The Dynamics of the Pulmonary Microbiome During Mechanical Ventilation in the Intensive Care Unit and the Association with Occurrence of Pneumonia

RATIONALE: Ventilator-associated pneumonia (VAP) is the most common nosocomial infections in patients admitted to the ICU. The adapted island model predicts several changes in the respiratory microbiome during intubation and mechanical ventilation. OBJECTIVES: We hypothesised that mechanical ventilation and antibiotic administration decrease the diversity of the respiratory microbiome and that these changes are more profound in patients who develop VAP. METHODS: Intubated and mechanically ventilated ICU-patients were included. Tracheal aspirates were obtained three times a week. 16S rRNA gene sequencing with the Roche 454 platform was used to measure the composition of the respiratory microbiome. Associations were tested with linear mixed model analysis and principal coordinate analysis. MEASUREMENTS AND MAIN RESULTS: 111 tracheal aspirates were obtained from 35 patients; 11 had VAP, 18 did not have VAP. Six additional patients developed pneumonia within the first 48 hours after intubation. Duration of mechanical ventilation was associated with a decrease in α diversity (Shannon index; fixed-effect regression coefficient (β): -0.03 (95% CI -0.05 to -0.005)), but the administration of antibiotic therapy was not (fixed-effect β: 0.06; 95% CI -0.17 to 0.30). There was a significant difference in change of β diversity between patients who developed VAP and control patients for Bray-Curtis distances (p=0.03) and for Manhattan distances (p=0.04). Burkholderia, Bacillales and, to a lesser extent, Pseudomonadales positively correlated with the change in β diversity. CONCLUSION: Mechanical ventilation, but not antibiotic administration, was associated with changes in the respiratory microbiome. Dysbiosis of microbial communities in the respiratory tract was most profound in patients who developed VAP.info:eu-repo/semantics/publishedVersio

ICU-acquired pneumonia is associated with poor health post-COVID-19 syndrome

Financial support was provided by the Instituto Carlos III de Madrid (COV20/00110, ISCIII) and by the Centro de Investigación Biomedica En Red—Enfermedades Respiratorias (CIBERES). DdGC has received financial support from Instituto de Salud Carlos III (Miguel Servet 2020: CP20/00041), co-funded by European Social Fund (ESF)/ “Investing in your future”.Martin-Loeches I, Motos A, Menéndez R, Gabarrús A, González J, Fernández-Barat L, Ceccato A, Pérez-Arnal R, García-Gasulla D, Ferrer R, Riera J, Lorente JÁ, Peñuelas Ó, Bermejo-Martin JF, de Gonzalo-Calvo D, Rodríguez A, Barbé F, Aguilera L, Amaya-Villar R, Barberà C, Barberán J, Blandino Ortiz A, Bustamante-Munguira E, Caballero J, Carbajales C, Carbonell N, Catalán-González M, Galbán C, Gumucio-Sanguino VD, de la Torre MDC, Díaz E, Gallego E, García Garmendia JL, Garnacho-Montero J, Gómez JM, Jorge García RN, Loza-Vázquez A, Marín-Corral J, Martínez de la Gándara A, Martínez Varela I, Lopez Messa J, Albaiceta GM, Novo MA, Peñasco Y, Ricart P, Urrelo-Cerrón L, Sánchez-Miralles A, Sancho Chinesta S, Socias L, Solé-Violan J, Tamayo Lomas L, Vidal P, Torres A

A Smart Wireless Car Ignition System for Vehicle Security

Copyright: © 2017 Haider A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.The paper proposes a novel car ignition system to replace the traditional wired technology and enhance vehicle security. This new system uses wireless transmissions to start the engine and hence eliminates the ignition wire behind the dashboard. It also allows the user to set a password of his/her choice to keep the system protected. A theft alarm that goes ‘’ON’’ when an unusual activity is sensed and/or when the wrong password is attempted to unlock the system is integrated in the system. Moreover, important factors such as economic feasibility, adaptability to the new vehicle technologies and customers’ preferences have been taken into consideration in the design of the proposed vehicle security system.Peer reviewedFinal Published versio

Invasive candidiasis in critical care: challenges and future directions.

Invasive candidiasis is the most common critical care-associated fungal infection with a crude mortality of ~ 40-55%. Important factors contributing to risk of invasive candidiasis in ICU include use of broad-spectrum antimicrobials, immunosuppressive drugs, and total parenteral nutrition alongside iatrogenic interventions which breach natural barriers to infection [vascular catheters, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), surgery]. This review discusses three key challenges in this field. The first is the shift in Candida epidemiology across the globe to more resistant non-albicans species, in particular, the emergence of multi-resistant Candida glabrata and Candida auris, which pose significant treatment and infection control challenges in critical care. The second challenge lies in the timely and appropriate initiation and discontinuation of antifungal therapy. Early antifungal strategies (prophylaxis, empirical and pre-emptive) using tools such as the Candida colonisation index, clinical prediction rules and fungal non-culture-based tests have been developed: we review the evidence on implementation of these tools in critical care to aid clinical decision-making around the prescribing and cessation of antifungal therapy. The third challenge is selection of the most appropriate antifungal to use in critical care patients. While guidelines exist to aid choice, this heterogenous and complex patient group require a more tailored approach, particularly in cases of acute kidney injury, liver impairment and for patients supported by extracorporeal membrane oxygenation. We highlight key research priorities to overcome these challenges in the future

Influenza and associated co-infections in critically ill immunosuppressed patients

BackgroundIt is unclear whether influenza infection and associated co-infection are associated with patient-important outcomes in critically ill immunocompromised patients with acute respiratory failure.MethodsPreplanned secondary analysis of EFRAIM, a prospective cohort study of 68 hospitals in 16 countries. We included 1611 patients aged 18years or older with non-AIDS-related immunocompromise, who were admitted to the ICU with acute hypoxemic respiratory failure. The main exposure of interest was influenza infection status. The primary outcome of interest was all-cause hospital mortality, and secondary outcomes ICU length of stay (LOS) and 90-day mortality.ResultsInfluenza infection status was categorized into four groups: patients with influenza alone (n=95, 5.8%), patients with influenza plus pulmonary co-infection (n=58, 3.6%), patients with non-influenza pulmonary infection (n=820, 50.9%), and patients without pulmonary infection (n=638, 39.6%). Influenza infection status was associated with a requirement for intubation and with LOS in ICU (PPeer reviewe

Corticosteroid treatment and mortality in mechanically ventilated COVID-19-associated acute respiratory distress syndrome (ARDS) patients: a multicentre cohort study Autor

15 páginasAntecedentes: Persisten algunas preguntas sin respuesta sobre la eficacia de los corticosteroides en pacientes con enfermedad grave por coronavirus 2019 (COVID-19). Nuestro objetivo fue evaluar el efecto clínico de los corticosteroides en la mortalidad en la unidad de cuidados intensivos (UCI) de pacientes con síndrome de dificultad respiratoria aguda (SDRA) asociado a COVID-19 y ventilación mecánica. Métodos: Estudio retrospectivo de datos prospectivos en 70 UCI (68 españolas, una andorrana y una irlandesa), incluyendo pacientes con SDRA asociado a COVID-19 y ventilación mecánica ingresados ​​entre el 6 de febrero y el 20 de septiembre de 2020. Se excluyó a los pacientes que recibieron corticosteroides por shock refractario. Los pacientes expuestos a corticosteroides al ingreso se emparejaron con pacientes sin corticosteroides mediante emparejamiento por puntuación de propensión. El resultado primario fue la mortalidad en UCI por cualquier causa. Los resultados secundarios compararon la mortalidad hospitalaria, los días sin ventilador a los 28 días, la sobreinfección respiratoria y la duración de la estancia entre pacientes con corticosteroides y sin corticosteroides. Se realizó un análisis de supervivencia considerando los riesgos competitivos y un análisis de sensibilidad de subgrupos. Resultados: Incluimos 1835 pacientes con SDRA asociado a COVID-19 y ventilación mecánica, de los cuales 1117 (60,9%) recibieron corticosteroides. Después del emparejamiento por puntaje de propensión, la mortalidad en la UCI no difirió entre los pacientes tratados con corticosteroides y los pacientes no tratados (33,8% frente a 30,9%; p = 0,28). En el análisis de supervivencia, el tratamiento con corticosteroides al ingreso en la UCI se asoció con un beneficio de supervivencia a corto plazo (HR 0,53; IC del 95%: 0,39-0,72), aunque después del día 17 de ingreso, este efecto cambió y hubo un aumento de la mortalidad en la UCI (HR a largo plazo 1,68; IC del 95%: 1,16-2,45). El análisis de sensibilidad reforzó los resultados. Los subgrupos de edad < 60 años, SDRA grave y corticosteroides más tocilizumab podrían tener el mayor beneficio de los corticosteroides, ya que se observó una disminución de la mortalidad en la UCI a corto plazo sin efectos negativos a largo plazo. Se observó una mayor duración de la estancia hospitalaria con corticosteroides en los pacientes que fallecieron, tanto en la UCI como en el hospital. No se observaron diferencias significativas en los demás resultados secundarios. Conclusiones: Nuestros resultados sugieren que el tratamiento con corticosteroides para el SDRA asociado a COVID-19 en ventilación mecánica tuvo un efecto bifásico y dependiente del tiempo sobre la mortalidad en la UCI. Subgrupos específicos mostraron un claro efecto en la mejora de la supervivencia con el uso de corticosteroides. Por lo tanto, se requieren más investigaciones para identificar subgrupos que respondan al tratamiento entre los pacientes con SDRA asociado a COVID-19 en ventilación mecánica

Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality

PURPOSE: To provide a practical overview of the management of the potential organ donor in the intensive care unit. METHODS: Seven areas of donor management were considered for this review: hemodynamic management; fluids and electrolytes; respiratory management; endocrine management; temperature management; anaemia and coagulation; infection management. For each subchapter, a narrative review was conducted. RESULTS AND CONCLUSIONS: Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations, or extrapolations from general ICU management strategies, and not on evidence from randomized controlled trials. The cardiorespiratory management of brain-dead donors is very similar to the management of critically ill patients, and the same applies to the management of anaemia and coagulation. Central diabetes insipidus is of particular concern, and should be diagnosed based on clinical criteria. Depending on the degree of vasopressor dependency, it can be treated with intermittent desmopressin or continuous vasopressin, intravenously. Temperature management of the donor is an area of uncertainty, but it appears reasonable to strive for a core temperature of > 35 °C. The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. Although the rate of infection transmission from donor to receptor is low, certain infections are still a formal contraindication to organ donation. However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely

Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality

PURPOSE: To provide a practical overview of the management of the potential organ donor in the intensive care unit. METHODS: Seven areas of donor management were considered for this review: hemodynamic management; fluids and electrolytes; respiratory management; endocrine management; temperature management; anaemia and coagulation; infection management. For each subchapter, a narrative review was conducted. RESULTS AND CONCLUSIONS: Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations, or extrapolations from general ICU management strategies, and not on evidence from randomized controlled trials. The cardiorespiratory management of brain-dead donors is very similar to the management of critically ill patients, and the same applies to the management of anaemia and coagulation. Central diabetes insipidus is of particular concern, and should be diagnosed based on clinical criteria. Depending on the degree of vasopressor dependency, it can be treated with intermittent desmopressin or continuous vasopressin, intravenously. Temperature management of the donor is an area of uncertainty, but it appears reasonable to strive for a core temperature of > 35 °C. The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. Although the rate of infection transmission from donor to receptor is low, certain infections are still a formal contraindication to organ donation. However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely

Procalcitonin levels in candidemia versus bacteremia: A systematic review

Background: Procalcitonin (PCT) is a biomarker used to assess systemic inflammation, infection, and sepsis and to optimize antimicrobial therapies. Its role in the in the differential diagnosis between candidemia and bacteremia is unclear. The aim of this systematic review was to summarize the current evidence about PCT values for differentiating candidemia from bacteremia. Methods: PubMed and EMBASE were searched for studies reporting data on the diagnostic performance of serum PCT levels in intensive care unit (ICU) or non-ICU adult patients with candidemia, in comparison to patients with bacteremia. Results: We included 16 studies for a total of 45.079 patients and 785 cases of candidemia. Most studies claimed to report data relating to the use of PCT values for differentiating between candidemia and bacteremia in septic patients in the intensive care unit. However, the studies identified were all retrospective, except for one secondary analysis of a prospective dataset, and clinically very heterogeneous and involved different assessment methods. Most studies did show lower PCT values in patients with candidemia compared to bacteremia. However, the evidence supporting this observation is of low quality and the difference seems insufficiently discriminative to guide therapeutic decisions. None of the studies retrieved actually studied guidance of antifungal treatment by PCT. PCT may improve diagnostic performance regarding candidemia when combined with other biomarkers of infection (e.g., beta-D-glucan) but more data is needed. Conclusions: PCT should not be used as a standalone tool for the differential diagnosis between candidemia and bacteremia due to limited supporting evidence

Procalcitonin levels in candidemia versus bacteremia: A systematic review

open7BackgroundProcalcitonin (PCT) is a biomarker used to assess systemic inflammation, infection, and sepsis and to optimize antimicrobial therapies. Its role in thein the differential diagnosis between candidemia and bacteremia is unclear. The aim of this systematic review was to summarize the current evidence about PCT values for differentiating candidemia from bacteremia.MethodsPubMed and EMBASE were searched for studies reporting data on the diagnostic performance of serum PCT levels in intensive care unit (ICU) or non-ICU adult patients with candidemia, in comparison to patients with bacteremia.ResultsWe included 16 studies for a total of 45.079 patients and 785 cases of candidemia. Most studies claimed to report data relating to the use of PCT values for differentiating between candidemia and bacteremia in septic patients in the intensive care unit. However, the studies identified were all retrospective, except for one secondary analysis of a prospective dataset, and clinically very heterogeneous and involved different assessment methods. Most studies did show lower PCT values in patients with candidemia compared to bacteremia. However, the evidence supporting this observation is of low quality and the difference seems insufficiently discriminative to guide therapeutic decisions. None of the studies retrieved actually studied guidance of antifungal treatment by PCT. PCT may improve diagnostic performance regarding candidemia when combined with other biomarkers of infection (e.g., beta-d-glucan) but more data is needed.ConclusionsPCT should not be used as a standalone tool for the differential diagnosis between candidemia and bacteremia due to limited supporting evidence.openCortegiani A.; Misseri G.; Ippolito M.; Bassetti M.; Giarratano A.; Martin-Loeches I.; Einav S.Cortegiani, A.; Misseri, G.; Ippolito, M.; Bassetti, M.; Giarratano, A.; Martin-Loeches, I.; Einav, S