ICU Length Research Articles

The role of the AVAPS ventilation mode combined with TCM monitoring in weaning patients with AECOPD

To explore the role of AVAPS combined with TCM monitoring in the weaning of patients with AECOPD. In this study, 100 patients with AECOPD were included, who were divided into the AVAPS group and the S/T group after weaning. The respiration-related parameters were compared between the two groups at the time of weaning and after 1 h and 12 h of noninvasive ventilation. The correlations between PtcCO2 and PaCO2 and the differences in each parameter were compared. The predictive value of PtcCO2 variability after 1 h and 12 h of noninvasive respiratory support for the 48-h reintubation rate were analysed. Logistic regression analysis was performed to explore the risk factors affecting the 48-h reintubation rate of AECOPD patients. After 1 h and 12 h of treatment with different ventilation modes, the variations in the respiration-related parameters in the AVAPS group were all significantly greater than those in the S/T group (P < 0.05). In the AVAPS group, the incidence of 48-hour reintubation was lower, the time to reintubation was longer, and length of hospital and ICU stays were shorter (P < 0.05). The ROC curve revealed that PtcCO2 variability− 2, the ROX index− 2 and their combination had predictive value for the 48-h reintubation rate of AECOPD patients. The logistic regression revealed that after 12 h of noninvasive support, a PtcCO2 variability ≥ − 5.8% with a ROX index ≤ 9.6 was independent risk factors affecting the 48 h reintubation rate in weaning patients with AECOPD (OR = 2.815; P < 0.05). For patients with AECOPD, the AVAPS ventilation mode combined with PtcCO2 monitoring can significantly improve respiratory physiological parameters and reduce the 48 h reintubation rate. After 12 h of noninvasive support, a PtcCO2 variability ≥ − 5.8% with a ROX index ≤ 9.6 is considered as a independent risk factor for reintubation 48 h after weaning.

The first comparative analysis of open and robotic tracheobronchoplasty for excessive Central airway collapse.

Tracheobronchoplasty is an operation to treat excessive central airway collapse by stabilizing the posterior tracheal membrane. In 2020, our institution transitioned from the traditional open approach to the robotic-assisted tracheobronchoplasty in select patients. This retrospective cohort study compares postoperative complications and short-term outcomes for patients undergoing open versus robotic tracheobronchoplasty at a high-volume complex airway center. A retrospective review of all patients who underwent open tracheobronchoplasty (2018-2020) and robotic tracheobronchoplasty (2020-2023) was conducted. During the study period, 43 and 69 patients underwent robotic and open tracheobronchoplasty, respectively. Robotic tracheobronchoplasty had longer median operative times than open (8.4 vs 6.2 hours; p = <0.01). Both median ICU length of stay (1.0 vs 3.0 days, p = <0.01) and hospital length of stay (5.0 vs 7.0 days, p = <0.01) were shorter after robotic tracheobronchoplasty. There were no significant differences in major or minor complications, total Clavien-Dindo Score, estimated blood loss, discharge to home, and 30-day readmission. The robotic group had two reoperations during the index hospitalization and three conversions to open. There were no mortalities in either group. Short-term (3-month) functional and quality of life outcomes were equivalent between groups. In selected patients with severe and symptomatic excessive central airway collapse, robotic tracheobronchoplasty is a safe and feasible alternative to the traditional open approach. Patients undergoing robotic tracheobronchoplasty have shorter ICU and total hospital stays with equivalent complication rates. As the robotic approach becomes more prevalent, further comparative outcomes are necessary with longer follow-up to ensure durability of the robotic-assisted repair.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Pediatric Abdominal Rhabdomyosarcoma: Experience of a Reference Pediatric Oncosurgical Center.

Pediatric abdominal rhabdomyosarcoma (RMS) represents an oncosurgical challenge. For adults with peritoneal carcinomatosis and for children/adolescents with desmoplastic small round cell tumors (DSRCT), cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to be an effective treatment. Thereby, we present the largest series on CRS and HIPEC in patients with abdominal RMS. Between August 2013 and January 2024, 18 patients (9 female and 9 male) with abdominal RMS underwent CRS and HIPEC at our institution. All patients were treated according to an institutionalized protocol. The indication for surgery was established by a multidisciplinary national tumor board. HIPEC was performed using cisplatin (37.5-100mg/m2) and doxorubicin (15-30mg/m2) for 60min at 42°C. A retrospective review of patient's records was performed. The median age at operation was 3.8 years. A complete cytoreduction was achieved in 17/18 patients. Median length of hospital stay was 11 days. Mean length of ICU stay was 2.5 days. No procedure-associated complications and no major short-/long-term toxicities were recorded. The median follow-up was 20 months. The 5-year overall survival (OS) and event-free survival (EFS) were 72% and 53%, respectively. Patients >10 years and those with alveolar histology had the worst prognosis (OS 0%). Patients with relapse after HIPEC (6/18) had a significantly poorer survival compared with those without recurrence (OS 33% vs. 100%, p=0.001). CRS and HIPEC are effective in patients with abdominal RMS. Patients >10 years, those with alveolar RMS and those with relapse after HIPEC had the worst outcome.

Aerosolized plus intravenous polymyxin B in comparison to intravenous polymyxin B alone for the management of HAP caused by carbapenem-resistant gram-negative bacteria: A prospective multicenter cohort study.

This study aimed to evaluate the clinical effectiveness of combined aerosolized (AER) and intravenous (IV) polymyxin B in managing patients with hospital-acquired pneumonia (HAP) caused by carbapenem-resistant gram-negative organism (CRO). This multicenter prospective cohort study was conducted across six intensive care units in municipal and above-municipal hospitals in Shaanxi, China, from January 1, 2021 to December 31, 2022. Patients with CRO pneumonia were categorized into the intravenous group (IV polymyxin B alone) and the combination group (AER plus IV polymyxin B). Primary outcomes included ICU mortality, 28-day mortality and bacterial clearance, while secondary outcomes included the duration of mechanical ventilation and length of ICU stay. A total of 64 patients were included in the study, with 29 receiving AER plus IV polymyxin B and 35 receiving IV polymyxin B alone. On the seventh day of treatment, the combination group showed a significant reduction in the APACHE II score (17.86 ± 5.03 vs. 19.17 ± 11.02, P = 0.041) and procalcitonin levels (1.27 ± 0.20 vs. 3.18 ± 0.69, P < 0.001) compared to the intravenous group. Additionally, the combination group exhibited a higher bacterial eradication rate (62.1% vs. 42.9%), lower ICU mortality (27.6% vs. 37.1%), shorter duration of mechanical ventilation (371.39 ± 68.97 h vs. 563.94 ± 100.25 h), and reduced ICU stay (34.41 ± 17.87 d vs. 35.03 ± 21.66 d), although the differences were not statistically significant. In patients with CRO pneumonia, combination therapy resulted in significant reductions in APACHE II scores and procalcitonin, but did not lead to statistically significant improvements in clinical outcomes, compared to IV polymyxin B alone.

Normothermic Machine Perfusion vs. Static Cold Storage in Liver Transplantation: A Systematic Review and Meta-Analysis.

Normothermic machine perfusion (NMP) represents an alternative to prolong liver preservation and reduce organ discard rates. We performed an updated systematic review and meta-analysis to compare NMP with static cold storage (SCS) in liver transplantation. MEDLINE, Embase, and Cochrane were searched for randomized controlled trials (RCTs) or observational studies. Risk ratios (RR) and mean differences were calculated. p < 0.05 was considered significant. A random-effects model was applied for all outcomes. CRD42023486184. We included 1295 patients from 5 RCTs and 6 observational studies from 2016 to 2023. 592 (45.7%) underwent NMP. A subgroup RCT analysis favored NMP for non-anastomotic strictures (RR 0.4; 95% CI 0.2, 0.9), postreperfusion syndrome (RR 0.4; 95% CI 0.27, 0.56), and early allograft dysfunction (RR 0.6; 95% CI 0.4, 0.9). NMP favored higher organ utilization rates (RR 1.1; 95% CI 1.02, 1.18). No significant differences between NMP and SCS were observed in graft survival or patient survival at 12 months, primary non-function, serious adverse events, overall biliary complications, AST, or bilirubin levels peak within the first 7 days, ICU or hospital length of stay. Our findings suggest that NMP is associated with lower non-anastomotic biliary stricture rates, postreperfusion syndrome, early allograft dysfunction, and higher organ utilization in the RCT subgroup analysis, without increasing adverse events.

P-723. Incidence, Etiology, and Outcomes of Viral Pneumonia in Adults with Cancer at a Tertiary Care Centre in Eastern India: A One Year Prospective Cohort Study

Abstract Background We identified pneumonia in adult cancer patients admitted to the ICU over one year, delineated viral pneumonia, assessed etiology, and studied clinical outcomes.Figure 1:Etiology of pneumonia cases where viruses were detected (n=90) Methods Pneumonia cases were clinically and radiologically identified from October 2022-September 2023. Pneumonia was categorized as community-acquired or healthcare-associated. Viral detection was done using Qiagen’s QIAstat-Dx Respiratory SARS-CoV-2 Panel and bioMeriéux’s BioFire® FilmArray® Pneumonia Panel. Bacterial, fungal, and mycobacterial detection involved microscopy, culture, ELISA, PCR, and CBNAATs. All cases where bacteria, mycobacteria, and fungi were detected along with viruses were assigned “co-infection/ superadded infections". Frequency of pathogens were compared using a modified Z-test. Seasonality was assessed using the chi-square test for homogeneity. Lengths of hospital and ICU stay were compared using linear regression and mortality was compared using logistic regression and Kaplan-Meier survival analysis.Figure 2:Kaplan-Meier survival analysis for pneumonia cases where viruses were detected stratified by etiology Results 355 cases of pneumonia were identified. Viruses were detected in 90 (25.4%). Of these 40 were viral pneumonia [incidence: 1.8% (95% CI: 1.3-2.4%)] among 2279 in-patients, and 50 were viral co-infections/ superadded infections (figure 1). Rhinovirus/ enterovirus (27) was the commonest followed by SARS-CoV2 (15), influenza A (12), and RSV A/B (10). RSV A/B was more common in CAP cases (p=0.005). CMV was more common in HAP (p=0.042). Seasonal variation was seen in influenza A/B only with the highest frequency during monsoon (p=0.000). Aspergillus (23) was most frequently detected alongside viruses, followed by Klebsiella pneumoniae (17), Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter (10 each). The overall length of hospital stay in this cohort was 16.3 days, length of ICU stay was 9.6 days, and 90-day mortality was 54.4%. Length of ICU stay was higher in viral co-infections/ superadded infections (table 2, figure 2). Conclusion Majority of pneumonia cases with viral detection are co-infections/ superadded infections associated with prolonged ICU stay. There is a need for diagnostic stewardship to ensure rapid diagnosis, and appropriate antimicrobial prophylaxis for antibacterial and antifungal cover. Disclosures All Authors: No reported disclosures

P-2279. Breakthrough Invasive Fungal Infections in Patients with Acute Myeloid Leukemia on Anti-Fungal Prophylaxis (2022)

Abstract Background Patients with hematologic malignancies, particularly Acute Myeloid Leukemia (AML), are at high risk for invasive fungal infection (IFI). Mold Active-Primary Antifungal Prophylaxis (MA-PAP) is recommended in these patients to prevent IFI, which carries high morbidity and mortality risk. Very few studies have compared rates of breakthrough IFIs (bIFIs) in AML patients treated with different MA-PAP regimens. Methods This is a single-center, retrospective cohort study of adults with AML aimed at determining the efficacy of MA-PAP and the incidence and characteristics of bIFIs. We reviewed the medical records of patients ≥ 18 years old with a diagnosis of AML admitted to Robert Wood Johnson University Hospital (RWJUH) in 2022 and received MA-PAP with either Micafungin (MYC), Voriconazole (VCZ), Posaconazole (PCZ), or Isavuconazole (ISA) for &amp;gt; 7 days. bIFIs were classified as possible, probable or proven (based on the modified EORTC/MSG criteria) if they occurred after at least 7 days of MA-PAP initiation to within two weeks of discontinuation. Results A total of 87 patients were included. Twenty patients (24.1%) experienced a total of 22 bIFI events, with 2 considered proven, 5 probable, and 15 possible. The incidence of bIFI was 15.4% for MYC, 18% for VCZ, 28% for ISA, and 0% for PCZ. 59.1% of bIFIs were in patients that were neutropenic for &amp;gt; 2 weeks at the time of bIFI. Proven bIFI were due to Candida Krusei and Mucormycosis. The mean length of hospital and ICU stay was the longest in the MYC group at 31 and 6 days respectively. Those who received VCZ experienced the highest number of reported adverse events (28, 41%) most often hepatotoxicity. Mortality was highest in PCZ (15.4%) followed by VCZ (11.5%). Conclusion Our institution experienced a high rate of bIFI, particularly among patients who received MA-PAP with VCZ or ISA. Prolonged neutropenia was an important risk factor for bIFI. Larger cohort studies are needed to accurately assess the risk factors and possibly mitigate the incidence of bIFI in this patient population on various MA-PAP. A comprehensive 10-year retrospective study is currently underway at RWJUH. Disclosures Pinki Bhatt, MD, Sanofi: Grant/Research Support Navaneeth Narayanan, PharmD, MPH, BCIDP, Astellas: Honoraria|Beckman Coulter: Honoraria|Merck: Grant/Research Support|Shionogi: Grant/Research Support

P-1030. Mortality attributable to candidemia: Results from the European Confederation of Medical Mycology Multinational Observational Cohort Study Candida III

Abstract Background Despite advances in antifungals, Candida infections still have a high mortality rate of up to 40%. The ECMM Candida III study in Europe investigated the changing epidemiology and outcomes, highlighting the need to understand and manage these infections. Methods In this observational cohort study, participating hospitals enrolled the first ten consecutive adults with confirmed candidemia. Data collected included patient demographics, risk factors, hospital stay length (with a 90-day follow-up), diagnostic procedures, Candida species, treatment details, and outcome. Controls were matched in a 1:1 ratio from the same hospitals, ensuring similarity in age, underlying illness, ICU versus normal ward stay, and recent major surgery. The study described overall and attributable mortality and assessed survival probability for both cases and controls. Results The study included 171 pairs consisting of patients with candidemia and matched controls from 28 institutions. In those with candidemia, overall mortality was 40.4%. The attributable mortality was 18.1% overall but differed among the causative Candida species (7.7% for Candida albicans, 23.7% for Candida glabrata, 7.7% for Candida parapsilosis, and 63.6% for Candida tropicalis). Regarding risk factors, the presence of central venous catheter, total parenteral nutrition, and acute or chronic kidney disease were significantly more common in cases versus controls. Length of hospitalization and ICU stay were significantly longer in candidemia cases (20 days (IQR 10-33) vs. 15 days (IQR 7-28); p=0.004). Conclusion Although overall mortality remains high in this matched case/control analysis, attributable mortality has decreased compared to historical cohorts. This may be due to a better prognosis for candidemia caused by Candida albicans, which has an attributable mortality of 7.7%, while candidemia cases caused by non-albicans Candida exhibit higher attributable mortality. Disclosures Oliver A. Cornely, Prof. Dr., Abbott: Honoraria|Abbvie: Advisor/Consultant|Abbvie: Honoraria|AiCuris: Advisor/Consultant|Akademie fur Infektionmedizin: Honoraria|Al-Jazeera Pharmaceuticals/Hikma: Honoraria|amedes: Honoraria|AstraZeneca: Honoraria|Basilea: Advisor/Consultant|Biocon: Advisor/Consultant|BMBF: Grant/Research Support|Boston Strategic Partners: Advisor/Consultant|CIdara: Advisor/Consultant|CIdara: Expert Testimony|CIdara: Grant/Research Support|CIdara: Participation on a DRC or DSMB|CoRe Consulting: Stocks/Bonds (Private Company)|Deutscher Arzteverlag: Honoraria|DZIF: Grant/Research Support|EasyRadiology: Stocks/Bonds (Private Company)|EU-DG RTD: Grant/Research Support|F2G: Grant/Research Support|Gilead: Advisor/Consultant|Gilead: Grant/Research Support|Gilead: Honoraria|Grupo Biotoscana/United Medical/Knight: Honoraria|GSK: Advisor/Consultant|GSK: Honoraria|IQVIA: Advisor/Consultant|IQVIA: Participation on a DRC or DSMB|Janssen: Advisor/Consultant|Janssen: Participation on a DRC or DSMB|Matinas: Advisor/Consultant|MedPace: Advisor/Consultant|MedPace: Grant/Research Support|MedPace: Participation on a DRC or DSMB|Medscape/WebMD: Honoraria|MedUpdate: Honoraria|Menarini: Advisor/Consultant|Moderna: Honoraria|Molecular Partners: Advisor/Consultant|MSD: Grant/Research Support|MSD: Honoraria|MSG-ERC: Advisor/Consultant|Mundipharma: Advisor/Consultant|Mundipharma: Grant/Research Support|Mundipharma: Honoraria|Noscendo: Honoraria|Noxxon: Advisor/Consultant|Octapharma: Advisor/Consultant|Octapharma: Grant/Research Support|Pardes: Advisor/Consultant|Partner Therapeutics: Advisor/Consultant|Patent: US18/562644|Paul-Martini-Stiftung: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Pfizer: Honoraria|PSI: Advisor/Consultant|PSI: Participation on a DRC or DSMB|Pulmocide: Participation on a DRC or DSMB|Sandoz: Honoraria|Scynexis: Advisor/Consultant|Scynexis: Grant/Research Support|Seqirus: Advisor/Consultant|Seqirus: Honoraria|Seres: Advisor/Consultant|Shionogi: Advisor/Consultant|Shionogi: Honoraria|streamedup!: Honoraria|The Prime Meridian Group: Advisor/Consultant|Touch Independent: Honoraria|Vitis: Honoraria Jean-Pierre Gangneux, Prof., Gilead: Honoraria|MundiPharma: Advisor/Consultant|MundiPharma: Honoraria|Pfizer: Honoraria|Shionogi: Honoraria Matteo Bassetti, PhD, Angelini: Advisor/Consultant|Angelini: Honoraria|Astellas: Advisor/Consultant|Astellas: Honoraria|bioMerieux: Advisor/Consultant|bioMerieux: Honoraria|Cidara: Advisor/Consultant|Cidara: Honoraria|Gilead: Advisor/Consultant|Gilead: Honoraria|Menarini: Advisor/Consultant|Menarini: Honoraria|MSD: Advisor/Consultant|MSD: Honoraria|Nabriva: Advisor/Consultant|Nabriva: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria|Tetraphase: Advisor/Consultant|Tetraphase: Honoraria

P-421. Impact of Rapid Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Polymerase Chain Reaction (PCR) Screening on Duration of Vancomycin (Vanc) Therapy for Suspected Pneumonia (PNA) in Adult Patients (Pts) Admitted to the Trauma Intensive Care Unit (TICU)

Abstract Background At this institution on June 30, 2022, universal nasal decolonization with mupirocin ointment was replaced by nasal MRSA PCR assay screening at ICU admission to capture MRSA colonization and direct nasal decolonization. The aim of this study was to evaluate the impact of nasal MRSA PCR assay screening on duration of vanc for suspected PNA in adults admitted to the TICU.Table 1.Baseline and Treatment Characteristics Methods This single-center, retrospective cohort study compared pts from Jan - Jun 2022 (pre cohort) and Jan - Jun 2023 (post cohort). Pts ≥ 18 years of age admitted to the TICU that received empiric cefepime, meropenem, or piperacillin/tazobactam for suspected PNA documented on chest imaging were included. Pts who received vancomycin for a non-PNA indication, were previously treated for PNA during the admission, had structural lung disease, or had a pathogen identified on culture at the time of antibiotic (abx) initiation were excluded. The primary outcome was duration of vanc (hrs). Secondary outcomes included nasal MRSA PCR assay correlation with culture results from respiratory specimens, opportunities for vanc de-escalation based on negative nasal MRSA PCR assay within 36 hrs, ICU and hospital length of stay and mortality.Table 2.Primary and Secondary Outcomes Results 37 pts were included in each cohort. There were no significant differences in baseline characteristics (Table 1). 36 (97%) pts received vanc in the pre cohort compared to 26 (70%) pts in the post cohort (P &amp;lt; 0.01). The primary outcome (Table 2) of median vancomycin duration was 25 [14, 49] hrs in the pre cohort compared to 14 [0, 36] hrs in the post cohort (P = 0.02). Secondary outcomes are reported in Tables 2 and 3. The negative predictive value of the nasal MRSA PCR assay for PNA with MRSA was 100% in this study. MRSA was not identified on respiratory culture in either cohort.Table 3.Opportunities for De-escalation (Post Cohort) Conclusion Vanc usage and duration of therapy were significantly reduced after nasal MRSA PCR assay screening on ICU admission was implemented in the TICU. However, additional opportunities for improved stewardship of empiric initiation of vanc were identified based on the described vanc usage and lack of MRSA PNA. Disclosures John C. Williamson, PharmD, Armata Pharmaceuticals: Grant/Research Support|Blue Collar Vaccines and Therapeutics: Board Member|Blue Collar Vaccines and Therapeutics: Ownership Interest|Paratek Pharmaceuticals: Grant/Research Support|ST Pharm Co, Ltd: Grant/Research Support

590. Impact of Universal Nasal Decolonization with an Alcohol-Based Nasal Antiseptic (ABNA) Versus Mupirocin on Infection Rates and Antimicrobial Utilization in Patients (Pts) Admitted to the Burn Service

Abstract Background On Jan 31, 2023, ABNA replaced universal mupirocin nasal decolonization in pts admitted to the burn service. The purpose of this study was to evaluate the impact of universal nasal decolonization with ABNA vs mupirocin on infection rates and antimicrobial utilization in this pt population.Table 1.Baseline Characteristics Methods This was a single-center, retrospective, cohort analysis of adults ≥ 18 yrs of age admitted to an academic medical center burn service from Feb 2022 - Sept 2022 (mupirocin cohort) and Feb 2023 - Sept 2023 (ABNA cohort) who received ≥ 1 dose of nasal mupirocin or ABNA. Pts were excluded if they were admitted for a non-burn injury, on the burn service for &amp;lt; 4 days, or received nasal decolonization ≤ 6 months prior to admission. The primary outcome was incidence of staphylococcal infection, defined as a staphylococcal organism identified from a blood, respiratory, or wound culture with corresponding diagnosis of pneumonia (PNA), bacteremia, or skin and soft tissue infection (SSTI). Secondary outcomes included incidence of PNA, bacteremia, and SSTIs; MRSA bacteremia LabID event rate and CLABSI event rate as defined by the National Healthcare Safety Network; antimicrobial days of therapy; ICU and hospital length of stay; and hospital mortality.Table 2.Primary and Secondary Outcomes Results 73 pts in the mupirocin cohort and 81 pts in the ABNA cohort were included. The only significant difference in baseline characteristics (Table 1) was 56 (76%) pts in the mupirocin cohort were male vs 46 (57%) pts in the ABNA cohort (P &amp;lt; 0.01). Staphylococcal infection occurred in 7 (10%) pts in the mupirocin cohort vs 16 (20%) pts in the ABNA cohort (P = 0.08, Table 2). A Kaplan Meier analysis of time to staphylococcal infection is reported in Figure 1. Secondary outcomes are reported in Table 2. 2 (3%) pts in mupirocin cohort had staphylococcal bacteremia vs 10 (12%) pts in the ABNA cohort (P = 0.03). 12 (16%) pts in the mupirocin cohort vs 27 (33%) pts in the ABNA cohort had an infection (PNA, SSTI, or bacteremia) caused by any organism (P = 0.02), including 3 (4%) pts vs 12 (15%) pts with bacteremia (P = 0.03, Table 3).Table 3:Microbiology of Bacteremia Conclusion Pts who received ABNA had a higher incidence of staphylococcal bacteremia, overall bacteremia, and overall infections when compared to pts who received nasal mupirocin. Additional studies are needed to further evaluate the effectiveness of ABNA.Figure 1.Kaplan Meier Analysis, Time to Staphylococcal Infection Disclosures John C. Williamson, PharmD, Armata Pharmaceuticals: Grant/Research Support|Blue Collar Vaccines and Therapeutics: Board Member|Blue Collar Vaccines and Therapeutics: Ownership Interest|Paratek Pharmaceuticals: Grant/Research Support|ST Pharm Co, Ltd: Grant/Research Support

P-426. Antimicrobial Resistance Focus in French ICU: A national surveillance network analysis on ventilator acquired pneumonia

Abstract Background The aim of this study was to perform a characterization of patients who underwent mechanical ventilation, the incidence rate of ventilator acquired pneumoniae (VAP) as well as identification of the pathogens involved, their resistance profiles, and the associated clinical outcomes. This group will be scrutinized for patterns and outcomes specifically associated with ventilator use. Cumulative incidence of VAP Methods Adult patients undergoing mechanical ventilation hospitalized in France for at least 48 hours in ICU participating to REA-REZO surveillance network between 2018 and 2021 were included in this cohort. To estimate the cumulative incidence of VAP, extubation and death were considered as competing event. Description of the cohort Results In this cohort, 98 047 patients were included. Among them, 12 251 (12.5%) had a VAP; the incidence rate for 1000 ventilation days was 18.9 cases per 1000 ventilation days. The median age of the cohort is 66 [55-75] years old with a male predominance (63.0 %). The SAPS score is 49 [36-63], the mortality is 24.4 % and the median ICU length of stay is 7 [4-15] days. Ventilated patients are more frequently admitted for medical (63.0 %) compared to surgical (37.0%) reason. At day 30, the attributable mortality associated with ventilator-associated pneumonia (VAP) was estimated at 4.9% (3.7% - 6.2%). Out of 15,575 diagnosed cases of VAP, there were 4,695 instances of polymicrobial VAP, which constitutes 30.1% of the cases. Non-fermenting Gram-negative bacteria were a significant group, contributing to 25.4% of the VAP cases, with Pseudomonas aeruginosa being the most significant contributor (3 924 cases, 76.2% of non-fermenters) Description of the microbial ecology of VAP Conclusion The development of VAP is frequent, especially in patients admitted for medical reasons, with high severity and appears to be associated with an increased use of medical devices, like urinary and central venous catheters, reflecting the complexity of their clinical management. Disclosures Xavier Bourge, PharmD, MSD France: Employee Arnaud Friggeri, MD, MSD France: Advisor/Consultant Alain Lepape, MD, MSD France: Grant/Research Support Claire Prevot, n/a, MSD France: Employee Anais Machut, n/a, MSD France: Grant/Research Support Charles-Hervé Vacheron, MD, MSD France: Grant/Research Support

P-1524. Clinical Characteristics and Outcomes of Patients with Candida auris at RUHS

Abstract Background Invasive Candidiasis Clinical Associations *: Immunocompromised status including patients on chemotherapy, status post organ transplant, HIV positive, etc. Methods We conducted a retrospective chart review of C. auris fungemia cases in adult hospitalized patients at RUHS between January 2022 to December 2023. Demographic data, clinical associations, antifungal susceptibility and clinical outcomes were noted using descriptive statistics. Antifungal Susceptibility Results Nine patients (n = 9) were identified. 8/9 (89%) presented from a long-term care facility. 5/9 (56%) patients were male gender averaging 65 years old (range 45-86yo). Charlson comorbidity index was 8.11. Clinical associations: invasive devices (9/9, 100%), long-term care residence (8/9, 89%), hospitalization within 90 days (7/9, 78%), IV antibiotic within 90 days (8/9, 89%), and surgery (5/9, 56%). All patients were treated with micafungin. Despite 100% susceptibility to echinocandins, fungemia duration was long (mean 242.1 hours; range 39.13-1431.75 hours) and 4/9 (44%) patients required a dose increase of micafungin (mean dose 194 mg; range 100-300 mg). Cases were further characterized by prolonged ICU length of stay (LOS (mean 15d, range 3-41d)), prolonged hospital LOS (mean 39.3d, range 9-65d), and high mortality (4/9, 44%). 2/5 (40%) survivors versus 0/4 (0%) deceased patients had source control. The majority of survivors 4/5 (80%) had a primary line-associated fungemia. 2/5 survivors (40%) were readmitted within 6 months. Mortality in Relation to Source Control Conclusion Patients from long-term care facility with additional clinical associations appear to have high risk for C. auris infection and complications. Consideration of higher initial dose echinocandins should be considered in management of patients presenting with C.auris fungemia. Aggressive source control of fungemia etiology should be pursued when possible. Disclosures All Authors: No reported disclosures

P-1814. Say it Ain't Steno - Impact of a Microbiology Nudge Comment on Treatment of Respiratory Colonization

Abstract Background Stenotrophomonas maltophilia (SM) is a known colonizer of the respiratory tract, in which treatment is not required. Microbiological comment “nudges” have been successful as passive stewardship interventions. The study objective was to describe the effect of a targeted SM respiratory culture nudge on antibiotic use in patients with colonization. Methods IRB approved quasi-experiment of adult patients with a SM respiratory culture between 01/01/2022-01/27/2023 (pre-nudge) and 03/27/2023-12/31/2023 (post-nudge). Patients with criteria for active community/hospital/ventilator-acquired pneumonia or on targeted antibiotics prior to culture were excluded. Nudge comment implemented 2/2023: “S. maltophilia is a frequent colonizer of the respiratory tract. Clinical correlation for infection is required. Colonizers do not require antibiotic treatment.” The primary outcome was absence of SM therapy; secondary outcomes were SM therapy &amp;gt; 72 hours, hospital and ICU length of stay (LOS), and in-hospital all-cause mortality. Safety outcomes included antibiotic-related adverse events. Results 94 patients were included: 53 (56.4%) pre- and 41 (43.6%) post-nudge. Most patients were men (53, 56.4%), had underlying lung disease (61, 64.8%), and required invasive ventilatory support (70, 74.5%). 11 (11.7%) patients were admitted from a long-term care facility. The absence of SM therapy was observed in 13 (23.1%) pre- vs 32 (78.0%) post-nudge patients (P&amp;lt; 0.001). There were no differences in SM therapy &amp;gt; 72 hours (36/40 [90%] vs. 8/9 [88.9%], P=1.0), mortality (11 [20.8%] vs. 7 [17.5%], P=0.69), median (IQR) hospital LOS (24 [10-49] vs. 16 [8-29]), P=0.37), and median (IQR) ICU LOS [15 [2-35] vs. 11 [3-25], P=0.40) between pre- and post-nudge groups, respectively. Safety outcomes of patients treated &amp;gt; 72 hours (n=41); elevated SCr 12 (29.3%), fluid overload 18 (43.9%), hyponatremia 17 (41.5%), and hyperkalemia 5 (12.2%). After adjustment for confounders, post-nudge was associated with 11-fold increased odds of the absence of SM therapy (Table 1). Conclusion A targeted SM nudge was associated with a reduction in treatment of SM colonization. Patient outcomes, including length of stay and all-cause mortality, were comparable between the two groups. Disclosures Rachel M. Kenney, PharmD, BCIDP, Medtronic Inc: Spouse is an employee, stockholder

P-1617. Clinical and microbiologic outcomes associated with implementation of MALDI-TOF on patients with anerobic, fungal, and non-lactose fermenting specimens

Abstract Background MALDI-TOF is a rapid-diagnostic technology that improves the speed and accuracy of organism identification. Using it to identify resistant pathogens and fastidious organisms is a high impact diagnostic stewardship opportunity. This study aims to evaluate its effect on the management of infections caused by non-lactose fermenting (NLF) Gram-negative rods (GNRs), anaerobes, and yeast from sterile sites.Figure 1.Screening Process Methods This was a single center, quasi-experimental study of patients with NLF GNRs in respiratory specimens and anaerobes and/or yeast from sterile sites before and after the implementation of MALDI-TOF from 2021-2023. There were no changes in antimicrobial stewardship culture review or audit and feedback processes during the study period. The primary outcome was time to organism identification. Secondary endpoints were time to antimicrobial adjustment, inpatient antibiotic duration, and in-hospital mortality. Categorical descriptive data was expressed as percentages and as median/interquartile range (IQR) if continuous. Chi-squared/Fisher’s Exact test and Mann-Whitney-U were used as appropriate to compare endpoints between groups.Table 1.Patient characteristics and Secondary Endpoints by MALDI-TOF Identified Organism Results Of 225 patients screened, 108 were included (Figure 1). The median Charlson score was 3 (1-5). The overall length of stay was 30 (13-54) days; 75 (70%) patients had an ICU stay with a median ICU length of stay of 17 (4-31) days. The most common organisms identified were Pseudomonas aeruginosa, Bacteroides spp, Candida albicans, and Nakaseomyces glabratus (formerly C. glabrata) (Figure 2). Time from Gram-stain to organism identification was reduced from 77 (41-119) hours to 41 (26-56) hours (p&amp;lt; 0.001) (Table 1). Time to antimicrobial adjustment and inpatient duration of antibiotics were not different between pre- and post- implementation of MALDI-TOF for infections caused by anaerobic and NLF GNRs but was reduced in patients with yeast in sterile sites. There was no difference in in-hospital mortality.Figure 2.Percentages of Organisms Identified by MALDI-TOF Conclusion Implementation of MALDI-TOF for identification of these organisms improved culture processing turn-around time, antimicrobial optimization, particularly for yeast, and stewardship efforts at our institution. Disclosures Daniel Diekema, MD, MS, D(ABMM), Affinity Biosensors: Grant/Research Support|bioMerieux, Inc: Grant/Research Support

P-1722. Short versus Long Duration of Empiric Antifungal Use Among Patients with Sepsis or Septic Shock

Abstract Background Invasive candidiasis is associated with high mortality rates among critically ill patients. There are currently no data to guide duration of empiric antifungal therapy (EAT) when indicated in high-risk patients with sepsis. The aim of this study was to evaluate clinical outcomes associated with a short versus long course of EAT in patients with sepsis or septic shock. Methods This was a retrospective cohort study of adults admitted to the medical ICU who received &amp;gt; 2 days of EAT with fluconazole or caspofungin for sepsis or septic shock. Patients were excluded if they expired within 48 hours, had a positive fungal culture from a sterile site, were exposed to a systemic antifungal for &amp;gt; 48 hours in the 14 days preceding treatment, received prophylactic antifungals, or were neutropenic. In addition, patients who expired within 96 hours of EAT initiation were excluded from the primary outcome analysis. Patients were grouped according to receipt of EAT for ≤ 4 days (short duration) or &amp;gt; 4 days (long duration). The primary outcome was 30-day all-cause mortality. Secondary outcomes included time to mortality, hospital and ICU length of stay (LOS), vasopressor-free days over 14 days, and 30-day new proven fungal infection. Results Of 135 included patients, 79 patients received short course EAT vs. 56 patients long course (Figure 1). Baseline variables were well balanced between groups apart from older age and lower body weight observed in the short duration group (Table 1). The primary outcome, evaluable in a total of 114 patients, was observed in 33 (56.9%) patients who received a short duration and 26 (46.4%) patients who received a long duration (p=0.263; OR 1.52, 95% CI [0.73 – 3.19]). There were no significant differences in all-cause inpatient mortality or time to mortality (Figure 2). Among patients who were discharged alive, there were no significant differences in secondary outcomes with the exception of fewer vasopressor-free days in the short course group (Table 2). Conclusion Most clinical outcomes were not significantly different between patients with sepsis or septic shock who received a short versus long course of EAT. Duration of EAT is an important target for stewardship programs. This study adds to knowledge in the area, though a randomized trial may be necessary to substantiate our findings. Disclosures All Authors: No reported disclosures

P-1761. Safety and Efficacy of Antimicrobial Optimization based on Negative Results from BioFire FilmArray Pneumonia Panel

Abstract Background The BioFire FilmArray Pneumonia (BFP) panel is a multiplexed nucleic acid test intended for detection of multiple respiratory viral and bacterial specimens from sputum or bronchoalveolar lavage (BAL) specimens, with high specificity and turnaround time. Efficacy and safety of de-escalation strategies in patients with negative BFP have not been adequately described. Methods This was a multi-center, retrospective analysis of adult patients with suspected pneumonia and sputum or BAL samples that tested negative on BFP. Patients for whom antibiotic therapy was discontinued (ATDC Group) were compared to patients who had their antibiotic therapy continued (ATC Group). Outcomes included in-hospital mortality, 30-day readmission, and hospital and ICU length of stay. Impact on the total number of days on antibiotics and the safety of the intervention were also assessed. Results Out of 500 patients with negative BFP assay, a total of 185 patients were included in the final analysis (59 ATDC Group vs. 126 ATC Group). 67.6% of samples were sputum and 32.4% were BAL in the entire cohort. The groups were generally well-balanced in baseline characteristics, but more patients in ATC Group had community-acquired pneumonia (59% vs 79%, p = 0.006), higher initial white blood cell count (10 vs 13, p = 0.038), and higher quick Pitt Bacteremia Score (1 [IQR 0-1] vs 1 [IQR 0-3], p = 0.020). The ATDC Group had significantly shorter days of total antibiotic therapy (1.0 days vs 10.6 days, p &amp;lt; 0.001). 30-day readmission rates (16.95% vs 15.87%, p = 0.853) and the hospital length of stay (8.34 days vs 7.75, p = 0.960) did not differ. The ATDC Group experienced fewer AKI (8% vs 37%, p = 0.004). Duration of Antibiotics Conclusion Antibiotic discontinuation based on BFP was associated with significant reduction in the number of total days on antibiotics. Discontinuation was not associated with increases in in-hospital mortality, length of stay, or readmission, but was associated with a significant reduction in acute kidney injury. Disclosures All Authors: No reported disclosures

P-1077. Study of Prescribing patterns and Effectiveness of Ceftolozane/Tazobactam (C/T) Real-world Analysis (SPECTRA): Clinical Outcomes and Treatment Patterns from Mexico

Abstract Background Reported are results of SPECTRA data from Mexico Methods SPECTRA (n=617) is a 7-country multicentre retrospective observational study, including hospitalized adult patients (≥18 years) treated with C/T for ≥48 hours. Medical records were reviewed for 30 days after the last dose of C/T or until death. Reported are clinical outcomes and treatment patterns in Mexico.Table 2.All-cause in-hospital mortality (ACHM) in the Mexico cohort Results Mean age of patients (n=59) is 55.2 years, and 47.5% were female. Common comorbidities were diabetes mellitus (DM) uncomplicated (18.6%) and DM with end organ damage (3.4%), transplantation (16.9%), heart disease (16.9%), chronic kidney disease (11.9%), chronic pulmonary disease (10.2%), acute kidney injury (10.2%), and end-stage renal disease (3.4%). From positive cultures (n=32) were found 21 multi-drug resistant (MDR) Pseudomonas aeruginosa (PsA) (65.6%) and 4 MDR Enterbacterecea (12.5%). C/T was used to treat pneumonia (30/59, 50.8%), complicated intra-abdominal infection (9/59,15.3%), complicated urinary tract infection (8/59, 13.6%), bone and joint infection (8/59, 13.6%), and sepsis (8/59, 13.6%). Mean time from the index hospitalization admission to C/T initiation is 16.0 days. Mean time from the first microbiology (MB) sample for the index infection to C/T initiation is 1.9 days. C/T treatment duration was median 8.0 days (Q1:Q3; 5, 11). Doses included 54.2% 1.5g/Q8h; 39.0% 3g/Q8h; 5.1% 750mg/Q8h; 1.7% 1g/Q8h. C/T rank of initiations: first-line (49.2%), second-line (42.4%), third-line (6.8%), fourth-line (0), fifth-line (1.7%), sixth+line (0). Of all the cases, empiric therapy accounted for (37/59) 62.7%, definitive therapy in (17/59) 28.8%, and undetermined (5/59) (8.5%). Clinical success rate for treating the index infection with C/T is 79.7% of patients (Table 1). All-Cause-Hospital-Mortality (ACHM) is 16.9%. Median time from index date to death is 12.0 days (Table 2). ICU admission is reported in 42.4% of cases, with a median ICU length of stay at 20.0 days (Table 3).Table 3.ICU admission and LOS during the index hospitalisation from the Mexico† ICU LOS if ICU admission was related to index infection.CI, confidence interval; ICU, intensive care unit; LOS, length of stay; SD, standard deviation. Conclusion Results show real-world effectiveness of C/T in Mexico, more research is warranted. Disclosures Yanbing Zhou, PhD, Merck: I am a full time Merck Employee and own stocks in the retirement plan provided by Merck.|Merck: Stocks/Bonds (Public Company) Thales Polis, MD, MSD: Stocks/Bonds (Public Company) Emre Yucel, PhD, Merck: I am a full time Merck Employee and own stocks in the retirement plan provided by Merck.|Merck: Stocks/Bonds (Public Company)

Cytomegalovirus Blood DNAemia in Patients with Severe SARS-CoV-2 Pneumonia

Introduction: Cytomegalovirus (CMV) DNAemia has been described in critically ill patients, including patients with severe acute respiratory syndrome-coronavirus2 (SARS-CoV-2) infection. Our objective is to evaluate the prevalence and clinical impact of CMV DNAemia among patients undergoing invasive mechanical ventilation (IMV) for severe SARS-CoV-2 infection and to explore the association between CMV DNAemia levels and clinical outcomes. Methods: In this retrospective monocentric study, we included patients admitted in a tertiary ICU for severe COVID-19 and who required IMV. We aimed to compare clinical and demographic variables between patients with and without CMV DNAemia. Univariate and Cox regression analyses were performed to identify factors associated with CMV DNAemia. Results: During the study period, CMV blood DNAemia occurred in 30/135 patients (22%). Patients with CMV blood DNAemia had longer ICU and hospital length of stay, as well as longer duration of IMV, and were more likely to have received dexamethasone. However, there was no significant difference in ICU mortality between patients with and without CMV DNAemia (64.8% vs. 56.7%, p = 0.42). The Cox regression analysis showed that dexamethasone was the only factor independently associated with CMV blood DNAemia (HR 4.23 [1.006–17.792], p = 0.049). Conclusions: In patients with severe SARS-CoV-2 pneumonia requiring IMV, CMV DNAemia is common and associated with prolonged ventilation and increased LOS but not with increased mortality.

Hypocapnia and its relationship with in-hospital mortality in acute heart failure patients: Insights from the Indonesian multicenter ICCU registry

Acute heart failure (AHF) presents serious risks for hospitalized patients. The aim of this study was to explore the relationship between arterial partial pressure of carbon dioxide (PaCO2) levels and outcomes in AHF patients admitted to the intensive cardiovascular care unit (ICCU), utilizing data from the IndONEsia ICCU Registry (One ICCU Registry). A multicenter retrospective observational study was performed covering data between August 2021-2023. Participants were categorized by PaCO2 levels: hypocapnia (&lt;35 mmHg), normocapnia (35–45 mmHg), and hypercapnia (&gt;45 mmHg). The primary outcomes included ICCU mortality, in-hospital mortality, and 30-day mortality, whereas the length of the stays in the ICCU or hospital and ventilation requirement were set as the secondary outcomes. Mortality risks were assessed using Cox proportional hazards models. Of the 1,870 patients, 1,102 (58.96%) had hypocapnia, 645 (34.5%) had normocapnia, and 123 (6.5%) had hypercapnia. Hypocapnia patients had significantly higher ICCU, in-hospital, and at 30-day mortality rates compared to normocapnic patients (all p&lt;0.001), along with longer lengths of stay in ICCU and in hospital (p&lt;0.001). Hypocapnia significantly increased noninvasive and mechanical ventilation requirement compared to normocapnia patients. Multivariate analysis identified factors impacting patients’ survival, including age, treatment with angiotensin-converting enzyme inhibitors (ACEi)/angiotensin II receptor blockers (ARBs) drugs, and severity scores such as the quick sequential organ failure assessment (qSOFA) and simplified acute physiology score II (SAPS II). In conclusion, hypocapnia in AHF patients could increase in-hospital, ICU and 30-days mortality rates and length of hospital stays, as well as noninvasive and mechanical ventilation requirements.

Effects of osteosynthesis of the bony thorax in the context of polytrauma compared to conservative treatment: a systematic review

PurposeOsteosynthesis seems to have effects regarding clinical outcomes in trauma patients. However, current knowledge on chest wall osteosynthesis in polytrauma patients is insufficient, leaving its potential unanswered. Therefore, the objective of this systematic review is to assess the safety and effects of chest wall osteosynthesis compared to conservative treatment on clinical outcomes in adult polytrauma patients.MethodsWe searched PubMed to identify completed and ongoing studies from inception of each database to May, 2022. We included systematic reviews including RCTs comparing chest wall osteosynthesis to conservative treatment in adult polytrauma patients.ResultsWe included one RCT with 50 patients (nosteosyntheses = 25, ncontrol = 25, median age 37.4 years, 82% male). We found that surgical rib fixation makes little or no difference to in-hospital mortality compared to conservative treatment (RR 2.00, 95% CI 0.40 to 9.95; RD 80 more per 1,000, 95% CI 48 fewer to 716 more; 1 study, 50 participants, low quality of evidence). We found that surgical rib fixation makes little or no difference to the need for mechanical ventilation compared to conservative treatment (RR 0.90, 95% CI -0.66 to 1.23; RD 80 fewer per 1,000, 95% CI 272 fewer to 184 more; 1 study, 50 participants, low certainty of evidence).ConclusionThere is limited evidence regarding chest wall osteosynthesis compared to conservative treatment in polytrauma patients. One RCT shows no effect of surgical rib fixation compared to conservative treatment regarding mortality and clinical status, but a potential benefit regarding ICU length of stay.