IMPACTO-MR: a Brazilian nationwide platform study to assessinfections and multidrug resistance in intensive care units

To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria. We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform. The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database. The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.

What's trending in the infection prevention and control literature? From HIS 2012 to HIS 2014, and beyond

Survival from critical illness has improved in recent years, leading to increased attention to the sequelae of such illness. Neuromuscular weakness in the intensive care unit (ICU) is common, persistent, and has significant public health implications. The differential diagnosis of weakness in the ICU is extensive and includes critical illness neuromyopathy. Prolonged immobility and bedrest lead to catabolism and muscle atrophy, and are associated with critical illness neuromyopathy and ICU-acquired weakness. Early mobilization therapy has been advocated as a mechanism to prevent ICU-acquired weakness. Early mobilization is safe and feasible in most ICU patients, and improves outcomes. Implementation of early mobilization therapy requires changes in ICU culture, including decreased sedation and bedrest. Various technologies exist to increase compliance with early mobilization programs. Drugs targeting muscle pathways to decrease atrophy and muscle-wasting are in development. Additional research on early mobilization in the ICU is needed.

BACKGROUND AND OBJECTIVES:Patients in the ICU have encountered an increasing emergence and spread of antibiotic-resistant pathogens. We examined patterns of antimicrobial susceptibility in gram-negative isolates to commonly used drugs in an adult ICU at a tertiary care hospital in Riyadh, Saudi Arabia.METHODS:A retrospective study was carried out of gram-negative isolates from the adult ICU of King Fahad National Guard Hospital (KFNGH) between 2004 and 2009. Organisms were identified and tested by an automated identification and susceptibility system, and the antibiotic susceptibility testing was confirmed by the disk diffusion method.RESULTS:The most frequently isolated organism was Acinetobacter baumannii, followed by Pseudomonas aeruginosa, Escherichia coli, Klebsiella pnemoniae, Stenotrophomonas maltophilia, and Enterobacter. Antibiotic susceptibility patterns significantly declined in many organisms, especially A baumannii, E coli, S marcescens, and Enterobacter. A baumannii susceptibility was significantly decreased to imipenem (55% to 10%), meropenem (33% to 10%), ciprofloxacin (22% to 10%), and amikacin (12% to 6%). E coli susceptibility was markedly decreased (from 75% to 50% or less) to cefuroxime, ceftazidime, cefotaxime, and cefepime. S marcescens susceptibility was markedly decreased to cefotaxime (100% to 32%), ceftazidime (100% to 35%), and cefepime (100% to 66%). Enterobacter susceptibility was markedly decreased to ceftazidime (34% to 5%), cefotaxime (34% to 6%), and pipracillin-tazobactam (51% to 35%). Respiratory samples were the most frequently indicative of multidrug-resistant pathogens (63%), followed by urinary samples (57%).CONCLUSION:Antimicrobial resistance is an emerging problem in the KFNGH ICU, justifying new more stringent antibiotic prescription guidelines. Continuous monitoring of antimicrobial susceptibility and strict adherence to infection prevention guidelines are essential to eliminate major outbreaks in the future.

The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe. A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14). A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries. More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Influence of perceived functional and employment status on cardiopulmonary resuscitation directives

Are Unselected Risk Scores in the Cardiac Intensive Care Unit Needed?

Systematic Intensive Respiratory Care

Antimicrobial resistance and resistance mechanisms of Enterobacteriaceae in ICU and non-ICU wards in Europe and North America: SMART 2011-2013.

Serious infections in intensive care unit patients caused by multidrug-resistant (MDR) Klebsiella pneumoniae represent a major threat worldwide owing to increased mortality and limited treatment options. With the application of tigecycline for MDR pathogens, tigecycline-non-susceptible K. pneumoniae isolates have recently emerged in China. To identify the susceptibility profile of MDR K. pneumoniae to tigecycline and evaluate the molecular characterization of tigecycline resistance, 214 MDR K. pneumoniae isolates were collected from blood samples of patients in intensive care units. MICs and clonal relatedness were determined by standard broth microdilution and multilocus sequence typing, respectively. Expression levels of efflux pumps and their global regulators were examined using real-time PCR. Mutations of local repressor were identified by PCR and sequencing. Our results show that the tigecycline resistance rate of 214 MDR K. pneumoniae isolates was 6.07 %. ST11 was the predominant clone type of tigecycline-non-susceptible K. pneumoniae isolates. Expression of efflux pump AcrB and global regulator RamA correlated with tigecycline MICs (AcrB: x2=8.91, P=0.03; RamA: x2=13.91, P<0.01), and mean expression levels of AcrB for the MICs ≥4 mg l-1 were significantly higher than MICs ≤2 mg l-1 (t=2.48, P=0.029). In addition, one tigecycline-resistant isolate harboured a deletion mutation in the ramR gene. These data indicated a linear correlative trend for overexpression of the AcrB and the tigecycline MICs resulting from the upregulation of RamA. The emergence of molecular type ST11 of MDR K. pneumoniae isolates should be monitored to identify factors that contribute to tigecycline resistance in intensive care units.

Who Should Supervise Respiratory Intensive Care Units?

Cross-transmission of Gram-negative bacteria increases the likelihood of acquisition of infections and emergence of antibiotic resistance in intensive care units. Respiratory tracts of mechanically ventilated patients are frequently colonized with Gram-negative bacteria and endotracheal suctioning may facilitate cross-transmission. It is unknown whether closed suction systems, as compared with open suction systems, prevent cross-transmission. The objective was to determine whether closed suction systems, as compared with open suction systems, reduce the incidence of cross-transmission of Gram-negative bacteria in intensive care units. We performed a prospective crossover study in which both systems were tested unitwide in four intensive care units. Two intensive care units from a university hospital and two from a teaching hospital participated in the trial between January 2007 and February 2008. All patients admitted to the intensive care unit for >24 hrs were included. Closed suction systems and open suction systems were used for all patients requiring mechanical ventilation during 6-month clusters with the order of systems randomized per intensive care unit. Acquisition and cross-transmission rates of selected Gram-negative bacteria were determined through extensive microbiological surveillance and genotyping. Among 1,110 patients (585 with closed suction systems and 525 with open suction systems), acquisition for selected Gram-negative bacteria was 35.5 and 32.5 per 1,000 patient-days at risk during closed suction period and open suction period, respectively (adjusted hazard ratio, 1.14; 95% confidence interval, 0.9-1.4). During closed suction period, adjusted hazard ratios for acquisition were 0.66 (95% confidence interval, 0.45-0.97) for Pseudomonas aeruginosa and 2.03 (95% confidence interval, 1.15-3.57) for Acinetobacter species; acquisition rates of other pathogens did not differ significantly. Adjusted hazard ratios for cross-transmission during closed suction period 0.9 (0.4-1.9) for P. aeruginosa, 6.7 (1.5-30.1) for Acinetobacter, and 0.3 (0.03-2.7) for Enterobacter species. Overall cross-transmission rates were 5.9 (closed suction systems) and 4.7 (open suction systems) per 1,000 patient-days at risk. Closed suction systems failed to reduce cross-transmission and acquisition rates of the most relevant Gram-negative bacteria in intensive care unit patients.

Antibiotic resistance is an important factor influencing clinical outcome for patients in intensive care units. It is also associated with increased healthcare costs resulting from prolonged patient stays. The problem of antibiotic resistance is particularly acute in intensive care units because they house seriously ill patients who are predisposed to infection, as a result of which, antibiotic use is extremely common. Strategies for controlling resistance in intensive care units have focused on attempting to reduce unnecessary antibiotic use, while at the same time ensuring adequate antibiotic cover is provided. The formulation of policies for the effective use of antibiotics in individual intensive care units requires a multidisciplinary approach, entailing regular epidemiological surveillance, together with input from critical care specialists, infectious disease specialists and pharmacists.

The project entitled Surveillance of Antibiotic Use and Resistance in Intensive Care Units (SARI) was initiated in Germany in 2000. In this article, we describe developments in antibiotic use and resistance rates in the participating intensive care units over the years 2001-2015. The intensive care units supplied monthly figures on patient days, antibiotic use (in defined daily doses, DDD), and resistance data for 13 pathogens. The density of antibiotic use per 1000 patient days was calculated on the basis of antibiotic use, DDD, and patient days, and the resistance density per 1000 patient days was calculated from the number of resistant pathogens. In the years 2001-2015, data on 2 920 068 patient days were collected in 77 intensive care units. The average overall antibiotic use rose by 19% over this period, with a marked increase in the density of carbapenem use (from 76 to 250 DDD per 1000 patient days, +230%) and piperacillin-tazobactam use (from 42 to 146 DDD per 1000 patient days, +247%). The proportion of Escherichia coli and Klebsiella pneumoniae isolates that were resistant to third-generation cephalosporins increased markedly initially, then remained stable over the remainder of the observation period. The proportion of methicillin-resistant Staphylococcus aureus was stable over the entire period. The rates of vancomycin resistance among Enterococcus faecium isolates and imipenem resistance among gram-negative pathogens increased from 2.3% to 13.3% and from 0.1% to 0.3%, respectively. The resistance density of gram-negative multiresistant pathogens in the participating intensive care units increased markedly. The rise in imipenem-resistant pathogens arouses particular concern. The increased use of broad-spectrum/reserve antibiotics may well have contributed to this development. Efforts to use antibiotics rationally, e.g., with the support of multidisciplinary "antibiotic stewardship" teams, are therefore vitally important. As participation in SARI is voluntary, these surveillance data cannot be considered representative of Germany as a whole.

Gram-negative resistance is an increasingly important consideration when initiating empiric antimicrobial therapy in intensive care units. Infection with a resistant organism has been associated with increased morbidity and mortality as well as increased hospital cost. Gram-negative resistance in intensive care units will likely continue to increase. Clinicians must aggressively manage infections in the intensive care unit while practicing the appropriate steps to minimize future resistance. This review article summarizes the epidemiology, risk factors, mechanisms of resistance, and management of infections due to resistant gram-negative organisms.