Molecular epidemiology of Candida albicans and Candida glabrata strains isolated from intensive care unit patients in Poland

Over the last decades, Candida spp have been responsible for an increasing number of infections, especially in patients requiring intensive care. Knowledge of local epidemiology and analysis of the spread of these pathogens is important in understanding and controlling their transmission. The aim of this study was to evaluate the genetic diversity of 31 Candida albicans and 17 Candida glabrata isolates recovered from intensive care unit patients from the tertiary hospital in Krakow between 2011-2012. The strains were typed by random amplified polymorphic DNA (RAPD) polymerase chain reaction using five primers (CD16AS, HP1247, ERIC-2, OPE-3 and OPE-18). The results of the present investigation revealed a high degree of genetic diversity among the isolates. No clonal relationship was found among the C. albicans strains, whereas two C. glabrata isolates were identical. The source of Candida infection appeared to be mostly endogenous; however, the presence of two clonal C. glabrata strains suggested the possibility of cross-transmission of these pathogens. Our study confirmed the high discriminatory power of the RAPD technique in the molecular typing of Candida clinical isolates. This method may be applied to the evaluation of transmission routes of pathogenic fungi on a local level.

Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: the EUROBACT International Cohort Study.

PURPOSE: The recent increase in drug-resistant micro-organisms complicates the management of hospital-acquired bloodstream infections (HA-BSIs). We investigated the epidemiology of HA-BSI and evaluated the impact of drug resistance on outcomes of critically ill patients, controlling for patient characteristics and infection management. METHODS: A prospective, multicentre non-representative cohort study was conducted in 162 intensive care units (ICUs) in 24 countries. RESULTS: We included 1,156 patients [mean ± standard deviation (SD) age, 59.5 ± 17.7 years; 65 % males; mean ± SD Simplified Acute Physiology Score (SAPS) II score, 50 ± 17] with HA-BSIs, of which 76 % were ICU-acquired. Median time to diagnosis was 14 [interquartile range (IQR), 7-26] days after hospital admission. Polymicrobial infections accounted for 12 % of cases. Among monomicrobial infections, 58.3 % were gram-negative, 32.8 % gram-positive, 7.8 % fungal and 1.2 % due to strict anaerobes. Overall, 629 (47.8 %) isolates were multidrug-resistant (MDR), including 270 (20.5 %) extensively resistant (XDR), and 5 (0.4 %) pan-drug-resistant (PDR). Micro-organism distribution and MDR occurrence varied significantly (p < 0.001) by country. The 28-day all-cause fatality rate was 36 %. In the multivariable model including micro-organism, patient and centre variables, independent predictors of 28-day mortality included MDR isolate [odds ratio (OR), 1.49; 95 % confidence interval (95 %CI), 1.07-2.06], uncontrolled infection source (OR, 5.86; 95 %CI, 2.5-13.9) and timing to adequate treatment (before day 6 since blood culture collection versus never, OR, 0.38; 95 %CI, 0.23-0.63; since day 6 versus never, OR, 0.20; 95 %CI, 0.08-0.47). CONCLUSIONS: MDR and XDR bacteria (especially gram-negative) are common in HA-BSIs in critically ill patients and are associated with increased 28-day mortality. Intensified efforts to prevent HA-BSIs and to optimize their management through adequate source control and antibiotic therapy are needed to improve outcomes.

Delay for admission of unstable hospitalized patients to intensive care unit: a need for a medical emergency team?

INTRODUCTION. Patients admitted in Intensive Care Unit (ICU) from general wards are more severe and have a higher mortality than those admitted from emergency department as reported [1]. The majority of them develop signs of instability (e.g. tachypnea, tachycardia, hypotension, decreased oxygen saturation and change in conscious state) several hours before ICU admission. Considering this fact and that in-hospital cardiac arrests and unexpected deaths are usually preceded by warning signs, immediate on site intervention by specialists may be effective. This gave an impulse to medical emergency team (MET) implementation, which has been shown to decrease cardiac arrest, morbidity and mortality in several hospitals. OBJECTIVES AND METHODS. In order to verify if the same was true in our hospital and to determine if there was a need for MET, we prospectively collected all non elective ICU admissions of already hospitalized patients (general wards) and of patients remaining more than 3 h in emergency department (considered hospitalized). Instability criteria leading to MET call correspond to those described in the literature. The delay between the development of one criterion and ICU admission was registered. RESULTS. During an observation period of 12 months, 321 patients with our MET criteria were admitted to ICU. 88 patients came from the emergency department, 115 from the surgical and 113 from the medical ward. 65% were male. The median age was 65 years (range 17-89). The delay fromMETcriteria development to ICU admission was higher than 8 h in 155 patients, with a median delay of 32 h and a range of 8.4 h to 10 days. For the remaining 166 patients, an early MET criterion was present up to 8 h (median delay 3 h) before ICU admission. These results are quite concordant with the data reported in the literature (ref 1-8). 122 patients presented signs of sepsis or septic shock, 70 patients a respiratory failure, 58 patients a cardiac emergency. Cardiac arrest represent 5% of our collective of patients. CONCLUSIONS.Similar to others observations, the majority of hospitalized patients admitted on emergency basis in our ICU have warning signs lasting for several hours. More than half of them were unstable for more than 8 h. This shows there is plenty of time for early acute management by dedicated and specialized team such as MET. However, further studies are required to determine if MET implementation can reduce in-hospital cardiac arrests and influence the morbidity, the length of stay and the mortality.

Delirium auf der Intensivstation [Delirium in the intensive care unit.]

The prevalence of delirium in the Intensive Care Unit (ICU) is reported to vary from 20 to 80 %. Delirium in the ICU is not only a frightening experience for the patient and his or her family, it is also a challenge for the nurses and physicians taking care of the patient. Furthermore, it is also associated with worse outcome, prolonged hospitalisation, increased costs, long-term cognitive impairment and higher mortality rates. Thus, strategies to prevent ICU-delirium in addition to the early diagnosis and treatment of delirium are important. The pathophysiology of delirium is still incompletely understood, but numerous risk factors for the development of delirium have been identified in ICU-patients, among which are potentially modifiable factors such as metabolic disturbances, hypotension, anaemia, fever and infection. Key factors are the prevention and management of common risk factors, including avoiding overzealous sedation and analgesia and creating an environment that enhances reintegration. Once delirium is diagnosed, treatment consists of the use of typical and atypical antipsychotics. Haloperidol is still the drug of choice for the treatment of delirium and can be given intravenously in incremental doses of 1 to 2 to 5 (to 10) mg every 15 - 20 minutes.

Is it worth treating fever in intensive care unit patients? Preliminary results from a randomized trial of the effect of external cooling.

BACKGROUND: Antipyresis is a common clinical practice in intensive care, although it is unknown if fever is harmful, beneficial, or a negligible adverse effect of infection and inflammation. METHODS: In a randomized study, rectal temperature and discomfort were assessed in 38 surgical intensive care unit patients without neurotrauma or severe hypoxemia and with fever (temperature >/=38.5 degrees C) and systemic inflammatory response syndrome. Eighteen patients received external cooling while 20 received no antipyretic treatment. RESULTS: Temperature and discomfort decreased similarly in both groups after 24 hours. No significant differences in recurrence of fever, incidence of infection, antibiotic therapy, intensive care unit and hospital length of stay, or mortality were noted between the groups. CONCLUSIONS: These results suggest that the systematic suppression of fever may not be useful in patients without severe cranial trauma or significant hypoxemia. Letting fever take its natural course does not seem to harm patients with systemic inflammatory response syndrome or influence the discomfort level and may save costs.

Intégrer les préférences des patients dans les projets thérapeutiques de médecine intensive [To integrate patient's preferences in intensive care treatment plans]

An increasing number of terminally ill patients are admitted into the intensive care unit, and decisions of limitation, or of palliative care are made to avoid medical futility. The principle of autonomy states that the patient (or in case of necessity his relatives) should make end of life decision after detailed information. The exercise of autonomy is difficult due to the disease of the patient and the nature of invasive treatments, but also due to organisational and communication barriers. The latter can be surmounted by a proactive approach. Early communication with the patient and relatives about the sometimes-limited expectations of an invasive treatment plan, and the possibility of palliative care allow to integer patient's preferences in the formulation of a therapeutical plan.

Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians.

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment.

Use of a multidimensional assessment tool in a psychiatric adolescent care unit.

AIMS: Adolescent mental health problems require treatment and care that are adapted to their needs. To evaluate this issue, it was decided to implement a multidimensional instrument focused on a global approach to adolescent social and behavioural functioning, combined with the ICD-10 classification. METHODS: The combination of an assessment interview and a classification tool enabled the method to integrate the measurement of several domains of patient-based outcome rather than focus on the measurement of symptoms. A group of 68 adolescents from an inpatient unit were compared with 67 adolescents from the general population. RESULTS: Results suggest that adolescents from the care unit adopt significantly riskier behaviour compared with adolescents from the control group. As expected, the main problems identified refer to the psychological and familial areas. A cluster analysis was performed and provided three different profiles: a group with externalizing disorders and two groups with internalizing disorders. On the basis of a structured interview it was possible to obtain information in a systematic way about the adolescents' trajectory (delinquency, physical and sexual abuse, psychoactive substance use). CONCLUSION: It was shown that treatment and care should not focus exclusively on mental health symptoms, but also upon physical, psychological and social aspects of the adolescent. A global approach helps in the consideration of the multitude of factors which must be taken into account when working with people with serious mental health problems and may help to turn the care unit's activity more specifically towards the needs of these adolescents.

Mechanical ventilation and clinical practice heterogeneity in intensive care units: a multicenter case-vignette study.

BACKGROUND: Observational studies on mechanical ventilation (MV) show practice variations across ICUs. We sought to determine, with a case-vignette study, the heterogeneity of processes of care in ICUs focusing on mechanical ventilation procedures, and whether organizational patterns or physician characteristics influence practice variations. METHODS: We conducted a cross-sectional multicenter study using the case-vignette methodology. Descriptive analyses were calculated for each organizational pattern and respondent characteristics. An Index of Qualitative Variation (IQV, from 0, no heterogeneity, to a maximum of 1) was calculated. RESULTS: Forty ICUs from France (N = 33) and Switzerland (N = 7) participated; 396 physicians answered our case-vignettes. There was major heterogeneity of management processes related to MV within and across centers (mean IQV per center 0.51, SD 0.09). We observed the lowest variability (mean IQV per question < 0.4) for questions related to intubation procedure, ventilation of acute respiratory distress syndrome and the use of the semirecumbent position. We observed a high variability (mean IQV per question > 0.6) for questions related to management of endotracheal tube or suctioning, management of sedation and analgesia, and respect of autonomy. Heterogeneity was independent of respondent characteristics and of the presence of written procedures. There was a correlation between the processes associated with the highest variability (mean IQV per question > 0.6) and the annual volume of ICU admission (r = 0.32 (0.01 to 0.58)) and MV (r = 0.38 (0.07 to 0.63)). Within ICUs there was a large heterogeneity regarding knowledge of a local written procedure. CONCLUSIONS: Large clinical practice variations were found among ICUs. High volume centers were more likely to have heterogeneous practices. The presence of a local written procedure or respondent characteristics did not influence practice variation.

Candidoses en réanimation [Candidiasis and intensive care patients]

Le développement dune candidose invasive est une complication hospitalière particulièrement redoutée en raison de sa mortalité élevée, comparable à celle du choc septique (40 %-60 %). La candidémie survient chez 0,05 % des patients hospitalisés, mais touche près de 1 % de ceux séjournant en réanimation, et est responsable de 5 à 10 % des bactériémies nosocomiales. Bien quune proportion élevée de patients hospitalisés soient colonisés par des levures du genre Candida, seule une minorité développe une candidose sévère. Celle-ci est toutefois difficile à diagnostiquer : les signes évocateurs dune dissémination ne surviennent habituellement que tardivement. Un traitement empirique précoce ou préemptif pourrait améliorer le pronostic, mais pour des raisons tant épidémiologiques quéconomiques, un tel traitement ne peut être appliqué à tous les patients à risque de développer une candidose sévère. Chez les patients présentant des facteurs de risque, la pratique de cultures de surveillance systématiques permet de déceler le développement dune colonisation et d'en quantifier le degré, de manière à ne débuter un traitement préemptif que lorsque lindex de colonisation dépasse un seuil critique prédictif d'infection secondaire. Ces éléments physiopathologiques et la mise à disposition des dérivés triazolés moins toxiques que l'amphotéricine B ont permis l'application de traitements prophylactiques. Chez les patients immunosupprimés, la généralisation de cette approche a été incriminée comme lun des éléments déterminant de lémergence dinfections à Candida non albicans dont le pronostic est moins favorable. Pour les patients de réanimation, une stricte limitation aux groupes soigneusement identifiés comme étant à risque élevé et chez lesquels lefficacité de la prophylaxie a pu être démontrée doit contribuer à limiter cet impact épidémiologique défavorable.

Molecular epidemiology of pseudomonas aeruginosae in intensive care units (ICUs) over a 10-year period (1998-2007)

Pseudomonas aeruginosa, une bactérie environnementale ubiquitaire, est un des pathogènes nosocomiaux les plus fréquents aux soins intensifs. La source de ce microorganisme peut être soit endogène, 2,6 à 24 % des patients hospitalisés étant colonisés au niveau digestif, soit exogène. La proportion des cas d'infections à P. aeruginosa d'origine exogène, donc secondaires à une transmission par manuportage ou par l'eau du réseau utilisée pour la toilette ou d'autres soins, reste débattue. Or une meilleure évaluation du taux d'infections exogènes est importante pour la mise en place de mesures de contrôle appropriées. Le but de cette étude était de déterminer sur une période de 10 ans les rôles respectifs des sources exogènes (robinets, autres patients) et endogène dans la colonisation et/ou l'infection par P.aeruginosa chez les patients des Soins Intensifs, ainsi que de documenter les variations épidémiologiques au cours du temps. L'étude a été menée dans les unités de Soins Intensifs du Centre Hospitalier Universitaire Vaudois (CHUV). Les patients colonisés et/ou infectés par P. aeruginosa entre 1998 et 2007ont été identifiés via la base de données du laboratoire de microbiologie. Ils ont été inclus dans l'étude s'ils étaient hospitalisés dans une des unités de Soins Intensifs, Durant cette période, des prélèvements pour recherche de P. aeruginosa ont été effectués sur des robinets des soins intensifs. Un typage moléculaire a été effectué sur toutes les souches cliniques et environnementales isolées en 1998, 2000, 2003, 2004 et 2007. Les patients inclus dans l'étude ont été répartis en quatre catégories (A-D) selon le résultat du typage moléculaire leur souche de P. aeruginosa. La catégorie A inclut les cas pour lesquels le génotype de P. aeruginosa est identique à un des génotypes retrouvé dans l'environnement. La catégorie B comprend les cas pour lesquels le génotype est identique à celui d'au moins un autre patient. La catégorie C comprend les cas avec un génotype unique et la catégorie D comprend les cas pour lesquels la souche était non disponible pour le typage. Les cas des catégories A et B sont considérés comme ayant une origine exogène. Au cours des années de l'étude, le nombre d'admissions aux soins intensifs est resté stable. En moyenne, 86 patients par année ont été identifiés colonisés ou infectés par P. aeruginosa aux Soins Intensifs. Durant la première année d'investigation, un grand nombre de patients colonisés par une souche de P. aeruginosa identique à une de celles retrouvées dans l'environnement a été mis en évidence. Par la suite, possiblement suite à l'augmentation de la température du réseau d'eau chaude, le nombre de cas dans la catégorie A a diminué. Dans la catégorie B, le nombre de cas varie de 1,9 à 20 cas/1000 admissions selon les années. Ce nombre est supérieur à 10 cas/1000 admissions en 1998, 2003 et 2007 et correspond à des situations épidémiques transitoires. Tout au long des 10 ans de l'étude, le nombre de cas dans la catégorie C (source endogène) est demeuré stable et indépendant des variations du nombre de cas dans les catégories A et B. En conclusion, la contribution relative des réservoirs endogène et exogène dans la colonisation et/ou l'infection des patients de soins Intensifs varie au cours du temps. Les facteurs principaux qui contribuent à de telles variations sont probablement le degré de contamination de l'environnement, la compliance des soignants aux mesures de contrôle des infections et la génétique du pathogène lui-même. Etant donné que ce germe est ubiquitaire dans l'environnement aqueux et colonise jusqu'à 15% des patients hospitalisés, la disparition de son réservoir endogène semble difficile. Cependant, cette étude démontre que son contrôle est possible dans l'environnement, notamment dans les robinets en augmentant la température de l'eau. De plus, si une souche multi-résistante est retrouvée de manière répétée dans l'environnement, des efforts doivent être mis en place pour éliminer cette souche. Des efforts doivent être également entrepris afin de limiter la transmission entre les patients, qui est une cause importante et récurrente de contamination exogène. - Pseudomonas aeruginosa is one of the leading nosocomial pathogens in intensive care units (ICUs). The source of this microorganism can be either endogenous or exogenous. The proportion of cases as a result of transmission is still debated, and its elucidation is important for implementing appropriate control measures. To understand the relative importance of exogenous vs. endogenous sources of P. aeru¬ginosa, molecular typing was performed on all available P. aeruginosa isolated from ICU clinical and environmental specimens in 1998, 2000, 2003, 2004 and 2007. Patient samples were classified according to their P. aeruginosa genotypes into three categories: (A) identical to isolate from faucet; (B) identical to at least one other patient sample and not found in faucet; and (C) unique genotype. Cases in cat¬egories A and Β were considered as possibly exogenous, and cases in category C as possibly endogenous. A mean of 34 cases per 1000 admissions per year were found to be colonized or infected by P. aeruginosa. Higher levels of faucet contamination were correlated with a higher number of cases in category A. The number of cases in category Β varied from 1.9 to 20 cases per 1000 admissions. This num¬ber exceeded 10/1000 admissions on three occasions and was correlated with an outbreak on one occasion. The number of cases con¬sidered as endogenous (category C) was stable and independent of the number of cases in categories A and B. The present study shows that repeated molecular typing can help identify variations in the epidemiology of P. aeruginosa in ICU patients and guide infection control measures.