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Background Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment. Methods We performed an anonymous online survey in a random sample of 1,052 participants recruited via email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%. Results Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival (0–33% survival) when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients. Conclusion No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates.

PURPOSE: Intensive care interventions that prolong life without achieving meaningful benefit are considered clinically “inappropriate”. In 2012, the frequency of perceived-inappropriate critical care was 10.8% at one academic health system; and we aimed to re-evaluate this frequency. METHODS: For 4 months in 2017, we surveyed critical care physicians daily and asked whether each patient was receiving appropriate, probably inappropriate, or inappropriate critical care. Patients were categorized into three groups: 1) patients for whom treatment was never inappropriate, 2) patients with at least one assessment that treatment was probably inappropriate, but no inappropriate treatment assessments, and 3) patients who had at least one assessment of inappropriate treatment. RESULTS: Fifty-five physicians made 10,105 assessments on 1424 patients. Of these, 94 (6.6%) patients received at least one assessment of inappropriate critical care, which is lower than 2012 (10.8% (p0.05). Inpatient mortality in 2017 was 73% for patients receiving inappropriate critical care. CONCLUSIONS: Over five years the proportion of patients perceived to be receiving inappropriate critical care dropped by 40%. Understanding the reasons for such change might elucidate how to continue to reduce inappropriate critical care.

A terapia antimicrobiana inicial inadequada leva a maior mortalidade em pacientes com infecção de corrente sanguínea. Este estudo teve como objetivo avaliar a relação entre antibioticoterapia inadequada em pacientes com infecção da corrente sanguínea e a mortalidade hospitalar de pacientes críticos. Métodos: Estudo retrospectivo, coleta de dados entre janeiro a dezembro de 2015, 167 pacientes com infecção da corrente sanguínea foram avaliados retrospectivamente de acordo com a presença ou ausencia de antibioticoterapia inadequada. A mortalidade hospitalar foi a variável principal resultado foi comparado entre os dois grupos de estudo. Resultados: pacientes que receberam antibióticoterapia inadequada apresentaram mais diabetes mellitus, doença pulmonar obstrutiva crônica, doença renal crônica que pacientes infectados que inicialmente receberam terapia antibiótica adequada. Erro de dose e atraso no início da administração de antibiótico, foram mais frequentemente detectadas neste estudo e ambos foram fator determinantes relacionadas com aumento da mortalidade. Antibioticoterapia inicial foi mantida, escalonada e descalonada em 67,6%, 22,7% e 9,6% dos casos, respectivemente. Foi estatisticamente significativa correlação entre a morte e casos em que o antimicrobiando foi descalonado (p = 0,001), metade dos quais foram consideradas erros de prescrição. Estafilococos coagulase negativa representou o maioria atingindo 40,7% e microrganismos multi-resistentes foram detectados em 27,3% das infecções. Não houve diferença observada nas taxas de mortalidade entre as infecções causadas por microrganismos resistentes ou susceptíveis. Conclusao: O erro de dose e erro no início da administração de antibiótico, estava entre os erros mais frequentemente detectadas em nosso estudo e ambos foram fatores determinantes relacionadas para aumento da mortalidade. Introduction: Inappropriate initial antimicrobial therapy leads to higher mortality in patients with bloodstream infection. This study aimed to evaluate the relationship between inappropriate antibiotic therapy of bloodstream infection and hospital mortality for critically ill patients. Methods: Between January 2015 to December 2015, 167 patients with bloodstream infection were prospectively evaluated according to the presence or absence of inappropriate antibiotic therapy of infection. Hospital mortality was the main outcome variable compared between the two study groups. Results: Infected patients who received inappropriate antibiotic therapy had statistically more diabetes mellitus, chronic obstructive pulmonary disease, chronic renal disease and death than infected patients who initially received appropriate antibiotic therapy. Loading dose error and error in starting antibiotic administration were the most frequently detected error in our study and both were determinant factors related to increased mortality. Initial antibiotic therapy was maintained, escalation and deescalation 67.6%, 22.7% and 9.6% of cases, respectively. There was statistically significant correlation between death and cases in which treatment was de-escalation (p=0.001), half of these were considered prescription errors. Coagulase negative staphylococci represented the majority reaching 40.7% and multi-drug resistant microorganisms were detected in 27.3% of infections. There was no observed difference in mortality rates among infections caused by resistant or susceptible microorganisms. Conclusion: Loading dose error and error in starting antibiotic administration, were the most frequently detected error in our study and both were determinant factors related to increased mortality. Dissertação (Mestrado)

Resumen Las infecciones constituyen uno de las principales causas de morbimortalidad en la población. La elección del tratamiento empírico es una de las decisiones más habituales para cualquier médico responsable de su atención. Además, esta primera decisión puede tener consecuencias en cuanto al pronóstico del paciente o provocar un incremento de los costes asociados al proceso. Esta revisión intenta resumir cuáles son los aspectos que pueden provocar el fracaso al tratamiento antibiótico considerando aspectos microbiológicos, farmacológicos, del perfil del paciente y del control del foco infeccioso. Además, se establecen una serie de recomendaciones para minimizar este riesgo, desde el punto de vista de la precisión diagnóstica del foco y de la etiología, la estratificación adecuada de la gravedad del paciente, el conocimiento de los aspectos farmacocinéticos y farmacodinámicos de los antibióticos y el control, quirúrgico o mediante radiología intervencionista, del foco infeccioso. Abstract Infections are one of the main causes of morbidity and mortality in the population. The choice of empirical treatment is one of the most common decisions facing the physician. This first decision has consequences in the prognosis of the patient and the costs associated with the process. This review attempts to summarize the aspects that can lead to failure of antibiotic treatment by considering microbiological and pharmacological aspects, patient profile and infectious focus control. In addition, a series of recommendations are established to minimize this risk, from the point of view of diagnostic accuracy, adequate severity stratification of the patient, knowledge of the pharmacokinetic and pharmacodynamic aspects of antibiotics and control of the infectious focus.

The aims of this study were to compare the characteristics of adult patients with left‐sided infective endocarditis (LSIE) diagnosed and treated in a tertiary‐care hospital with those of patients referred from a second‐level community hospital, and to establish the accuracy of diagnosis and adequacy of treatment in referred patients and the influence of this factor on outcome. A prospective observational cohort study was conducted at Hospital Universitari Vall d’Hebron, a 1000‐bed teaching hospital in Barcelona (Spain) and a referral centre for cardiac surgery. One hundred and fourteen of 337 (34%) episodes of LSIE treated in our hospital occurred in transferred patients. As compared with patients diagnosed in our hospital, transferred patients acquired LSIE within the healthcare system less often (16.7% vs. 38.1%, p

Antimicrobial drug resistance remains a leading problem in modern healthcare, impacting on treatment options, mortality, infection control and economic issues. The introduction of new antimicrobial drugs has consistently been followed by the emergence of resistant bacteria. This review aims to answer the question of whether clinical improvement is likely if treatment of Staphylococcus aureus infections is attempted with an antimicrobial drug against which resistance is expressed in vitro (RD). Over time, S. aureus has acquired a broad range of antimicrobial resistance mechanisms, and methicillin-resistant S. aureus (MRSA) strains have become the most common multidrug-resistant healthcare-related infection-causing bacteria in Europe. As intention-to-treat studies with an RD would be unethical, only observational studies to evaluate the impact of RD therapy have been performed. Most of these studies bolster the assumption that RD therapy offers no benefit to the patient, but some do not show a detrimental effect. Limited antimicrobial treatment options for severe, invasive infections caused by MRSA might tempt physicians to use antimicrobials to which in vitro resistance is reported by the microbiological laboratory. Reasons for this non-evidence-based approach might include better pharmacokinetic/pharmacodynamic parameters, lower toxicity and better bioavailability in specific compartments, and/or the assumption of increased in vivo susceptibility of those microorganisms reported as resistant in vitro. In vitro resistance of a bacterium to a drug implies that exposing this bacterium to that drug should result in a worse clinical outcome than would be obtained with a drug to which resistance has not been observed (SD). As a counterpoint to in vitro resistance breakpoints, the concept of clinical breakpoints is therefore briefly revisited in this review. In a nutshell, no evidence has been published that S. aureus infections can be reliably treated with RDs, either as a single administration or in combination therapy.