Infected critically ill patients may have adverse outcomes as a result of inadeqaute antibiotic exposure; a paradigm change to more personalized antibiotic dosing may be necessary to improve outcomes for these most seriously ill patients.

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Compliance with all of the evidence-based bundle metrics was not high. Patients whose care included compliance with all of these metrics had a 40% reduction in the odds of dying in hospital with the 3-h bundle and 36% for the 6-h bundle.

We report on intensive care nosocomial pneumonia (NP) in Europe through a review of EU-VAP/CAP manuscripts: a prospective observational study, enrolling patients from 27 ICUs in nine European countries. From 2,436 eligible ICU patients, 827 cases presented NP, with 18.3 episodes of VAP per 1000 ventilator-days. Most common findings were worsening oxygenation, purulent respiratory secretions and temperature increase. At least three criteria from Clinical Pulmonary Infection score (CPIS) were present in 77.9 % of episodes, but only 0.2 % met six CPIS criteria. Diagnosis was confirmed mainly noninvasively (74.8 %), with half qualitative and quantitative cultures. The dominant isolate was S. aureus in Spain, France, Belgium and Ireland, P. aeruginosa in Italy and Portugal, Acinetobacter in Greece and Turkey, but Escherichia coli in Germany. NP resulted in 6 % higher mortality, longer ICU stay and duration of mechanical ventilation (12 and 10 days). COPD and age ≥45 years were not associated with higher VAP incidence but did correlate with increased mortality. Trauma had higher VAP incidence but lower mortality. Bacteremia (led by MRSA and Acinetobacter baumannii) was documented in 14.6 %, being associated with extra ICU stay and mortality. Vasopressors and ICUs with above 25 % prevalence of Potential Resistant Organisms (PRM) were independently associated with PRM, being documented in 50.7 % of patients with early-onset VAP without known risk factors. Most patients initially received combination therapy. Delay in appropriate antimicrobial choice significantly increased mortality, and LOS in survivors was six days longer (p < 0.05). In conclusion, NP management in Europe presents local differences and major shifts when compared to reports from North America, outcomes of randomized trials and general guidelines.

In European ICUs oral care is considered very important. It is experienced as a task that is difficult to perform, and that does not necessarily succeed in ensuring oral health in patients with prolonged intubation. Oral care consists primarily of mouth washes. The use of toothbrushes should be given more attention.

BackgroundThe clinical effects of varying pharmacokinetic exposures of antibiotics (antibacterials and antifungals) on outcome in infected critically ill patients are poorly described. A large-scale multi-centre study (DALI Study) is currently underway describing the clinical outcomes of patients achieving pre-defined antibiotic exposures. This report describes the protocol.MethodsDALI will recruit over 500 patients administered a wide range of either beta-lactam or glycopeptide antibiotics or triazole or echinocandin antifungals in a pharmacokinetic point-prevalence study. It is anticipated that over 60 European intensive care units (ICUs) will participate. The primary aim will be to determine whether contemporary antibiotic dosing for critically ill patients achieves plasma concentrations associated with maximal activity. Secondary aims will compare antibiotic pharmacokinetic exposures with patient outcome and will describe the population pharmacokinetics of the antibiotics included. Various subgroup analyses will be conducted to determine patient groups that may be at risk of very low or very high concentrations of antibiotics.DiscussionThe DALI study should inform clinicians of the potential clinical advantages of achieving certain antibiotic pharmacokinetic exposures in infected critically ill patients.

In this multicenter cohort study, ventilator-associated pneumonia did not occur more frequently among elderly, but the associated mortality in these patients was higher. New temperature rise was less common in elderly patients with ventilator-associated pneumonia, whereas more episodes among elderly patients were caused by Enterobacteriaceae.

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.