Recommendations of the Infectious Diseases Work Group (GTEI) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) and the Infections in Critically Ill Patients Study Group (GEIPC) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) for the diagnosis and treatment of influenza A/H1N1 in seriously ill adults admitted to the Intensive Care Unit.
Journal - Medicina intensiva / Sociedad Espanola de Medicina Intensiva y Unidades Coronarias
The diagnosis of influenza A/H1N1 is mainly clinical, particularly during peak or seasonal flu outbreaks. A diagnostic test should be performed in all patients with fever and flu symptoms that require hospitalization. The respiratory sample (nasal or pharyngeal exudate or deeper sample in intubated patients) should be obtained as soon as possible, with the immediate start of empirical antiviral treatment. Molecular methods based on nucleic acid amplification techniques (RT-PCR) are the gold standard for the diagnosis of influenza A/H1N1. Immunochromatographic methods have low sensitivity; a negative result therefore does not rule out active infection. Classical culture is slow and has low sensitivity. Direct immunofluorescence offers a sensitivity of 90%, but requires a sample of high quality. Indirect methods for detecting antibodies are only of epidemiological interest. Patients with A/H1N1 flu may have relative leukopenia and elevated serum levels of LDH, CPK and CRP, but none of these variables are independently associated to the prognosis. However, plasma LDH> 1500 IU/L, and the presence of thrombocytopenia <150x10(9)/L, could define a patient population at risk of suffering serious complications. Antiviral administration (oseltamivir) should start early (<48h from the onset of symptoms), with a dose of 75mg every 12h, and with a duration of at least 7 days or until clinical improvement is observed. Early antiviral administration is associated to improved survival in critically ill patients. New antiviral drugs, especially those formulated for intravenous administration, may be the best choice in future epidemics. Patients with a high suspicion of influenza A/H1N1 infection must continue with antiviral treatment, regardless of the negative results of initial tests, unless an alternative diagnosis can be established or clinical criteria suggest a low probability of influenza. In patients with influenza A/H1N1 pneumonia, empirical antibiotic therapy should be provided due to the possibility of bacterial coinfection. A beta-lactam plus a macrolide should be administered as soon as possible. The microbiological findings and clinical or laboratory test variables may decide withdrawal or not of antibiotic treatment. Pneumococcal vaccination is recommended as a preventive measure in the population at risk of suffering severe complications. Although the use of moderate- or low-dose corticosteroids has been proposed for the treatment of influenza A/H1N1 pneumonia, the existing scientific evidence is not sufficient to recommend the use of corticosteroids in these patients. The treatment of acute respiratory distress syndrome in patients with influenza A/H1N1 must be based on the use of a protective ventilatory strategy (tidal volume <10ml / kg and plateau pressure <35mmHg) and positive end-expiratory pressure set to high patient lung mechanics, combined with the use of prone ventilation, muscle relaxation and recruitment maneuvers. Noninvasive mechanical ventilation cannot be considered a technique of choice in patients with acute respiratory distress syndrome, though it may be useful in experienced centers and in cases of respiratory failure associated with chronic obstructive pulmonary disease exacerbation or heart failure. Extracorporeal membrane oxygenation is a rescue technique in refractory acute respiratory distress syndrome due to influenza A/H1N1 infection. The scientific evidence is weak, however, and extracorporeal membrane oxygenation is not the technique of choice. Extracorporeal membrane oxygenation will be advisable if all other options have failed to improve oxygenation. The centralization of extracorporeal membrane oxygenation in referral hospitals is recommended. Clinical findings show 50-60% survival rates in patients treated with this technique. Cardiovascular complications of influenza A/H1N1 are common. Such problems may appear due to the deterioration of pre-existing cardiomyopathy, myocarditis, ischemic heart disease and right ventricular dysfunction. Early diagnosis and adequate monitoring allow the start of effective treatment, and in severe cases help decide the use of circulatory support systems. Influenza vaccination is recommended for all patients at risk. This indication in turn could be extended to all subjects over 6 months of age, unless contraindicated. Children should receive two doses (one per month). Immunocompromised patients and the population at risk should receive one dose and another dose annually. The frequency of adverse effects of the vaccine against A/H1N1 flu is similar to that of seasonal flu. Chemoprophylaxis must always be considered a supplement to vaccination, and is indicated in people at high risk of complications, as well in healthcare personnel who have been exposed.Copyright © 2011 Elsevier España, S.L. y SEMICYUC. All rights reserved.
Impact of early oseltamivir treatment on outcome in critically ill patients with 2009 pandemic influenza A.
Journal - The Journal of antimicrobial chemotherapy (England )
The impact of oseltamivir on mortality in critically ill patients with 2009 pandemic influenza A (2009 H1N1) is not clear. The main objective of this study was to investigate the relationship between the timing of antiviral administration and intensive care unit (ICU) outcomes.Prospective, observational study of a cohort of ICU patients with confirmed 2009 H1N1 infection. Clinical data, treatment and outcome were compared between patients receiving early treatment (ET) with oseltamivir, initiated within 2 days, and patients administered late treatment (LT), initiated after this timepoint. Multivariate analysis and propensity score were used to determine the effect of oseltamivir on ICU mortality.Six hundred and fifty-seven patients were enrolled. Four hundred and four (61.5%) patients required mechanical ventilation (MV; mortality 32.6%). Among them, 385 received effective antiviral therapy and were included in the study group. All patients received oseltamivir for a median duration of 10 days (interquartile range 8-14 days). Seventy-nine (20.5%) ET patients were compared with 306 LT patients. The two groups were comparable in terms of main clinical variables. ICU length of stay (22.7?±?16.7 versus 18.4?±?14.2 days; P?=?0.03), hospital length of stay (34.0?±?20.3 versus 27.2?±?18.2 days; P?=?0.001) and MV days (17.4?±?15.2 versus 14.0?±?12.4; P?=?0.04) were higher in the LT group. ICU mortality was also higher in LT (34.3%) than in ET (21.5%; OR?=?1.9; 95% CI 1.06-3.41). A multivariate model identified ET (OR?=?0.44; 95% CI 0.21-0.87) as an independent variable associated with reduced ICU mortality. These results were confirmed by propensity score analysis (OR?=?0.44; 95% CI 0.22-0.90; P?0.001).Our findings suggest that early oseltamivir administration was associated with favourable outcomes among critically ill ventilated patients with 2009 H1N1 virus infection.
|ISSN : ||1460-2091|
|Mesh Heading : ||Adult Antiviral Agents Female Humans Influenza A Virus, H1N1 Subtype Influenza, Human Male Middle Aged Oseltamivir Prospective Studies Time Factors Treatment Outcome isolation & purification mortality virology|
|Mesh Heading Relevant : ||Critical Illness administration & dosage drug therapy administration & dosage|
First Influenza Season Outbreak After 2009 Pandemic Influenza A(H1N1) in Spain.
Journal - Chest (United States )
[Pandemic Influenza A in the ICU: Experience in Spain and Latin America GETGAG/SEMICYUC/(Spanish Work Group on Severe Pandemic Influenza A/SEMICYUC).]
Journal - Medicina intensiva / Sociedad Espanola de Medicina Intensiva y Unidades Coronarias
INTRODUCTION: Pandemic Influenza A (H1N1)v infection is the first pandemic in which intensive care units (ICU) play a fundamental role. It has spread very rapidly since the first cases were diagnosed in Mexico with the subsequent spread of the virus throughout the Southern Cone and Europe during the summer season. OBJECTIVE: This study has aimed to compare the clinical presentation and outcome among the critical patients admitted to the ICU until July 31, 2009 in Spain with some series from Latin America. MATERIAL AND METHOD: Six series of critically ill patients admitted to the ICU were considered. Clinical characteristics, complications and outcome were compared between series. RESULTS: Young patients (35-45 years) with viral pneumonia as a predominant ICU admission cause with severe respiratory failure and a high need of mechanical ventilation (60-100%) were affected. Obesity, pregnancy and chronic lung disease were risk factors associated with a worse outcome, however there was a high number of patients without comorbidities (40-50%). Mortality rate was between 25-50% and higher in the Latin America series, demonstrating the specific potential pathogenesis of the new virus. The use of antiviral treatment was delayed (between 3 and 6 days) and not generalized, with greater delay in Latin America in regards to Spain. CONCLUSIONS: These data suggest that a more aggressive treatment strategy, with earlier and easier access to the antiviral treatment might reduce the number of ICU admissions and mortality.Copyright © 2009 Elsevier España, S.L. y SEMICYUC. All rights reserved.
[Pandemic influenza A (H1N1)v in the intensive care unit: what have we learned?]
Journal - Archivos de bronconeumologia
The characteristics of pandemic influenza 2009 differ from those of seasonal influenza. In Australia-New Zealand the number of admissions to the intensive care unit (ICU) increased by 15-fold in the southern winter. We compared the characteristics of the Spanish series of the first ICU admissions in July with those of series published in Canada and Australia-New Zealand up to October 2009. Unlike the situation in Spain, only half the admissions in Canada and Australia-New Zealand were due to primary viral pneumonia but bacterial pneumonia was much more frequent. In all series, young people, many of whom had no comborbidities, were the most frequently affected population. The most common comorbidities were obesity, chronic pulmonary disease, pregnancy and heart disease. Diagnosis through reverse-transcriptase polymerase chain reaction can have a false-negative rate of 10%. Shock and acute renal insufficiency were more frequent in the Spanish series. A total of 10-30% of patients required ICU admission and 6 of 10 patients required mechanical ventilation with a high frequency of failure of non-invasive ventilation (75%). Mortality was similar among the series (14-25%) but was higher in patients requiring mechanical ventilation (30%). Early oseltamivir administration (< 48h after symptom onset) has been associated with better outcome. Therefore, early administration of this drug in patients with risk factors or those who, although free from risk factors, show clinical progression, could reduce ICU admissions and mortality.Copyright © 2010 Sociedad Española de Neumología y Cirugía Torácica. Published by Elsevier Espana. All rights reserved.
Mortality in ICU patients with bacterial community-acquired pneumonia: when antibiotics are not enough.
Journal - Intensive care medicine (United States )
BACKGROUND: It remains uncertain why immunocompetent patients with bacterial community-acquired pneumonia (CAP) die, in spite of adequate antibiotics. METHODS: This is a secondary analysis of the CAPUCI database which was a prospective observational multicentre study. Two hundred and twelve immunocompetent patients admitted to 33 Spanish ICUs for CAP were analyzed. Comparisons were made for lifestyle risk factors, comorbidities and severity of illness. ICU mortality was the principal outcome variable. RESULTS: Bacteremic CAP (43.3 vs. 21.1%) and empyema (11.5 vs. 2.2%) were more frequent (P < 0.05) in patients with Streptococcus pneumoniae CAP. Higher rates of adequate empiric therapy (95.8 vs. 75.5%, P < 0.05) were observed in patients with S. pneumoniae CAP. Patients with non-pneumococcal CAP experienced more shock (66.7 vs. 50.8%, P < 0.05), and need for mechanical ventilation (83.3 vs. 61.5%, P < 0.05). ICU mortality was 20.7 and 28% [OR 1.49(0.74-2.98)] among immunocompetent patients with S. pneumoniae (n = 122) and non-pneumococci (n = 90), in spite of initial adequate antibiotic. Multivariable regression analysis in these 184 immunocompetent patients with adequate empirical antibiotic treatment identified the following variables as independently associated with mortality: shock (HR 13.03); acute renal failure (HR 4.79), and APACHE II score higher than 24 (HR 2.22). CONCLUSIONS: Mortality remains unacceptably high in immunocompetent patients admitted to the ICU with bacterial pneumonia, despite adequate initial antibiotics and comorbidities management. Patients with shock, acute renal failure and APACHE II score higher than 24 should be considered for inclusion in trials of adjunctive therapy in order to improve CAP survival.
|ISSN : ||1432-1238|
|Mesh Heading : ||Anti-Bacterial Agents Combined Modality Therapy Community-Acquired Infections Empyema Female Health Status Hemofiltration Humans Intensive Care Units Kidney Failure, Acute Life Style Male Middle Aged Pneumonia, Bacterial Respiration, Artificial Risk Factors Streptococcal Infections Streptococcus pneumoniae epidemiology microbiology mortality methods microbiology microbiology isolation & purification|
|Mesh Heading Relevant : ||therapeutic use mortality therapy statistics & numerical data epidemiology therapy mortality therapy methods|
Combination antibiotic therapy improves survival in patients with community-acquired pneumonia and shock.
Journal - Critical care medicine (United States )
OBJECTIVE: To assess whether combination antibiotic therapy improves outcome of severe community-acquired pneumonia in the subset of patients with shock. DESIGN: Secondary analysis of a prospective observational, cohort study. SETTING: Thirty-three intensive care units (ICUs) in Spain. PATIENTS: Patients were 529 adults with community-acquired pneumonia requiring ICU admission. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Two hundred and seventy (51%) patients required vasoactive drugs and were categorized as having shock. The effects of combination antibiotic therapy and monotherapy on survival were compared using univariate analysis and a Cox regression model. The adjusted 28-day in-ICU mortality was similar (p = .99) for combination antibiotic therapy and monotherapy in the absence of shock. However, in patients with shock, combination antibiotic therapy was associated with significantly higher adjusted 28-day in-ICU survival (hazard ratio, 1.69; 95% confidence interval, 1.09-2.60; p = .01) in a Cox hazard regression model. Even when monotherapy was appropriate, it achieved a lower 28-day in-ICU survival than an adequate antibiotic combination (hazard ratio, 1.64; 95% confidence interval, 1.01-2.64). CONCLUSIONS: Combination antibiotic therapy does not seem to increase ICU survival in all patients with severe community-acquired pneumonia. However, in the subset of patients with shock, combination antibiotic therapy improves survival rates.
|ISSN : ||0090-3493|
|Mesh Heading : ||Aged Anti-Bacterial Agents Community-Acquired Infections Drug Therapy, Combination Female Hospital Mortality Humans Male Middle Aged Pneumonia, Bacterial Prospective Studies Shock Survival Analysis administration & dosage complications drug therapy mortality complications mortality etiology|
|Mesh Heading Relevant : ||Intensive Care Units therapeutic use drug therapy drug therapy|
Effects of high-dose of intravenous immunoglobulin and antibiotics on survival for severe sepsis undergoing surgery.
Journal - Shock (Augusta, Ga.) (United States )
The objective of this study was to assess the impact on outcome of adjuvant therapy (high-dose of immunoglobulin [Ig] M-enriched intravenous Ig, IVIG) in intensive care unit (ICU) patients who underwent surgery by abdominal sepsis. This was a prospective, randomized, double-blind, controlled study set in the medical/surgical ICUs of seven teaching hospitals. Patients with severe sepsis and septic shock of intra-abdominal origin admitted to the ICU within 24 h after the onset of symptoms were included in the study. Polyvalent IgM-enriched Ig (Pentaglobin; IVIG group) at a dosage of 7 mL/kg/day for 5 days or an equal amount of 5% human albumin (control group) was randomized. Fifty-six patients were enrolled. The overall mortality rate was 37.5.%. Twenty patients had shock and 36 had severe sepsis (the mortality rate was 55.0% and 25.0%, respectively). In the intent-to-treat analysis, the mortality rate was reduced from 48.1% in patients treated with antibiotic (ATB) plus albumin to 27.5% (P = 0.06) for patients with ATB plus IVIG. The organ failure score (1.0 +/- 0.6 vs. 1.2 +/- 0.9), organ dysfunction score (1.7 +/- 1.1 vs. 1.8 +/- 1.0), and reoperation rate (17.2% vs. 29.6%) were not different between IVIG and control groups, respectively. Eight patients (14.3%) received inappropriate ATB initial therapy (IAT), and seven died (87.5%). IAT was the only variable independently associated with death (odds ratio, 19.4) in a logistic regression model. We conclude that IVIG administration, when used in combination with adequate antibiotics, improved the survival of surgical ICU patients with intra-abdominal sepsis. The initial choice of antibiotic has a dramatic impact on outcome.
|ISSN : ||1073-2322|
|Mesh Heading : ||APACHE Adult Aged Aged, 80 and over Albumins Anti-Bacterial Agents Double-Blind Method Female Humans Immunoglobulin M Immunoglobulins, Intravenous Inflammation Intensive Care Logistic Models Male Middle Aged Multiple Organ Failure Prospective Studies Random Allocation Sepsis Time Factors metabolism administration & dosage chemistry therapeutic use administration & dosage drug therapy surgery|
|Mesh Heading Relevant : ||pharmacology pharmacology drug therapy mortality|