EPICO 2.0 project. Development of educational therapeutic recommendations using the DELPHI technique on invasive candidiasis in critically ill adult patients in special situations.

Background: Although there has been an improved management of invasive candidiasis in the last decade, still controversial issues remain, especially in different therapeutic critical care scenarios.

Aims: We sought to identify the core clinical knowledge and to achieve high agreement recommendations required to care for critically ill adult patients with invasive candidiasis for antifungal treatment in special situations and different scenarios.

Methods: Second prospective Spanish survey reaching consensus by the DELPHI technique, conducted anonymously by electronic e-mail in the first phase to 23 national multidisciplinary experts in invasive fungal infections from five national scientific societies including intensivists, anesthesiologists, microbiologists, pharmacologists and infectious disease specialists, answering 30 questions prepared by a coordination group after a strict review of literature in the last five years.

Multicenter, randomized, placebo-controlled phase III study of pyridoxalated hemoglobin polyoxyethylene in distributive shock (PHOENIX).

Objective: To compare the effectiveness and safety of the hemoglobin-based nitric oxide scavenger, pyridoxalated hemoglobin polyoxyethylene, against placebo in patients with vasopressor-dependent distributive shock.

Design: Multicenter, randomized, placebo-controlled, open-label study.

Setting: Sixty-one participating ICUs in six European countries (Austria, Belgium, Germany, the Netherlands, Spain, and United Kingdom).

Albumin administration in the acutely ill: what is new and where next?

Albumin solutions have been used worldwide for the treatment of critically ill patients since they became commercially available in the 1940s. However, their use has become the subject of criticism and debate in more recent years. Importantly, all fluid solutions have potential benefits and drawbacks.

Treatment with echinocandins during continuous renal replacement therapy.

Echinocandins are indicated as first-line treatment for invasive candidiasis in moderate to severe illness. As sepsis is the main cause of acute kidney injury, the combination of echinocandin treatment and continuous renal replacement therapy (CRRT) is common. Optimizing antibiotic dosage in critically ill patients receiving CRRT is challenging.

Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program.

Objectives: Compelling evidence has shown that aggressive resuscitation bundles, adequate source control, appropriate antibiotic therapy, and organ support are cornerstone for the success in the treatment of patients with sepsis. Delay in the initiation of appropriate antibiotic therapy has been recognized as a risk factor for mortality. To perform a retrospective analysis on the Surviving Sepsis Campaign database to evaluate the relationship between timing of antibiotic administration and mortality.

Blood culture differential time to positivity enables safe catheter retention in suspected catheter-related bloodstream infection: a randomized controlled trial.

Objective: To evaluate the clinical usefulness and safety of the differential-time-to-positivity (DTP) method for managing the suspicion of catheter-related bloodstream infection (CR-BSI) in comparison with a standard method that includes catheter removal in critically ill patients.

Methods-design: A prospective randomized study was carried out.

Setting: A 16-bed clinical-surgical ICU (July 2007-February 2009).

Future options for (economically) sustainable research in sepsis.

The relentless increase in healthcare costs and the global economic crisis require us to rethink the way research is done. The heterogeneity of patients is a major challenge in designing and coordinating high-quality studies about sepsis. Studies on new treatments and devices, such as polymyxin B hemoperfusion, must be optimized not only for potential benefits for a specific population (i.

Immunomodulation in sepsis: the role of endotoxin removal by polymyxin B-immobilized cartridge.

Severe sepsis results in high morbidity and mortality. Immunomodulation strategies could be an adjunctive therapy to treat sepsis. Endotoxin is a component of gram-negative bacteria and plays an important role in the pathogenesis of septic shock when it is recognized by immune cells.

Near-infrared spectroscopy StO2 monitoring to assess the therapeutic effect of drotrecogin alfa (activated) on microcirculation in patients with severe sepsis or septic shock.

Background: Sepsis is a leading cause of death despite appropriate management. There is increasing evidence that microcirculatory alterations might persist independently from macrohemodynamic improvement and are related to clinical evolution. Future efforts need to be directed towards microperfusion monitoring and treatment.

The impact of a quality improvement intervention to reduce nosocomial infections in a PICU.

Objective: To evaluate whether a quality improvement intervention could reduce nosocomial infection rates in a PICU and improve patient outcomes.

Design: Prospective interventional cohort study conducted during three periods: preintervention period, intervention period, and long-term follow-up.

Setting: A 14-bed medical and surgical PICU in a university hospital for children.

[Épico project: Development of educational recommendations using the DELPHI technique on invasive candidiasis in non-neutropenic critically ill adult patients. Grupo Proyecto Épico].

Background: Although there has been an improved management of invasive candidiasis in the last decade, controversial issues still remain, especially in the diagnostic and therapeutic approaches.

Aims: We sought to identify the core clinical knowledge and to achieve high level agreement recommendations required to care for critically ill adult patients with invasive candidiasis.

Methods: A prospective Spanish survey reaching consensus by the DELPHI technique was made.

Épico Project. Development of educational recommendations using the DELPHI technique on invasive candidiasis in non-neutropenic critically ill adult patients.

Background: Although there has been an improved management of invasive candidiasis in the last decade, controversial issues still remain, especially in the diagnostic and therapeutic approaches.

Aims: We sought to identify the core clinical knowledge and to achieve high level agreement recommendations required to care for critically ill adult patients with invasive candidiasis.

Methods: A prospective Spanish survey reaching consensus by the DELPHI technique was made.

Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated.

Background: Comatose patients present a high risk of early-onset ventilator-associated pneumonia (EO-VAP) for which antibiotic prophylaxis has been proposed. Comatose patients were studied to evaluate the efficacy of a single-dose of antibiotic prophylaxis at intubation against EO-VAP.

Methods: A prospective cohort of comatose patients (Glasgow Coma Score ≤ 8) who were admitted in 2009-2010 and administered a single-dose of antibiotic within 4 h of intubation was compared with comatose patients (admitted ≥ 4 h after intubation in 2009-2010 or admitted in 2007-2008) who did not receive antibiotic prophylaxis.

Antibiotic prescription patterns in the empiric therapy of severe sepsis: combination of antimicrobials with different mechanisms of action reduces mortality.

Introduction: Although early institution of adequate antimicrobial therapy is lifesaving in sepsis patients, optimal antimicrobial strategy has not been established. Moreover, the benefit of combination therapy over monotherapy remains to be determined. Our aims are to describe patterns of empiric antimicrobial therapy in severe sepsis, assessing the impact of combination therapy, including antimicrobials with different mechanisms of action, on mortality.

Effectiveness of an inspiratory pressure-limited approach to mechanical ventilation in septic patients.

Severe sepsis is one of the most common causes of acute lung injury (ALI) and is associated with high mortality. The aim of the study was to see whether a protective strategy based approach with a plateau pressure <30 cmH(2)O was associated with lower mortality in septic patients with ALI in the Surviving Sepsis Campaign international database. A retrospective analysis of an international multicentric database of 15,022 septic patients from 165 intensive care units was used.

Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support.

Background: Randomized trials assessing the effect of systemic corticosteroids on chronic obstructive pulmonary disease (COPD) exacerbations excluded patients who were mechanically ventilated or admitted to the intensive care unit (ICU). Critically ill patients constitute a population of persons who are prone to develop complications that are potentially associated with the use of corticosteroids (eg, infections, hyperglycemia, ICU-acquired paresis) that could prolong the duration of mechanical ventilation and even increase mortality.

Methods: A double-blind placebo-controlled trial was conducted to evaluate the efficacy and safety of systemic corticosteroid treatment in patients with an exacerbation of COPD who were receiving ventilatory support (invasive or noninvasive mechanical ventilation).

Appropriate antibiotic dosing in severe sepsis and acute renal failure: factors to consider.

Severe sepsis and septic shock cause considerable morbidity and mortality. Early appropriate empiric broad-spectrum antibiotics and advanced resuscitation therapy are the cornerstones of treatment for these conditions. In prescribing an antibiotic regimen in septic patients with acute renal failure treated with continuous renal replacement therapy, several factors should be considered: pharmacokinetics, weight, residual renal function, hepatic function, mode of renal replacement therapy (membrane and surface area, sieving coefficient, effluent and dialysate rate, and blood flow rate), severity of illness, microorganism, minimum inhibitory concentration, and others.

Physiologic parameters as biomarkers: what can we learn from physiologic variables and variation?

Sepsis generates an overwhelming host response characterized by changes in physiologic parameters. Monitoring these parameters can help identify and stratify septic patients. Recognizing sepsis early and identifying septic patients at risk of worsening are keys to successful treatment.

Cost-effectiveness of the Surviving Sepsis Campaign protocol for severe sepsis: a prospective nation-wide study in Spain.

Context: Severe sepsis is associated with high mortality and increased costs. The 'Surviving Sepsis Campaign' (SSC) protocol was developed as an international initiative to reduce mortality. However, its cost-effectiveness is unknown.

Treatment strategies for central venous catheter infections.

Intravascular catheters are essential in most hospital units. These devices are the most common source of nosocomial bloodstream infections. Catheter-related bloodstream infections (CR-BSI) are associated with increased morbidity and mortality, prolonged hospitalization, and increased costs.

Effectiveness of treatments for severe sepsis: a prospective, multicenter, observational study.

Rationale: Several Surviving Sepsis Campaign Guidelines recommendations are reevaluated.

Objectives: To analyze the effectiveness of treatments recommended in the sepsis guidelines.

Methods: In a prospective observational study, we studied all adult patients with severe sepsis from 77 intensive care units.

Bloodstream infection in the ICU.

Hospital-acquired infections (HAI) occur in 5%-10% of patients admitted to hospitals in the United States, and HAIs remain a leading cause of morbidity and mortality. Patients admitted to ICUs account for 45% of all hospital-acquired pneumonias and bloodstream infections (BSIs), although critical care units comprise only 5% to 10% of all hospital beds. The severity of underlying disease, invasive diagnostic and therapeutic procedures that breach normal host defenses, contaminated life-support equipment, and the prevalence of resistant microorganisms are critical factors in the high rate of infection in the ICUs.

Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain.

Context: Concern exists that current guidelines for care of patients with severe sepsis and septic shock are followed variably, possibly due to a lack of adequate education.

Objective: To determine whether a national educational program based on the Surviving Sepsis Campaign guidelines affected processes of care and hospital mortality for severe sepsis.

Design, Setting, And Patients: Before and after design in 59 medical-surgical intensive care units (ICUs) located throughout Spain.

Risk and prognostic factors of ventilator-associated pneumonia in trauma patients.

Objective: To assess the risk and prognostic factors of ventilator-associated pneumonia in trauma patients, with an emphasis on the inflammatory response.

Design: Case-control study.

Setting: Trauma intensive care unit.