https://www.medpagetoday.com/upload/2011/4/4/Clin%20Infect%20Dis.-2002-O'Grady-1281-307.pdf

Guidelines for the Prevention of Intravascular Catheter-related Infections

Guidelines for the management of patients with invasive candidiasis and mucosal candidiasis were prepared by an Expert Panel of the Infectious Diseases Society of America. These updated guidelines replace the previous guidelines published in the 15 January 2004 issue of Clinical Infectious Diseases and are intended for use by health care providers who care for patients who either have or are at risk of these infections. Since 2004, several new antifungal agents have become available, and several new studies have been published relating to the treatment of candidemia, other forms of invasive candidiasis, and mucosal disease, including oropharyngeal and esophageal candidiasis. There are also recent prospective data on the prevention of invasive candidiasis in high-risk neonates and adults and on the empiric treatment of suspected invasive candidiasis in adults. This new information is incorporated into this revised document.

https://www.easy-immune-health.com/support-files/clin_practice_guidelines_candidiasis.pdf

Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America.

Ventilator-associated pneumonia (VAP) continues to complicate the course of 8 to 28% of patients receiving mechanical ventilation (MV). In contrast to infections of more frequently involved organs (e.g., urinary tract and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate for VAP ranges from 24 to 50% and can reach 76% in some specific settings or when lung infection is caused by high-risk pathogens. The predominant organisms responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa, and Enterobacteriaceae, but etiologic agents widely differ according to the population of patients in an intensive care unit, duration of hospital stay, and prior antimicrobial therapy. Because appropriate antimicrobial treatment of patients with VAP significantly improves outcome, more rapid identification of infected patients and accurate selection of antimicrobial agents represent important clinical goals. Our personal bias is that using bronchoscopic techniques to obtain protected brush and bronchoalveolar lavage specimens from the affected area in the lung permits physicians to devise a therapeutic strategy that is superior to one based only on clinical evaluation. When fiberoptic bronchoscopy is not available to physicians treating patients clinically suspected of having VAP, we recommend using either a simplified nonbronchoscopic diagnostic procedure or following a strategy in which decisions regarding antibiotic therapy are based on a clinical score constructed from seven variables. Selection of the initial antimicrobial therapy should be based on predominant flora responsible for VAP at each institution, clinical setting, information provided by direct examination of pulmonary secretions, and intrinsic antibacterial activities of antimicrobial agents and their pharmacokinetic characteristics. Further trials will be needed to clarify the optimal duration of treatment and the circumstances in which monotherapy can be safely used.

Ventilator-associated pneumonia.

Naomi P. O'Grady, M.D., Mary Alexander, R.N. Lillian A. Burns, M.T., M.P.H., C.I.C. E. Patchen Dellinger, M.D. Jeffery Garland, M.D., S.M. Stephen O. Heard, M.D. Pamela A. Lipsett, M.D. Henry Masur, M.D. Leonard A. Mermel, D.O., Sc.M. Michele L. Pearson, M.D. Issam I. Raad, M.D. Adrienne Randolph, M.D., M.Sc. Mark E. Rupp, M.D. Sanjay Saint, M.D., M.P.H. and the Healthcare Infection Control Practices Advisory Committee (HICPAC).

/pdf/guidelines-for-the-prevention-of-intravascular-catheter-4xarsoczlz.pdf

Guidelines for the prevention of intravascular catheter-related infections, 2011

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

/pdf/clinical-practice-guideline-for-the-management-of-451dfbrsff.pdf

Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

The use of microbiologic investigations in routine clinical practice, their value in guiding antibiotic prescription, and their influence on outcome were prospectively studied in 113 consecutive adults who developed ventilator-associated pneumonia (VAP). Blood cultures were performed in 78.7% of cases, protected specimen brushing in 95.5%, and bronchoalveolar lavage in only 45.1%. No causative agent was identified in 13 episodes (11.5%), and results of microbial tests directed a change in therapy in 43 (38.0%). Bronchoscopic results revealed inadequate initial selection of antibiotic therapy in 27 cases (23.9%) and led to a change in antibiotic treatment. Inadequate initial selection was still associated with a significantly greater increase in related mortality than adequate initial therapy (37.0% versus 15.4%, p < 0.05), although the change in therapy permitted clinical resolution in 17 (62.9%) of these 27 episodes, and 10 patients were discharged alive. Bronchoscopic results also permitted the reduction of the antibiotic spectrum in seven episodes (6.1%). This study suggests that in patients with VAP, bronchoscopic results are frequently associated with changes in antibiotic therapy. Nevertheless, our findings also emphasize the critical importance of an appropriate early antibiotic therapy.

The Value of Routine Microbial Investigation in Ventilator-Associated Pneumonia

Objective: Pseudomonas aeruginosa is a frequent cause of ventilator-associated pneumonia. Recent evidence suggests that production of type III secretion proteins is correlated with increased pathogenicity in both cellular and animal models of infection. The objective of this study was to determine whether this system contributes to disease severity in humans with ventilator-associated pneumonia. Design: Retrospective pilot cohort study. Setting: University hospital. Patients: Thirty-five mechanically ventilated patients with bronchoscopically confirmed ventilator-associated pneumonia caused by P. aeruginosa. Measurements and Main Results: Ventilator-associated pneumonia was categorized as severe (patients died or had a recurrence of their pneumonia despite appropriate antibiotic therapy) or mild (patients uneventfully recovered from their pneumonia). The type III secretion genotypes and phenotypes of isolates cultured from the patients with ventilator-associated pneumonia were determined. Whereas every examined isolate harbored type III secretion genes, only 27 (77%) were capable of secreting detectable amounts of type III proteins in vitro. Twenty-two (81%) of the patients infected with these 27 isolates had severe disease. Of the eight isolates that did not secrete type III proteins, only three (38%) were cultured from patients with severe disease. Thus, infection with a type-III-secreting isolate correlated with severe disease (p <.05). In vitro assays indicated that ExoU, the type III effector protein most closely linked to mortality in animal models, was secreted in detectable amounts in vitro by 10 (29%) of the 35 examined isolates. Nine (90%) of these 10 isolates were cultured from patients with severe disease (p <.05 when compared with the nonsecreting isolates). In contrast, ExoS was secreted by 16 (46%) of the 35 examined isolates. Twelve (75%) of these 16 isolates were cultured from patients with severe disease (p =.14 when compared with the nonsecreting isolates). Conclusions: In patients with ventilator-associated pneumonia, type-III-secreting isolates were associated with worse clinical outcomes, suggesting that this secretion system plays an important role in human disease. Our findings support the hypothesis that antibodies targeted against these proteins may be useful as adjunctive therapy in intubated patients with P. aeruginosa colonization or infection.

Type III protein secretion is associated with poor clinical outcomes in patients with ventilator-associated pneumonia caused by Pseudomonas aeruginosa.

Fifty-seven patients developed an episode of catheter-related infection (CRI) in the bloodstream during their stay in the intensive care unit (cases) and were prospectively observed to establish the attributable mortality, increase in length of stay, and excess costs. Costs were estimated by multiplying the number of excess days of stay by the reimbursement provided. The outcomes for these cases were compared with those for matched control subjects without CRI. Eight cases were excluded as no control was found. Of the 49 cases, 31 were coagulase-negative staphylococci (CNS). The level of severity was similar for both groups (APACHE II 15.5 +/- 7. 2 versus 15.2 +/- 7.3). There were no significant differences (p > 0. 20) in the mortality observed in the hospital for the cases (22.4%, 95% confidence interval [CI] 0.3% to 34.9%) and the control subjects (34.7%, 95% CI 21.2% to 40.1%). Among the survivors, the hospital stay was increased by 19.6 d (95% CI -1.1; 40.4). This represents an added cost of 3,124 Euros per episode of CRI among the survivors. In conclusion, our cohort study failed to show a difference in attributable mortality due to CRI in intensive care unit patients. Nevertheless, these infections lead to an increase in hospital stay of approximately 20 d. Each episode of CRI represents an additional cost of more than 3,000 Euros.

https://www.atsjournals.org/doi/pdf/10.1164/ajrccm.162.3.9911093

Dolors Mariscal

Papers

The Value of Routine Microbial Investigation in Ventilator-Associated Pneumonia

Type III protein secretion is associated with poor clinical outcomes in patients with ventilator-associated pneumonia caused by Pseudomonas aeruginosa.

Evaluation of Outcome of Intravenous Catheter-related Infections in Critically Ill Patients

Microbiological Testing and Outcome of Patients With Severe Community-Acquired Pneumonia

The Role of Candida sp Isolated From Bronchoscopic Samples in Nonneutropenic Patients