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Savanur SS, Gururaj H. Study of Antibiotic Sensitivity and Resistance Pattern of Bacterial Isolates in Intensive Care Unit Setup of a Tertiary Care Hospital. Indian J Crit Care Med 2019; 23 (12):547-555.
Objective: To evaluate the antibiotic sensitivity and resistance pattern in an intensive care unit (ICU) setting of a tertiary care hospital.
Materials and methods: A cross-sectional, retrospective study was conducted for a period of 1 month in October 2017 on a total of 195 patients who were admitted to ICU of tertiary care hospital. The culture and sensitivity pattern of clinical isolates from blood, urine, sputum, endotracheal tube (ET) aspirate, catheter sites, and wound swabs were analyzed. Positive cultures were segregated and their antibiotic sensitivity testing was performed under the guidelines of clinical and laboratory standard institute (CLSI).
Results: Of the total 195 ICU admissions, cultures were sent for 167 cases. Of which 127 patients were culture positive and 40 cases were culture negative. Isolated bacteria were mostly gram-negative bacilli, of which Escherichia coli was (18.6%), Acinetobacter (14.5%), Klebsiella (11.6%), Pseudomonas (9.8%), and Proteus (1.74%). Among the gram-positive organisms, coagulase negative staphylococcus (CoNS) (15.6%) was most commonly isolated followed by Streptococcus (2.32%). Fungal growth was also seen in 26 (15.11%) samples. Samples that grew organisms were blood (n = 48), sputum (n = 17), urine (n = 39), ET aspirate (n = 40), pus (n = 11), catheter (n = 4), ear swab (n = 2), and stool (n = 1).
Conclusion: Gram-negative bacterial infections are increasing in ICUs, leading to inappropriate selection of antibiotics. Hence, antibiotic sensitivity and resistance pattern in a hospital setup has to be studied so as to guide the treating consultant to initiate empirical antibiotics in critical cases.
Background: Noninvasive ventilation (NIV) represents the delivery of positive pressure to the lungs without inserting an endotracheal tube. Noninvasive ventilation has been successfully used in patients with acute respiratory failure. There is a tremendous increase in usage of NIV in clinical settings aiming to reduce complications due to invasive ventilation and to improve resource utilization. It is imperative to watch for outcome of NIV in patients with acute respiratory failure.
Materials and methods: A total of 50 patients were included in this prospective longitudinal study and divided into two groups: type I and type II respiratory failure. All patients were administered bilevel positive airway pressure (BIPAP) ventilator support system using full-face mask or nasal mask depending on the status of the patient. Dyspnea quantitated by modified Borg dyspnea score, heart rate (HR), respiratory rate (RR), blood pressure, and arterial blood gas analysis were assessed at the end of 4, 12, and 24 hours.
Results: Respiratory rate and HR were significantly improved at the end of 4, 12, and 24 hours with NIPPV compared with baseline (0 hour) in both groups (p < 0.01). Statistically significant improvements in pH and PaO2 was seen with NIPPV at the end of 12 hours and 24 hours (p < 0.001) compared with the baseline in both type I and type II respiratory failure patients. Dryness of mouth and nose was noted in 3 (6.81%) patients with NIPPV.
Conclusion: Study indicates that a trial of BIPAP is effective in improving gas exchange, reducing intubation, and length of stay in hospital in patients with acute respiratory failure.
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Tam CW, Shum H, Yan W. Impact of Dysnatremia and Dyskalemia on Prognosis in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Indian J Crit Care Med 2019; 23 (12):562-567.
Background: Electrolyte disturbance is one of the complications of subarachnoid hemorrhage (SAH) and its prognostic value is not fully understood. The focus of this study is to evaluate the impact of dysnatremia and dyskalemia on functional outcomes in patients with aneurysmal SAH.
Materials and methods: Patients with spontaneous aneurysmal SAH who were admitted to our intensive care unit (ICU) between 1st January 2011 and 31st December 2016 were included. Demographic data, biochemical parameters from days 1 to day 11 of ICU admission, disease severity, and clinical outcome were recorded. The prognosis was estimated using the Glasgow outcome scale (GOS) at 3 months after the initial insult.
Results: A total of 244 patients were included in this study. There were 139 patients (57.0%) with hyponatremia (Na < 135 mmol/L) while 82 patients (33.6%) had hypernatremia (Na >146 mmol/L). Hyponatremia, hypernatremia, and sodium fluctuation >12 mmol/L were more commonly found in those patients with poor outcome. However, both hypokalemia and hyperkalemia were not shown to have a significant effect on the patient\'s prognosis. Logistic regression analysis identified the following independent predictors of poor outcome (GOS 1–3 at 3 months): age >55 years old, acute physiology and chronic health evaluation IV (APACHE IV) score >50, World Federation of Neurosurgical Societies (WFNS) grade >3, Fisher grade >2, presence of intracranial hemorrhage (ICH)/intraventricular hemorrhage (IVH), use of mannitol, use of loop diuretic aneurysms, involving posterior circulation, and hypernatremia >146 mmol/L.
Conclusion: Hypernatremia, but not hyponatremia, in patients with aneurysmal SAH is associated with poor outcome. Both hypokalemia and hyperkalemia were not shown to have a significant effect on the patient\'s prognosis. Further studies are required to determine whether the treatment of dysnatremia can influence outcomes.
Clinical significance: Dysnatremia and dyskalemia are common in patients with aneurysmal SAH, but only hypernatremia is associated with poor outcome. Further studies are required to determine whether the treatment of dysnatremia can influence outcomes.
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Agrawal K, Garg R, Bhatnagar S. Knowledge and Awareness of End-of-life Care among Doctors Working in Intensive Care Units at a Tertiary Care Center: A Questionnaire-based Study. Indian J Crit Care Med 2019; 23 (12):568-573.
Introduction: End-of-life care (EOLC) is an increasingly important concern in the management of terminally ill patients. Effective EOLC depends significantly on the physicians working in the critical care units. Thus, adequate knowledge of critical care professionals regarding EOLC is important. We conducted this study to evaluate the awareness and knowledge of doctors working in critical care units toward EOLC.
Materials and methods: Doctors working in critical care units were invited to fill paper-based questionnaire. The validated questionnaire was constructed based on the existing literature on EOLC and expert opinion. The questionnaire comprised four sections: demographic details, experience with EOLC situations, general awareness of EOLC, and specific awareness of EOLC in clinical practice. The collected data were analyzed by descriptive analysis.
Results: Most respondents had not counseled more than five families regarding EOLC over 1 month. Majority of the respondents (81.7%) had heard of EOLC; the major source of information being their work in the concerned specialty. Only 29.2% of the respondents applied EOLC principles in their clinical practice. Main barriers were lack of information and training. Only 20.3% of the respondents were aware of Indian guidelines about EOLC. Majority of the respondents disagree regarding the usage of critical care units and resuscitation of terminally ill patients and were in favor of home care. One-third respondents felt uncomfortable in discussing EOLC issues with the families. Half of the respondents felt that they were only somewhat competent in managing EOLC issues. Most respondents opined that training and education in medical curriculum for terminally ill patients are lacking and were in strong favor of inclusion of specific training for the same.
Conclusion: The EOLC needs to be an integral part of critical care management and teaching curriculum. An integral referral system may also be an option for various advance disease patients getting treatment from critical care specialists for EOLC decision.
Samba SR Pasupuleti,
Prashant M Agarwal
Background and aims: Acute liver failure (ALF) is a rare disease entity with a high mortality. Management is dependent on accurate prognostication.
Materials and methods: One hundred consecutive patients presenting with ALF were prospectively evaluated. The King\'s college criteria (KCC), ALF early dynamic model (ALFED), sequential organ failure assessment (SOFA) score, and acute physiology and health evaluation II (APACHE II) scores were compared to predict mortality.
Results: There were significant differences in means of all the scores between survivors and nonsurvivors. The SOFA 48 hours had the highest area under receiver operating characteristic curve (AUC) (0.857) closely followed by the ALFED score (0.844). The optimal cutoff for the SOFA score at 48 hours to predict subsequent survival outcome is ≥10 and for the ALFED score is ≥5. Sequential organ failure assessment 48 hours had a good sensitivity of 87%, and the ALFED score showed a good specificity of 84%. The decision curve analysis showed that between a threshold probability of 0.13 and 0.6, use of the SOFA score provided the maximum net benefit and at threshold probabilities of >0.6, the use of ALFED score provided the maximum clinical benefit.
Conclusion: Dynamic scoring results in better prognostication in ALF. The SOFA 48 hours and ALFED score have good prognostication value in nonacetaminophen-induced liver failure.
Monisha P Kumar,
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Kumar MP, Thyagarajan B, Haller N, Ciltea D. A Diagnostic Conundrum of Distributive Shock: Autoimmune Polyglandular Syndrome Type II. Indian J Crit Care Med 2019; 23 (12):582-583.
Autoimmune polyglandular syndrome (AIPS) is a heterogeneous condition characterized by the loss of immune tolerance and resultant dysfunction of multiple endocrine organs. Although this condition is insidious in nature, it frequently presents initially as adrenal insufficiency (AI). For patients in shock, physicians routinely assess for infections, volume depletion as well as cardiogenic and iatrogenic causes of shock. However, the case described in this report emphasizes the need for high suspicion of AI syndrome when the etiology of shock remains unclear after primary assessment. A subsequent evaluation for autoimmune etiology, especially in young adults in appropriate clinical setting, may also be warranted.
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Chopra P, Bhatia RS. Mild Encephalopathy/Encephalitis with Reversible Splenial Lesion in a Patient with Salmonella typhi Infection: An Unusual Presentation with Excellent Prognosis. Indian J Crit Care Med 2019; 23 (12):584-586.
Mild encephalopathy/encephalitis with reversible splenial lesion (MERS) is an uncommon clinicoradiological entity reported mainly in East Asian population. Mild encephalopathy/encephalitis with reversible splenial lesion is characterized by neuropsychiatric manifestations, magnetic resonance imaging (MRI) findings of the reversible lesions in the splenium of corpus callosum, and good clinical outcomes. These transient splenial lesions are not specific to a particular condition and have been described mainly in children in various situations including epilepsy or peri-ictal state, antiepileptic drug use, and infectious agents such as influenza virus, Mycoplasma pneumoniae, Legionella pneumophila, and O-157 Escherichia coli. Mild encephalopathy/encephalitis with reversible splenial lesion is an uncommon complication of Salmonella infection and has been described earlier in a child who made excellent clinical recovery. We report a case of Salmonella typhi encephalopathy in a young adult who presented with reversible transient splenial lesions on MRI. The patient recovered without neurological sequelae. Awareness of these lesions is important as these are uncommon findings on MRI and carry excellent prognosis.
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Shastri P, Kumar R, Gupta P. A Rare Case of Combined Pulmonary Cryptococcosis and Cryptococcal Meningitis in Renal Allograft Recipient. Indian J Crit Care Med 2019; 23 (12):587-589.
Invasive cryptococcosis is the third most common invasive fungal infection among organ transplant recipients.1 The most frequently encountered clinical manifestation is cryptococcal meningoencephalitis (CM) which may be easily missed because of varying clinical presentations. 1-year mortality is estimated at 20–30% even with long-term consolidated antifungal therapy. Here we report a case of combined pulmonary and cryptococcal meningitis in a renal allograft recipient. This case illustrates the difficulty of estimating the real extent of the disease when only clinical features are considered. The patient presented with nonspecific symptoms. Chest computed tomography (CT) scans revealed multiple pulmonary nodular shadows. The CT-guided biopsy of the pulmonary nodule clinched the diagnosis of pulmonary cryptococcosis (PC). The central nervous system (CNS) cryptococcosis was proved by positive culture and crypto-LA antigen in the cerebrospinal fluid (CSF).
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Sharma A, Kalita JM, Nag VL. Screening for Methicillin-resistant Staphylococcus aureus Carriage on the Hands of Healthcare Workers: An Assessment for Hand Hygiene Practices. Indian J Crit Care Med 2019; 23 (12):590-592.
Background: Methicillin-resistant Staphylococcus aureus (MRSA) is capable of causing a wide range of infections. Colonized healthcare workers (HCWs) and contaminated hand-touch surfaces act as a potential source of MRSA in hospitals. This study was conducted to detect the carriage of MRSA in the hands of HCWs during patient care to check awareness among HCWs to follow proper hand hygiene protocol.
Materials and methods: This study was a cross-sectional point prevalence study done in wards and intensive care units (ICUs) of a tertiary care hospital. Hand cultures were collected from HCWs after the clinical rounds, without prior information about the procedure. It was done on three consecutive days to include maximum HCWs from the hospital. Cultures were taken before and after the use of alcohol-based hand rub. Hand cultures were obtained by asking HCWs to touch the surface of chromogenic screening agar for MRSA with their fingertips and thumbs of both the hands.
Results: Of a total of 62 HCWs screened, 32 (51.61%) were positive for MRSA. Among these, seven were doctors. After using alcohol-based hand rub, six HCWs were still positive for MRSA. Another important finding on this screening agar was detection of Candida on the hands of HCWs.
Conclusion: Regular monitoring of hand hygiene compliance is vital to prevent the spread of nosocomial infections. The MRSA screening agar is rapid, simple, cost-effective, and useful to identify the carriage of not only MRSA but also Candida (in the wake of nosocomial outbreaks with Candida auris) in the hands of HCWs. Further studies are required to evaluate the transmission rate of MRSA from HCWs to patients in Indian hospitals.
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Mehta Y, Mithal A, P Kulkarni A, Reddy BR, Sharma J, Sivakumar M, Bathina H, Chakravarti S, Joshi A. Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med 2019; 23 (12):594-603.
Background and aim: Intensive-care practices and settings differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field.
Materials and methods: Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences.
Results: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered.
Conclusion: This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol.