Seminars in respiratory and critical care medicine
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The incidence of invasive candidiasis in critically ill patients has increased over the past decade and is associated with considerable morbidity and mortality. CANDIDA is identified in up to 17% of ICU patients, with candidemia occurring in ∼1%. CANDIDA ALBICANS continues to account for approximately half of the invasive candidiasis cases, with non- ALBICANS CANDIDA species, such CANDIDA GLABRATA, increasing in frequency. ⋯ Systemic antifungal therapy is also being utilized in patients at increased risk for invasive candidiasis based on surrogate markers of infection such as colonization (preemptive therapy), or in patients with unresolving sepsis despite appropriate management (empirical therapy). Recent guidelines on the use of antifungal therapy have better identified patients who can be treated with azole derivatives and those who may benefit from echinocandins or polyenes. However, prospective trials are still needed to better identify appropriate therapy for patients at risk for, or with, confirmed invasive CANDIDA infections.
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Semin Respir Crit Care Med · Apr 2011
ReviewValue of the serum procalcitonin level to guide antimicrobial therapy for patients with ventilator-associated pneumonia.
Procalcitonin's contribution to the diagnosis of nosocomial infection, particularly ventilator-associated pneumonia (VAP), is poor: its levels in patients with microbiologically documented VAP the day infection is diagnosed range from normal to extremely high. Moreover, the results of four studies showed that, despite relatively good specificity, this marker had low sensitivity for the diagnosis of VAP. ⋯ Two recent studies showed that a procalcitonin-based strategy (recommending that treating physicians stop antibiotics when the procalcitonin concentration was <0.5 ng/mL, or had decreased by ≥80%) led to less antibiotic consumption by VAP patients, compared with a conventional strategy, with no adverse outcome. Accordingly, for VAP patients, procalcitonin may be used to stop antibiotics as early as day 3 after their initiation, if its concentration is <0.5 ng/mL or has decreased by ≥80%, compared with the first peak concentration.
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Sepsis-induced cardiac dysfunction is a frequent and severe complication of septic shock. The mechanisms responsible for its development are complex and intricate. Echocardiography is the best method to make the diagnosis of cardiac dysfunction. ⋯ The transpulmonary thermodilution monitor and the pulmonary artery catheter can also be used to alert clinicians or to monitor the effects of inotropic therapy. Dobutamine is the first-line therapy. Its administration remains a matter of debate and should be carefully monitored in terms of efficacy and tolerance.
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Severe sepsis is one of the most common reasons for critically ill patients to be admitted to an intensive care unit (ICU) and has very high associated morbidity and mortality. The Surviving Sepsis Campaign was initiated with the hope that mortality might be reduced by standardizing care informed by data from an increasing number of clinical trials. Important methods for reducing mortality identified by recent studies include aggressive fluid resuscitation, early goal-directed therapy (EGDT), early administration of antibiotics, and the administration of activated protein C to eligible patients.
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Antimicrobial stewardship encompasses the optimization of agent selection, dose, and duration leading to the best clinical outcome in the treatment or prevention of infection. Ideally, these goals are met while producing the fewest side effects and lowest risk for subsequent resistance. The concept of antimicrobial stewardship can be directly applied to the prescription of empirical antibiotic therapy in the intensive care unit (ICU) because it is well described that inappropriate initial regimens lead to increased mortality. ⋯ Research efforts have concentrated on molecular diagnostic techniques to aid in more rapid organism detection and thus potential for earlier therapy appropriateness and deescalation, although limitations prohibiting widespread implementation of this technology exist. Also of great importance with regard to stewardship efforts is infection prevention. Effective prophylactic strategies reduce the occurrence of nosocomial infections and may therefore improve patient outcomes while obviating the need for otherwise necessary antimicrobial exposure.