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Treatment options for multidrug resistant Acinetobacter baumannii strains (MDR-AB) are limited. Minocycline has been used alone or in combination in the treatment of infections associated with AB. A systematic review of the clinical use of minocycline in nosocomial infections associated with MDR-AB was performed according to the PRISMA-P guidelines. PubMed-Medline, Scopus and Web of Science TM databases were searched from their inception until March 2019. Additional Google Scholar free searches were performed. Out of 2990 articles, 10 clinical studies (9 retrospective case series and 1 prospective single center trial) met the eligibility criteria. In total, 223 out of 268 (83.2%) evaluated patients received a minocycline-based regimen; and 200 out of 218 (91.7%) patients with available data received minocycline as part of a combination antimicrobial regimen (most frequently colistin or carbapenems). Pneumonia was the most common infection type in the 268 cases (80.6% with 50.4% ventilator-associated pneumonia). The clinical and microbiological success rates following minocycline treatment were 72.6% and 60.2%, respectively. Mortality was 20.9% among 167 patients with relevant data. In this systematic review, minocycline demonstrated promising activity against MDR-AB isolates. This review sets the ground for further studies exploring the role of minocycline in the treatment of MDR-AB associated infections.

International audience; Data regarding the epidemiology and diagnosis of invasive aspergillosis in the critically ill population are limited, with data regarding elderly patients (≥75 years old) even scarcer. We aimed to further compare the epidemiology, characteristics and outcome of elderly versus nonelderly critically ill patients with invasive aspergillosis (IA) Prospective, international, multicenter observational study (AspICU) including adult intensive care unit (ICU) patients, with a culture and/or direct examination and/or histopathological sample positive for Aspergillus spp. at any site. We compared clinical characteristics and outcome of IA in ICU patients using two different diagnostic algorithms. Elderly and nonelderly ICU patients with IA differed in a number of characteristics, including comorbidities, clinical features of the disease, mycology testing, and radiological findings. No difference regarding mortality was found. According to the clinical algorithm, elderly patients were more likely to be diagnosed with putative IA. Elderly patients had less diagnostic radiological findings and when these findings were present they were detected late in the disease course. The comparison between elderly survivors and nonsurvivors demonstrated differences in clinical characteristics of the disease, affected sites and supportive therapy needed. All patients who were diagnosed with proven IA died. Increased vigilance combined with active search for mycological laboratory evidence and radiological confirmation are necessary for the timely diagnosis of IA in the elderly patient subset. Although elderly state per se is not a particular risk factor for mortality, a high SOFA score and the decision not to administer antifungal therapy may have an impact on survival of elderly patients.

Background Clostridium difficile is one of the major causes of diarrhoea among critically ill patients and its prevalence increases exponentially in relation to the use of antibiotics and medical devices. We sought to investigate the incidence of C. difficile infection in Greek units, and identify potential risk factors related to C. difficile infection. Methods A prospective multicenter cohort analysis of critically ill patients (3 ICUs from 1/1/2014 to 31/12/2014). Results Among 970(100%) patients, 95(9.79%) with diarrhoea, were included. Their demographic, comorbidity and clinical characteristics were recorded on admission to the unit. The known predisposing factors for the infection were recorded and the diagnostic tests to confirm C. difficile were conducted, based on the current guidelines. The incidence of C. difficile infection was 1.3% (n = 13). All-cause mortality in patients with diarrhoea, C. difficile infection and attributable mortality in patients with C. difficile infection was 28%, 38.5% and 30.8% respectively. Sequential Organ Failure Assessment (SOFA) scores on admission were significantly lower and prior C. difficile infection was more common in patients with current C. difficile infection. Regarding other potential risk factors, no difference was found between groups. No factor was independently associated with C. difficile infection. Conclusions C. difficile infection is low in Greek intensive care units, but remains a serious problem among the critically-ill. Mortality was similar to reports from other countries. No factor was independently associated with C. difficile infection.

BACKGROUND Intra-abdominal candidiasis (IAC) has a considerable cost in terms of mortality and morbidity. We sought to study the epidemiology, characteristics and outcome of elderly (>75 years old) versus non-elderly patients with IAC and risk factors for mortality in elderly patients. METHODS Post-hoc analysis of a retrospective multinational cohort study over a 3-year period (2011-2013). RESULTS Of 482 patients, 124 (25.7%) were elderly and 358 (74.3%) were non-elderly. The mean age was 80.4±3.9 and 56.3±13.8 years, respectively. Fifty-four of 124 (43.5%) and 75/358 (20.9%) died until the end of observation. The majority of isolates were Candida albicans. Echinocandins were the most prescribed initial agent. Elderly patients were more likely to have a higher APACHE II Score, and to suffer from chronic obstructive pulmonary disease and heart disease. Non-elderly patients were more likely to be treated with immunosuppressants and steroids, and to have received solid organ transplantation. Mortality was significantly higher in the elderly group. Regarding risk factors for mortality in elderly patients, non-survivors were more likely to be males, reoperated, develop septic shock, receive vasopressors, suffer from end-stage renal disease (ESRD), and have inadequate abdominal source control within 48 hours. They had a higher APACHE II Score and a higher number of acquired organ dysfunction. ESRD and inadequate abdominal source control were significantly associated with mortality. CONCLUSIONS Factors independently predicting mortality in elderly patients with IAC were ESRD and inadequate abdominal source control. Elderlies were found to have more pulmonary and cardiac morbidities and had higher mortality than non-elderlies.

Background Treatment options for multi-drug-resistant (including extensively and pandrug-resistant) Acinetobacter baumannii strains (herein MDR-AB) are limited. Minocycline, a synthetic tetracycline derivative, has been used alone or in combination in the treatment of infections associated with AB. We systematically reviewed the available clinical evidence regarding its role in the treatment of nosocomial infections caused by MDR-AB isolates in adult patients. Methods A systematic review of the published literature examining the clinical use of minocycline in nosocomial infections associated with MDR-AB isolates (defined according to ECDC guidance) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. PubMed, Scopus and Web of Sciences™ databases were searched from their inception until the March 20, 2018. Three researchers individually evaluated the available clinical studies according to predefined inclusion and exclusion criteria. No language restrictions were applied. Results Out of 2,576 articles, 9 clinical studies (8 retrospective case series and 1 prospective single-center trial) met the eligibility criteria. In total, 221 out of 265 (83.4%) evaluated adult patients received a minocycline-based antimicrobial regimen and 44 out of 265 (16.6%) received other antimicrobial agents (most frequently aminoglycocides); 198 out of 216 (91.7%) patients with available data, received minocycline as part of an antimicrobial combination regimen (most frequently colistin and carbapenems). Pneumonia was the most prevalent infection (81.5% with 50.4% ventilator associated pneumonias). Clinical and microbiological success rates in the minocycline group were 72.4% and 59.7%, respectively. Mortality rate was 21.2% among 165 patients with relevant data. In the non-minocycline group, clinical and microbiological cure rates were 45.5% and 18.2%, respectively. Conclusion In this systematic review, minocycline demonstrated promising activity against MDR-AB isolates. This study could set the grounds for further research with large randomized, controlled trials that would explore and establish the role of minocycline in the treatment of MDR-AB-associated infections. Disclosures All authors: No reported disclosures.

Ventilator-associated pneumonia (VAP) is a major cause of morbidity and mortality in the critical care setting. It incurs great additional cost and the antibiotics prescribed for patients with VAP account for the majority of total antibiotic prescriptions. The increased cost of VAP as well as the emergence of antimicrobial resistance and the potential adverse events because of treatment indicate that the application of shorter antibiotic regimens for the treatment of VAP poses as a one-way choice.According to the findings of relevant randomized controlled trials, patients receiving short-course regimens for the treatment of VAP have significantly more antibiotic-free days without any negative impact on mortality. Additionally, no other differences were found regarding other secondary outcomes. However, there were higher relapse rates in patients with VAP because of nonfermenting Gram-negative bacilli and there was a lower emergence of multidrug-resistant pathogens.The shortening of the duration of treatment for VAP is promising, as long as a holistic approach that combines methods ensuring the adequate sterilization of septic foci, the optimization of antibiotic levels, the multifaceted delivery of antimicrobials in the lung and the usage of biomarkers that allow the monitoring of the disease course and the effectiveness of administered treatment are incorporated in clinical practice.

To the Editor, A report on the use of tigecycline for treatment of carbapenem-resistant Klebsiella pneumoniae (CRKp) infections in critically ill patients was recently published in this journal [1]...

Fungal infections represent a major burden in the critical care setting with increasing morbidity and mortality. Candidiasis is the leading cause of such infections, with C. albicans being the most common causative agent, followed by Aspergillosis and Mucormycosis. The diagnosis of such infections is cumbersome requiring increased clinical vigilance and extensive laboratory testing, including radiology, cultures, biopsies and other indirect methods. However, it is not uncommon for definitive evidence to be unavailable. Risk and host factors indicating the probability of infections may greatly help in the diagnostic approach. Timely and adequate intervention is important for their successful treatment. The available therapeutic armamentarium, although not very extensive, is effective with low resistance rates for the newer antifungal agents. However, timely and prudent use is necessary to maximize favorable outcomes.