Jordi Rello - Academia.edu (original) (raw)
Papers by Jordi Rello
Enfermedades infecciosas y microbiologia clinica, Jan 26, 2015
The role of influenza viruses in severe acute respiratory infection (SARI) in Intensive Care Unit... more The role of influenza viruses in severe acute respiratory infection (SARI) in Intensive Care Units (ICU) remains unknown. The post-pandemic influenza A(H1N1)pdm09 period, in particular, has been poorly studied. To identify influenza SARI patients in ICU, to assess the usefulness of the symptoms of influenza-like illness (ILI), and to compare the features of pandemic vs. post-pandemic influenza A(H1N1) pdm09 infection. A prospective observational study with SARI patients admitted to ICU during the first three post-pandemic seasons. Patient demographics, characteristics and outcomes were recorded. An influenza epidemic period (IEP) was defined as >100 cases/100,000 inhabitants per week. One hundred sixty-three patients were diagnosed with SARI. ILI was present in 65 (39.9%) patients. Influenza infection was documented in 41 patients, 27 (41.5%) ILI patients, and 14 (14.3%) non-ILI patients, 27 of them during an IEP. Influenza A viruses were mainly responsible. Only five patients ha...
International journal of antimicrobial agents, 2015
Telavancin was the first marketed lipoglycopeptide. Although licensed in Europe in 2011 for the t... more Telavancin was the first marketed lipoglycopeptide. Although licensed in Europe in 2011 for the treatment of nosocomial pneumonia caused by meticillin-resistant Staphylococcus aureus (MRSA), it did not become clinically available until March 2014. Given the limited clinical experience with telavancin in Europe, this review provides an overview of its antimicrobial and clinical activity as well as its position among today's antimicrobials, with particular focus on the implications of its licensing requirements. Telavancin has potent in vitro activity against isolates of Gram-positive pathogens, including MRSA and glycopeptide-intermediate S. aureus strains. In addition, at clinically attainable doses telavancin inhibits Gram-positive isolates of antibiotic-resistant strains from biofilm models. The in vitro potency of telavancin has been corroborated in the clinical setting. Comparative clinical studies of telavancin demonstrate non-inferiority compared with vancomycin in the tre...
Journal of clinical microbiology, 1997
A prospective study of 45 central venous catheters was conducted to assess, by strain delineation... more A prospective study of 45 central venous catheters was conducted to assess, by strain delineation, the turnover of skin and catheter hub (superficial) colonization and the relative contributions of catheter hub and skin colonization to catheter tip colonization. Serial quantitative cultures of skin and catheter hub were performed. Catheter tip, blood, and specimens for culture from targeted superficial sites (TSSs) were also collected at the time of catheter removal. Strains from 17 tip-positive catheters were delineated by pulsed-field gel electrophoresis. Only 12 (28.6%) of 42 skin strains and 14 (31.1%) of 45 catheter hub strains were found to be present at the time of catheter removal. In addition, only 9 (29.0%) of the 31 tip-colonizing strains were present on TSSs. Moreover, 15 (48.4%) of the 31 tip-colonizing strains had a superficial origin, and the other 16 (51.6%) were of unknown origin. In catheters suspected of infection, cultures of TSSs had a negative predictive value ...
International journal of antimicrobial agents, 2014
An unexpectedly high incidence of invasive pulmonary aspergillosis (IPA) has been reported in non... more An unexpectedly high incidence of invasive pulmonary aspergillosis (IPA) has been reported in non-neutropenic intensive care unit (ICU) patients. After the respiratory tract, the brain is most often affected by invasive aspergillosis. However, little is known about brain involvement by Aspergillus in critically ill patients. In this study, demographics, risk profile, diagnosis, treatment and outcome of proven cases of invasive cerebral aspergillosis (ICA) taken from a cohort of 563 adult patients with evidenced Aspergillus involvement during their ICU stay were reviewed. Ten patients with central nervous system aspergillosis were identified. All had one or more host factors predisposing for invasive aspergillosis. The clinical and radiological presentation was non-specific and exclusively pulmonary-related. All but one patient had proven or probable/putative IPA. On cerebral computed tomography, lesions appeared as either solitary and hyperdense or were multiple and randomly distrib...
Clinical Pulmonary Medicine, 2009
... Lisboa, Thiago MD*; Craven, Donald E. MD; Rello, Jordi MD, PhD*. ... 32,33 Because of its i... more ... Lisboa, Thiago MD*; Craven, Donald E. MD; Rello, Jordi MD, PhD*. ... 32,33 Because of its importance and impact on morbidity in ICU patients, VAP prevention was included in the Institute for Health Improvement (IHI) campaign to save 100,000 lives (www.ihi.org). ...
![Research paper thumbnail of [Oral hygiene with chlorhexidine on the prevention of ventilator-associated pneumonia in intubated patients: a systematic review of randomized clinical trials]](https://attachments.academia-assets.com/45944168/thumbnails/1.jpg)
](Higiene oral Clorhexidina Neumonía asociada a la ventilació n R E S U M E N Fundamento y objetivo... more Higiene oral Clorhexidina Neumonía asociada a la ventilació n R E S U M E N Fundamento y objetivos: La ventilació n mecá nica se usa al menos en una tercera parte de los pacientes ingresados en unidades de cuidados intensivos (UCI). La neumonía asociada a la ventilació n (NAV) es la complicació n má s frecuente, que afecta de un 8-28% de los pacientes. La prevenció n de NAV surge como una estrategia importante para el tratamiento de pacientes en UCI. Se han propuesto diferentes estrategias en prevenció n y, dentro de estas, la higiene oral con clorhexidina surge como una herramienta ú til. El objetivo de este trabajo fue evaluar el efecto de la clorhexidina sobre la prevenció n de NAV. Pacientes y método: Se realizó una revisió n sistemá tica de la literatura mé dica de ensayos clínicos controlados que evalú an el efecto de la clorhexidina sobre la prevenció n de NAV. Se realizó una bú squeda de los artículos indexados en PubMed usando las palabras claves: )oral care OR oral higiene OR chlorhexidine AND ventilator-associated pneumonia*. Un revisor independiente evaluó los estudios segú n los criterios de inclusió n y extrajo los datos. Resultados: Se encontraron 120 artículos. De estos, consideramos 10 estudios que cumplían los criterios de inclusió n. Se apreció una falta de uniformidad en la aplicació n del tratamiento de clorhexidina. Se encontró una reducció n en el riesgo de NAV en el grupo clorhexidina comparado con el grupo control (odds ratio: 56, intervalo de confianza del 95%: 44-0,73). Sin embargo, no se apreció una reducció n en la mortalidad, el tiempo de ventilació n mecá nica ni los días de estancia. Conclusiones: La higiene oral con clorhexidina en combinació n con otras estrategias de prevenció n de NAV debe estar incluida en el cuidado general del paciente de UCI.
Introduction: It remains unknown why some intubated patients remain infection-free while others d... more Introduction: It remains unknown why some intubated patients remain infection-free while others develop tracheobronchitis (VAT) or pneumonia (VAP). Objective: To identify and compare VAP/VAT gene expression ''signatures'' using genome-wide oligonucleotide microarrays. Material and methods: A prospective translational study of gene expression profiles of VA P and VAT groups was carried out, establishing comparisons in both pre-infection and infection phases. Pathway and functional analyses were performed with Ingenuity Pathway Analysis (IPA). Data analysis and hierarchical clustering of the genes involved in the signalling pathways expressed differentially in the two groups were performed with GeneSpring GX 11.0. Results: Eight patients developing respiratory infections (3 VA P and 5 VAT) after 4 days of mechanical ventilation were assessed. Comparison of gene expression profiles in the preinfection period revealed 5595 genes expressed differentially between VA P and VAT (p < 0.01, fold change >2). Comparative IPA analysis identified a significant depression of the complement system signalling pathway in the VA P group, affecting the classical pathway along with the final common pathway (p < 0.05). In addition, the cAMP and calcium signalling pathways were also significantly depressed in the VA P group during the pre-infection phase also. Conclusion: Intubated patients complicated with pneumonia developed immune impairment in the pre-infection period, manifesting as a relatively lower expression of genes involved in the complement system that differed from patients developing tracheobronchitis. These findings suggest that a significant proportion of VA P episodes cannot be prevented, but might be treatable through pre-emptive therapy. Documento descargado de http://www.medintensiva.org el 28/11/2013. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
Risk factors for β-lactam antibiotic underdosing in critically ill patients have not been describ... more Risk factors for β-lactam antibiotic underdosing in critically ill patients have not been described in large-scale studies. The objective of this study was to describe pharmacokinetic/pharmacodynamic (PK/PD) target non-attainment envisioning empirical dosing in critically ill patients and considering a worst-case scenario as well as to identify patient characteristics that are associated with target non-attainment. This analysis uses data from the DALI study, a prospective, multi-centre pharmacokinetic point-prevalence study. For this analysis, we assumed that these were the concentrations that would be reached during empirical dosing, and calculated target attainment using a hypothetical target minimum inhibitory concentration (MIC), namely the susceptibility breakpoint of the least susceptible organism for which that antibiotic is commonly used. PK/PD targets were free drug concentration maintained above the MIC of the suspected pathogen for at least 50 % and 100 % of the dosing interval respectively (50 % and 100 % f T (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;MIC)). Multivariable analysis was performed to identify factors associated with inadequate antibiotic exposure. A total of 343 critically ill patients receiving eight different β-lactam antibiotics were included. The median (interquartile range) age was 60 (47-73) years, APACHE II score was 18 (13-24). In the hypothetical situation of empirical dosing, antibiotic concentrations remained below the MIC during 50 % and 100 % of the dosing interval in 66 (19.2 %) and 142 (41.4 %) patients respectively. The use of intermittent infusion was significantly associated with increased risk of non-attainment for both targets; creatinine clearance was independently associated with not reaching the 100 % f T( &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;MIC) target. This study found that-in empirical dosing and considering a worst--case scenario--19 % and 41 % of the patients would not achieve antibiotic concentrations above the MIC during 50 % and 100 % of the dosing interval. The use of intermittent infusion (compared to extended and continuous infusion) was the main determinant of non-attainment for both targets; increasing creatinine clearance was also associated with not attaining concentrations above the MIC for the whole dosing interval. In the light of this study from 68 ICUs across ten countries, we believe current empiric dosing recommendations for ICU patients are inadequate to effectively cover a broad range of susceptible organisms and need to be reconsidered.
To evaluate de-escalation of antibiotic therapy in patients with ventilator-associated pneumonia.... more To evaluate de-escalation of antibiotic therapy in patients with ventilator-associated pneumonia. Prospective observational study during a 43-month period. Medical-surgical intensive care unit. One hundred and fifteen patients admitted to the intensive care unit with clinical diagnosis of ventilator-associated pneumonia. All the episodes of ventilator-associated pneumonia received initial broad-spectrum coverage followed by reevaluation according to clinical response and microbiology. Quantitative cultures obtained by bronchoscopic examination or tracheal aspirates were used to modify therapy. : None. One hundred and twenty-one episodes of ventilator-associated pneumonia were diagnosed. Change of therapy was documented in 56.2%, including de-escalation (the most frequent cause) in 31.4% (increasing to 38% if isolates were sensitive). Overall intensive care unit mortality rate was 32.2%. Inappropriate antibiotic therapy was identified in 9% of cases and was associated with 14.4% excess intensive care unit mortality. Quantitative tracheal aspirates and bronchoscopic samples (58 protected specimen brush and three bronchoalveolar lavage) were associated with 32.7% and 29.5% intensive care unit mortality and 29.3% and 34.4% de-escalation rate. De-escalation was lower (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05) in the presence of nonfermenting Gram-negative bacillus (2.7% vs. 49.3%) and in the presence of late-onset pneumonia (12.5% vs. 40.7%). When the pathogen remained unknown, half of the patients died and de-escalation was not performed. De-escalation was the most important cause of antibiotic modification, being more feasible in early-onset pneumonia and less frequent in the presence of nonfermenting Gram-negative bacillus. The impact of quantitative tracheal aspirates or bronchoscopic techniques was comparable in terms of mortality.
Cómo citar este artículo: Masclans JR, et al. Objetivos docentes en la formación de médicos resid... more Cómo citar este artículo: Masclans JR, et al. Objetivos docentes en la formación de médicos residentes en trasplante de órganos sólidos. Med Intensiva. 2012. http://dx.
Critical Care Medicine, 2014
To estimate the prevalence of ventilator-associated pneumonia caused by Pseudomonas aeruginosa in... more To estimate the prevalence of ventilator-associated pneumonia caused by Pseudomonas aeruginosa in patients at risk for ventilator-associated pneumonia and to describe risk factors for P. aeruginosa ventilator-associated pneumonia. Prospective, observational study. ICUs at 56 sites in 11 countries across four regions: the United States (n = 502 patients), Europe (n = 495), Latin America (n = 500), and Asia Pacific (n = 376). Adults intubated and mechanically ventilated for 48 hours to 7 days, inclusive. None (local standard of care). Ventilator-associated pneumonia prevalence as defined by local investigators were 15.6% (293/1,873) globally, 13.5% in the United States, 19.4% in Europe, 13.8% in Latin America, and 16.0% in Asia Pacific (p = 0.04). Corresponding P. aeruginosa ventilator-associated pneumonia prevalences were 4.1%, 3.4%, 4.8%, 4.6%, and 3.2% (p = 0.49). Of 50 patients with P. aeruginosa ventilator-associated pneumonia who underwent surveillance testing, 19 (38%) had prior P. aeruginosa colonization and 31 (62%) did not (odds ratio, 7.99; 95% CI, 4.31-14.71). Of predefined risk factors for multidrug resistance (hereafter, risk factors), the most frequent in all patients were antimicrobial therapy within 90 days (51.9% of enrolled patients) and current hospitalization of more than or equal to 5 days (45.3%). None of these risk factors were significantly associated with P. aeruginosa ventilator-associated pneumonia by multivariate logistic regression. Risk factors associated with prior P. aeruginosa colonization were antimicrobial therapy within 90 days (odds ratio, 0.46; 95% CI, 0.29-0.73) and high proportion of antibiotic resistance in the community or hospital unit (odds ratio, 1.79; 95% CI, 1.14-2.82). Our findings suggest that ventilator-associated pneumonia remains a common ICU infection and that P. aeruginosa is one of the most common causative pathogens. The odds of developing P. aeruginosa ventilator-associated pneumonia were eight times higher in patients with prior P. aeruginosa colonization than in uncolonized patients, which in turn was associated with local resistance.
Medicina Intensiva (English Edition), 2013
The Lancet. Respiratory medicine, 2015
Sepsis continues to be a major cause of death, disability, and health-care expenditure worldwide.... more Sepsis continues to be a major cause of death, disability, and health-care expenditure worldwide. Despite evidence suggesting that host genetics can influence sepsis outcomes, no specific loci have yet been convincingly replicated. The aim of this study was to identify genetic variants that influence sepsis survival. We did a genome-wide association study in three independent cohorts of white adult patients admitted to intensive care units with sepsis, severe sepsis, or septic shock (as defined by the International Consensus Criteria) due to pneumonia or intra-abdominal infection (cohorts 1-3, n=2534 patients). The primary outcome was 28 day survival. Results for the cohort of patients with sepsis due to pneumonia were combined in a meta-analysis of 1553 patients from all three cohorts, of whom 359 died within 28 days of admission to the intensive-care unit. The most significantly associated single nucleotide polymorphisms (SNPs) were genotyped in a further 538 white patients with s...
Medicina intensiva / Sociedad Española de Medicina Intensiva y Unidades Coronarias, 2011
During the 2009 influenza pandemic, several reports were published, nevertheless, data on the cli... more During the 2009 influenza pandemic, several reports were published, nevertheless, data on the clinical profiles of critically ill patients with the new virus infection during this second outbreak are still lacking. Prospective, observational, multi-center study conducted in 148 Spanish intensive care units (ICU) during epidemiological weeks 50-52 of 2010 and weeks 1 - 4 of 2011. Three hundred patients admitted to an intensive care unit (ICU) with confirmed An/H1N1 infection were analyzed. The median age was 49 years [IQR=38-58] and 62% were male. The mean APACHE II score was 16.9 ± 7.5 and the mean SOFA score was 6.3 ± 3.5 on admission. Comorbidities were present in 76% (n=228) of cases and 111 (37.4%) patients were reportedly obese and 59 (20%) were COPD. The main presentation was viral pneumonia with severe hypoxemia in 65.7% (n=197) of the patients whereas co-infection was identified in 54 (18%) patients. All patients received antiviral treatment and initiated empirically in 194 ...
Optimal therapy against Legionella infection is based on agents with a high intrinsic activity, a... more Optimal therapy against Legionella infection is based on agents with a high intrinsic activity, an appropriate pharmacokinetic and pharmacodynamic profile (including the ability to penetrate phagocytic cells), a low incidence of adverse reactions and an advantageous cost-efficacy rela- tionship. Newer macroazalides and fluoroquinolones are among the first-line therapies and in severe infections, particularly those occurring in immunocompromised patients, azithromycin and later fluoroquinolones are the agents of choice. Delay in the onset of adequate therapy is a key factor associated with a poor outcome. Thus, all patients with pneumonia associated with respiratory failure, shock or underlying disease causing severe immunodeficiency should ini- tially receive an agent active against Legionella spp., at least while the aetiology remains unknown. Adjunctive measures improve outcome in critically ill patients. In intubated patients with delayed resolution, superinfection by Pseudomonas...
Clinical Pulmonary Medicine, 1997
Critical Care Medicine - CRIT CARE MED, 2007
Page 1. Letters to the Editor Intensive care unit treatment in patients >65 yrs with a first-d... more Page 1. Letters to the Editor Intensive care unit treatment in patients >65 yrs with a first-day sequential organ failure assessment score >15 is not futile To the Editor: With great interest, we read the study by Kaarlola and colleagues ...
Intensive Care Medicine - INTENS CARE MED
Enfermedades infecciosas y microbiologia clinica, Jan 26, 2015
The role of influenza viruses in severe acute respiratory infection (SARI) in Intensive Care Unit... more The role of influenza viruses in severe acute respiratory infection (SARI) in Intensive Care Units (ICU) remains unknown. The post-pandemic influenza A(H1N1)pdm09 period, in particular, has been poorly studied. To identify influenza SARI patients in ICU, to assess the usefulness of the symptoms of influenza-like illness (ILI), and to compare the features of pandemic vs. post-pandemic influenza A(H1N1) pdm09 infection. A prospective observational study with SARI patients admitted to ICU during the first three post-pandemic seasons. Patient demographics, characteristics and outcomes were recorded. An influenza epidemic period (IEP) was defined as >100 cases/100,000 inhabitants per week. One hundred sixty-three patients were diagnosed with SARI. ILI was present in 65 (39.9%) patients. Influenza infection was documented in 41 patients, 27 (41.5%) ILI patients, and 14 (14.3%) non-ILI patients, 27 of them during an IEP. Influenza A viruses were mainly responsible. Only five patients ha...
International journal of antimicrobial agents, 2015
Telavancin was the first marketed lipoglycopeptide. Although licensed in Europe in 2011 for the t... more Telavancin was the first marketed lipoglycopeptide. Although licensed in Europe in 2011 for the treatment of nosocomial pneumonia caused by meticillin-resistant Staphylococcus aureus (MRSA), it did not become clinically available until March 2014. Given the limited clinical experience with telavancin in Europe, this review provides an overview of its antimicrobial and clinical activity as well as its position among today's antimicrobials, with particular focus on the implications of its licensing requirements. Telavancin has potent in vitro activity against isolates of Gram-positive pathogens, including MRSA and glycopeptide-intermediate S. aureus strains. In addition, at clinically attainable doses telavancin inhibits Gram-positive isolates of antibiotic-resistant strains from biofilm models. The in vitro potency of telavancin has been corroborated in the clinical setting. Comparative clinical studies of telavancin demonstrate non-inferiority compared with vancomycin in the tre...
Journal of clinical microbiology, 1997
A prospective study of 45 central venous catheters was conducted to assess, by strain delineation... more A prospective study of 45 central venous catheters was conducted to assess, by strain delineation, the turnover of skin and catheter hub (superficial) colonization and the relative contributions of catheter hub and skin colonization to catheter tip colonization. Serial quantitative cultures of skin and catheter hub were performed. Catheter tip, blood, and specimens for culture from targeted superficial sites (TSSs) were also collected at the time of catheter removal. Strains from 17 tip-positive catheters were delineated by pulsed-field gel electrophoresis. Only 12 (28.6%) of 42 skin strains and 14 (31.1%) of 45 catheter hub strains were found to be present at the time of catheter removal. In addition, only 9 (29.0%) of the 31 tip-colonizing strains were present on TSSs. Moreover, 15 (48.4%) of the 31 tip-colonizing strains had a superficial origin, and the other 16 (51.6%) were of unknown origin. In catheters suspected of infection, cultures of TSSs had a negative predictive value ...
International journal of antimicrobial agents, 2014
An unexpectedly high incidence of invasive pulmonary aspergillosis (IPA) has been reported in non... more An unexpectedly high incidence of invasive pulmonary aspergillosis (IPA) has been reported in non-neutropenic intensive care unit (ICU) patients. After the respiratory tract, the brain is most often affected by invasive aspergillosis. However, little is known about brain involvement by Aspergillus in critically ill patients. In this study, demographics, risk profile, diagnosis, treatment and outcome of proven cases of invasive cerebral aspergillosis (ICA) taken from a cohort of 563 adult patients with evidenced Aspergillus involvement during their ICU stay were reviewed. Ten patients with central nervous system aspergillosis were identified. All had one or more host factors predisposing for invasive aspergillosis. The clinical and radiological presentation was non-specific and exclusively pulmonary-related. All but one patient had proven or probable/putative IPA. On cerebral computed tomography, lesions appeared as either solitary and hyperdense or were multiple and randomly distrib...
Clinical Pulmonary Medicine, 2009
... Lisboa, Thiago MD*; Craven, Donald E. MD; Rello, Jordi MD, PhD*. ... 32,33 Because of its i... more ... Lisboa, Thiago MD*; Craven, Donald E. MD; Rello, Jordi MD, PhD*. ... 32,33 Because of its importance and impact on morbidity in ICU patients, VAP prevention was included in the Institute for Health Improvement (IHI) campaign to save 100,000 lives (www.ihi.org). ...
Higiene oral Clorhexidina Neumonía asociada a la ventilació n R E S U M E N Fundamento y objetivo... more Higiene oral Clorhexidina Neumonía asociada a la ventilació n R E S U M E N Fundamento y objetivos: La ventilació n mecá nica se usa al menos en una tercera parte de los pacientes ingresados en unidades de cuidados intensivos (UCI). La neumonía asociada a la ventilació n (NAV) es la complicació n má s frecuente, que afecta de un 8-28% de los pacientes. La prevenció n de NAV surge como una estrategia importante para el tratamiento de pacientes en UCI. Se han propuesto diferentes estrategias en prevenció n y, dentro de estas, la higiene oral con clorhexidina surge como una herramienta ú til. El objetivo de este trabajo fue evaluar el efecto de la clorhexidina sobre la prevenció n de NAV. Pacientes y método: Se realizó una revisió n sistemá tica de la literatura mé dica de ensayos clínicos controlados que evalú an el efecto de la clorhexidina sobre la prevenció n de NAV. Se realizó una bú squeda de los artículos indexados en PubMed usando las palabras claves: )oral care OR oral higiene OR chlorhexidine AND ventilator-associated pneumonia*. Un revisor independiente evaluó los estudios segú n los criterios de inclusió n y extrajo los datos. Resultados: Se encontraron 120 artículos. De estos, consideramos 10 estudios que cumplían los criterios de inclusió n. Se apreció una falta de uniformidad en la aplicació n del tratamiento de clorhexidina. Se encontró una reducció n en el riesgo de NAV en el grupo clorhexidina comparado con el grupo control (odds ratio: 56, intervalo de confianza del 95%: 44-0,73). Sin embargo, no se apreció una reducció n en la mortalidad, el tiempo de ventilació n mecá nica ni los días de estancia. Conclusiones: La higiene oral con clorhexidina en combinació n con otras estrategias de prevenció n de NAV debe estar incluida en el cuidado general del paciente de UCI.
Introduction: It remains unknown why some intubated patients remain infection-free while others d... more Introduction: It remains unknown why some intubated patients remain infection-free while others develop tracheobronchitis (VAT) or pneumonia (VAP). Objective: To identify and compare VAP/VAT gene expression ''signatures'' using genome-wide oligonucleotide microarrays. Material and methods: A prospective translational study of gene expression profiles of VA P and VAT groups was carried out, establishing comparisons in both pre-infection and infection phases. Pathway and functional analyses were performed with Ingenuity Pathway Analysis (IPA). Data analysis and hierarchical clustering of the genes involved in the signalling pathways expressed differentially in the two groups were performed with GeneSpring GX 11.0. Results: Eight patients developing respiratory infections (3 VA P and 5 VAT) after 4 days of mechanical ventilation were assessed. Comparison of gene expression profiles in the preinfection period revealed 5595 genes expressed differentially between VA P and VAT (p < 0.01, fold change >2). Comparative IPA analysis identified a significant depression of the complement system signalling pathway in the VA P group, affecting the classical pathway along with the final common pathway (p < 0.05). In addition, the cAMP and calcium signalling pathways were also significantly depressed in the VA P group during the pre-infection phase also. Conclusion: Intubated patients complicated with pneumonia developed immune impairment in the pre-infection period, manifesting as a relatively lower expression of genes involved in the complement system that differed from patients developing tracheobronchitis. These findings suggest that a significant proportion of VA P episodes cannot be prevented, but might be treatable through pre-emptive therapy. Documento descargado de http://www.medintensiva.org el 28/11/2013. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
Risk factors for β-lactam antibiotic underdosing in critically ill patients have not been describ... more Risk factors for β-lactam antibiotic underdosing in critically ill patients have not been described in large-scale studies. The objective of this study was to describe pharmacokinetic/pharmacodynamic (PK/PD) target non-attainment envisioning empirical dosing in critically ill patients and considering a worst-case scenario as well as to identify patient characteristics that are associated with target non-attainment. This analysis uses data from the DALI study, a prospective, multi-centre pharmacokinetic point-prevalence study. For this analysis, we assumed that these were the concentrations that would be reached during empirical dosing, and calculated target attainment using a hypothetical target minimum inhibitory concentration (MIC), namely the susceptibility breakpoint of the least susceptible organism for which that antibiotic is commonly used. PK/PD targets were free drug concentration maintained above the MIC of the suspected pathogen for at least 50 % and 100 % of the dosing interval respectively (50 % and 100 % f T (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;MIC)). Multivariable analysis was performed to identify factors associated with inadequate antibiotic exposure. A total of 343 critically ill patients receiving eight different β-lactam antibiotics were included. The median (interquartile range) age was 60 (47-73) years, APACHE II score was 18 (13-24). In the hypothetical situation of empirical dosing, antibiotic concentrations remained below the MIC during 50 % and 100 % of the dosing interval in 66 (19.2 %) and 142 (41.4 %) patients respectively. The use of intermittent infusion was significantly associated with increased risk of non-attainment for both targets; creatinine clearance was independently associated with not reaching the 100 % f T( &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;MIC) target. This study found that-in empirical dosing and considering a worst--case scenario--19 % and 41 % of the patients would not achieve antibiotic concentrations above the MIC during 50 % and 100 % of the dosing interval. The use of intermittent infusion (compared to extended and continuous infusion) was the main determinant of non-attainment for both targets; increasing creatinine clearance was also associated with not attaining concentrations above the MIC for the whole dosing interval. In the light of this study from 68 ICUs across ten countries, we believe current empiric dosing recommendations for ICU patients are inadequate to effectively cover a broad range of susceptible organisms and need to be reconsidered.
To evaluate de-escalation of antibiotic therapy in patients with ventilator-associated pneumonia.... more To evaluate de-escalation of antibiotic therapy in patients with ventilator-associated pneumonia. Prospective observational study during a 43-month period. Medical-surgical intensive care unit. One hundred and fifteen patients admitted to the intensive care unit with clinical diagnosis of ventilator-associated pneumonia. All the episodes of ventilator-associated pneumonia received initial broad-spectrum coverage followed by reevaluation according to clinical response and microbiology. Quantitative cultures obtained by bronchoscopic examination or tracheal aspirates were used to modify therapy. : None. One hundred and twenty-one episodes of ventilator-associated pneumonia were diagnosed. Change of therapy was documented in 56.2%, including de-escalation (the most frequent cause) in 31.4% (increasing to 38% if isolates were sensitive). Overall intensive care unit mortality rate was 32.2%. Inappropriate antibiotic therapy was identified in 9% of cases and was associated with 14.4% excess intensive care unit mortality. Quantitative tracheal aspirates and bronchoscopic samples (58 protected specimen brush and three bronchoalveolar lavage) were associated with 32.7% and 29.5% intensive care unit mortality and 29.3% and 34.4% de-escalation rate. De-escalation was lower (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05) in the presence of nonfermenting Gram-negative bacillus (2.7% vs. 49.3%) and in the presence of late-onset pneumonia (12.5% vs. 40.7%). When the pathogen remained unknown, half of the patients died and de-escalation was not performed. De-escalation was the most important cause of antibiotic modification, being more feasible in early-onset pneumonia and less frequent in the presence of nonfermenting Gram-negative bacillus. The impact of quantitative tracheal aspirates or bronchoscopic techniques was comparable in terms of mortality.
Cómo citar este artículo: Masclans JR, et al. Objetivos docentes en la formación de médicos resid... more Cómo citar este artículo: Masclans JR, et al. Objetivos docentes en la formación de médicos residentes en trasplante de órganos sólidos. Med Intensiva. 2012. http://dx.
Critical Care Medicine, 2014
To estimate the prevalence of ventilator-associated pneumonia caused by Pseudomonas aeruginosa in... more To estimate the prevalence of ventilator-associated pneumonia caused by Pseudomonas aeruginosa in patients at risk for ventilator-associated pneumonia and to describe risk factors for P. aeruginosa ventilator-associated pneumonia. Prospective, observational study. ICUs at 56 sites in 11 countries across four regions: the United States (n = 502 patients), Europe (n = 495), Latin America (n = 500), and Asia Pacific (n = 376). Adults intubated and mechanically ventilated for 48 hours to 7 days, inclusive. None (local standard of care). Ventilator-associated pneumonia prevalence as defined by local investigators were 15.6% (293/1,873) globally, 13.5% in the United States, 19.4% in Europe, 13.8% in Latin America, and 16.0% in Asia Pacific (p = 0.04). Corresponding P. aeruginosa ventilator-associated pneumonia prevalences were 4.1%, 3.4%, 4.8%, 4.6%, and 3.2% (p = 0.49). Of 50 patients with P. aeruginosa ventilator-associated pneumonia who underwent surveillance testing, 19 (38%) had prior P. aeruginosa colonization and 31 (62%) did not (odds ratio, 7.99; 95% CI, 4.31-14.71). Of predefined risk factors for multidrug resistance (hereafter, risk factors), the most frequent in all patients were antimicrobial therapy within 90 days (51.9% of enrolled patients) and current hospitalization of more than or equal to 5 days (45.3%). None of these risk factors were significantly associated with P. aeruginosa ventilator-associated pneumonia by multivariate logistic regression. Risk factors associated with prior P. aeruginosa colonization were antimicrobial therapy within 90 days (odds ratio, 0.46; 95% CI, 0.29-0.73) and high proportion of antibiotic resistance in the community or hospital unit (odds ratio, 1.79; 95% CI, 1.14-2.82). Our findings suggest that ventilator-associated pneumonia remains a common ICU infection and that P. aeruginosa is one of the most common causative pathogens. The odds of developing P. aeruginosa ventilator-associated pneumonia were eight times higher in patients with prior P. aeruginosa colonization than in uncolonized patients, which in turn was associated with local resistance.
Medicina Intensiva (English Edition), 2013
The Lancet. Respiratory medicine, 2015
Sepsis continues to be a major cause of death, disability, and health-care expenditure worldwide.... more Sepsis continues to be a major cause of death, disability, and health-care expenditure worldwide. Despite evidence suggesting that host genetics can influence sepsis outcomes, no specific loci have yet been convincingly replicated. The aim of this study was to identify genetic variants that influence sepsis survival. We did a genome-wide association study in three independent cohorts of white adult patients admitted to intensive care units with sepsis, severe sepsis, or septic shock (as defined by the International Consensus Criteria) due to pneumonia or intra-abdominal infection (cohorts 1-3, n=2534 patients). The primary outcome was 28 day survival. Results for the cohort of patients with sepsis due to pneumonia were combined in a meta-analysis of 1553 patients from all three cohorts, of whom 359 died within 28 days of admission to the intensive-care unit. The most significantly associated single nucleotide polymorphisms (SNPs) were genotyped in a further 538 white patients with s...
Medicina intensiva / Sociedad Española de Medicina Intensiva y Unidades Coronarias, 2011
During the 2009 influenza pandemic, several reports were published, nevertheless, data on the cli... more During the 2009 influenza pandemic, several reports were published, nevertheless, data on the clinical profiles of critically ill patients with the new virus infection during this second outbreak are still lacking. Prospective, observational, multi-center study conducted in 148 Spanish intensive care units (ICU) during epidemiological weeks 50-52 of 2010 and weeks 1 - 4 of 2011. Three hundred patients admitted to an intensive care unit (ICU) with confirmed An/H1N1 infection were analyzed. The median age was 49 years [IQR=38-58] and 62% were male. The mean APACHE II score was 16.9 ± 7.5 and the mean SOFA score was 6.3 ± 3.5 on admission. Comorbidities were present in 76% (n=228) of cases and 111 (37.4%) patients were reportedly obese and 59 (20%) were COPD. The main presentation was viral pneumonia with severe hypoxemia in 65.7% (n=197) of the patients whereas co-infection was identified in 54 (18%) patients. All patients received antiviral treatment and initiated empirically in 194 ...
Optimal therapy against Legionella infection is based on agents with a high intrinsic activity, a... more Optimal therapy against Legionella infection is based on agents with a high intrinsic activity, an appropriate pharmacokinetic and pharmacodynamic profile (including the ability to penetrate phagocytic cells), a low incidence of adverse reactions and an advantageous cost-efficacy rela- tionship. Newer macroazalides and fluoroquinolones are among the first-line therapies and in severe infections, particularly those occurring in immunocompromised patients, azithromycin and later fluoroquinolones are the agents of choice. Delay in the onset of adequate therapy is a key factor associated with a poor outcome. Thus, all patients with pneumonia associated with respiratory failure, shock or underlying disease causing severe immunodeficiency should ini- tially receive an agent active against Legionella spp., at least while the aetiology remains unknown. Adjunctive measures improve outcome in critically ill patients. In intubated patients with delayed resolution, superinfection by Pseudomonas...
Clinical Pulmonary Medicine, 1997
Critical Care Medicine - CRIT CARE MED, 2007
Page 1. Letters to the Editor Intensive care unit treatment in patients >65 yrs with a first-d... more Page 1. Letters to the Editor Intensive care unit treatment in patients >65 yrs with a first-day sequential organ failure assessment score >15 is not futile To the Editor: With great interest, we read the study by Kaarlola and colleagues ...
Intensive Care Medicine - INTENS CARE MED