathing. From the preliminary data reported here, we believe that TGI may help patients experiencing difficulty during weaning.
Intensive Care Medicine 12/1995; 21(11):904-12. DOI:10.1007/BF01712331 · 7.21 Impact Factor