ObjectiveTo evaluate the prophylactic use of enteral fluconazole to prevent invasive candidal infections in critically ill surgical patients.
Summary Background DataInvasive fungal infections are increasingly common in the critically ill, especially in surgical patients. Although fungal prophylaxis has been proven effective in certain high-risk patients such as bone marrow transplant patients, few studies have focused on surgical patients and prevention of fungal infection.
MethodsThe authors conducted a prospective, randomized, placebocontrolled trial in a single-center, tertiary care surgical intensive care unit (ICU). A total of 260 critically ill surgical patients with a length of ICU stay of at least 3 days were randomly assigned to receive either enteral fluconazole 400 mg or placebo per day during their stay in the surgical ICU at Johns Hopkins Hospital.
ResultsThe primary end point was the time to occurrence of fungal infection during the surgical ICU stay, with planned secondary analysis of patients "on-therapy" and alternate definitions of fungal infections. In a time-to-event analysis, the risk of candidal infection in patients receiving fluconazole was significantly less than the risk in patients receiving placebo. After adjusting for potentially confounding effects of the Acute Physiology and Chronic Health Evaluation (APACHE) III score, days to first dose, and fungal colonization at enrollment, the risk of fungal infection was reduced by 55% in the fluconazole group. No difference in death rate was observed between patients receiving fluconazole and those receiving placebo.
ConclusionsEnteral fluconazole safely and effectively decreased the incidence of fungal infections in high-risk, critically ill surgical patients.Fungal pathogens increasingly cause nosocomial infections, especially among surgical patients and the high-risk critically ill, with an attributable death rate estimated at 38%. [1][2][3][4][5][6][7][8][9] In our institution, yeast species accounted for 15% of bloodstream isolates in the period from 1992 to 1995.
• Background Infected central venous catheters cause morbidity and mortality.
• Objective To compare the risk for colonization of central venous catheters used for total parenteral nutrition with that of catheters used for other purposes.
• Methods Retrospective review of prospectively acquired data on 260 patients with a stay in a surgical intensive care unit longer than 3 days. Single-lumen catheters used solely for total parenteral nutrition were inserted into the subclavian vein and cared for by a dedicated team. Catheters for other purposes were placed and cared for by other staff. Catheters were cultured if clinical findings suggested infection.
• Results Of 854 central venous catheters, 61 (7%) were used for total parenteral nutrition. During 4712 catheter days of observation, 89 catheters of all types were colonized. Risk factors for colonization included duration of catheterization (P < .001), having 3 or more lumens (hazard ratio, 1.7; 95% CI, 1.1–2.6), pulmonary artery catheterization (hazard ratio, 1.7; 95% CI, 1.1–2.7), and placement in the internal jugular vein (hazard ratio, 1.6; 95% CI, 1.1–2.5). Catheters used for total parenteral nutrition (hazard ratio, 0.14; 95% CI, 0.04–0.57) and those in the subclavian vein (hazard ratio, 0.51; 95% CI, 0.3–0.8) were at lower risk of colonization. In a multivariate Cox model, the only significant factor was a 5-fold lower risk of infection for catheters used for total parenteral nutrition (hazard ratio, 0.19; 95% CI, 0.04–0.83).
• Conclusion Rates of colonization were lowest for catheters used solely for total parenteral nutrition, suggesting that a team approach improves patients’ care.
The attributable cost of ICU care associated with VRE infection is $33,251 (38,088 euros) and per ICU patient day was $304 (348 euros). VRE and VSE infections do not differ in associated cost of ICU care, LOS, or mortality. Any VRE control strategy is be cost-effective if the overall cost per ICU patient-day is less than $304 (348 euros).
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