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      Diabetes and Hemoglobin A1c as Risk Factors for Nosocomial Infections in Critically Ill Patients

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          Abstract

          Objective. To evaluate whether diabetes mellitus (DM) and hemoglobin A1c (HbA1c) are risk factors for ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) in critically ill patients. Methods. Prospective observational study; patients were recruited from the intensive care unit (ICU) of a general district hospital between 2010 and 2012. Inclusion criteria: ICU hospitalization >72 hours and mechanical ventilation >48 hours. HbA1c was calculated for all participants. DM, HbA1c, and other clinical and laboratory parameters were assessed as risk factors for VAP or BSI in ICU. Results. The overall ICU incidence of VAP and BSI was 26% and 30%, respectively. Enteral feeding OR (95%CI) 6.20 (1.91–20.17; P = 0.002) and blood transfusion 3.33 (1.23–9.02; P = 0.018) were independent risk factors for VAP. BSI in ICU ( P = 0.044) and ICU mortality ( P = 0.038) were significantly increased in diabetics. Independent risk factors for BSI in ICU included BSI on admission 2.45 (1.14–5.29; P = 0.022) and stroke on admission2.77 (1.12–6.88; P = 0.029). Sepsis 3.34 (1.47–7.58; P = 0.004) and parenteral feeding 6.29 (1.59–24.83; P = 0.009) were independently associated with ICU mortality. HbA1c ≥ 8.1% presented a significant diagnostic performance in diagnosing repeated BSI in ICU. Conclusion. DM and HbA1c were not associated with increased VAP or BSI frequency. HbA1c was associated with repeated BSI episodes in the ICU.

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          Immune dysfunction in patients with diabetes mellitus (DM).

          Patients with diabetes mellitus (DM) have infections more often than those without DM. The course of the infections is also more complicated in this patient group. One of the possible causes of this increased prevalence of infections is defects in immunity. Besides some decreased cellular responses in vitro, no disturbances in adaptive immunity in diabetic patients have been described. Different disturbances (low complement factor 4, decreased cytokine response after stimulation) in humoral innate immunity have been described in diabetic patients. However, the clinical relevance of these findings is not clear. Concerning cellular innate immunity most studies show decreased functions (chemotaxis, phagocytosis, killing) of diabetic polymorphonuclear cells and diabetic monocytes/macrophages compared to cells of controls. In general, a better regulation of the DM leads to an improvement of these cellular functions. Furthermore, some microorganisms become more virulent in a high glucose environment. Another mechanism which can lead to the increased prevalence of infections in diabetic patients is an increased adherence of microorganisms to diabetic compared to nondiabetic cells. This has been described for Candida albicans. Possibly the carbohydrate composition of the receptor plays a role in this phenomenon.
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            Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients.

            Underinflation of the tracheal cuff frequently occurs in critically ill patients and represents a risk factor for microaspiration of contaminated oropharyngeal secretions and gastric contents that plays a major role in the pathogenesis of ventilator-associated pneumonia (VAP). To determine the impact of continuous control of tracheal cuff pressure (P(cuff)) on microaspiration of gastric contents. Prospective randomized controlled trial performed in a single medical intensive care unit. A total of 122 patients expected to receive mechanical ventilation for at least 48 hours through a tracheal tube were randomized to receive continuous control of P(cuff) using a pneumatic device (intervention group, n = 61) or routine care of P(cuff) (control group, n = 61). The primary outcome was microaspiration of gastric contents as defined by the presence of pepsin at a significant level in tracheal secretions collected during the 48 hours after randomization. Secondary outcomes included incidence of VAP, tracheobronchial bacterial concentration, and tracheal ischemic lesions. The pneumatic device was efficient in controlling P(cuff). Pepsin was measured in 1,205 tracheal aspirates. Percentage of patients with abundant microaspiration (18 vs. 46%; P = 0.002; OR [95% confidence interval], 0.25 [0.11-0.59]), bacterial concentration in tracheal aspirates (mean ± SD 1.6 ± 2.4 vs. 3.1 ± 3.7 log(10) cfu/ml, P = 0.014), and VAP rate (9.8 vs. 26.2%; P = 0.032; 0.30 [0.11-0.84]) were significantly lower in the intervention group compared with the control group. However, no significant difference was found in tracheal ischemia score between the two groups. Continuous control of P(cuff) is associated with significantly decreased microaspiration of gastric contents in critically ill patients.
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              Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients.

              To determine the impact of early enteral feeding on the outcome of critically ill medical patients. Retrospective analysis of a prospectively collected large multi-institutional ICU database. A total of 4,049 patients requiring mechanical ventilation for > 2 days. Patients were classified according to whether or not they received enteral feeding within 48 h of mechanical ventilation onset. The 2,537 patients (63%) who did receive enteral feeding were labeled as the "early feeding group," and the remaining 1,512 patients (37%) were labeled as the "late feeding group." The overall ICU and hospital mortality were lower in the early feeding group (18.1% vs 21.4%, p = 0.01; and 28.7% vs 33.5%, p = 0.001, respectively). The lower mortality rates in the early feeding group were most evident in the sickest group as defined by quartiles of severity of illness scores. Three separate models were done using each of the different scores (acute physiology and chronic health evaluation II, simplified acute physiology score II, and mortality prediction model at time 0). In all models, early enteral feeding was associated with an approximately 20% decrease in ICU mortality and a 25% decrease in hospital mortality. We also analyzed the data after controlling for confounding by matching for propensity score. In this analysis, early feeding was again associated with decreased ICU and hospital mortality. In all adjusted analysis, early feeding was found to be independently associated with an increased risk of ventilator-associated pneumonia (VAP) developing. Early feeding significantly reduces ICU and hospital mortality based mainly on improvements in the sickest patients, despite being associated with an increased risk of VAP developing. Routine administration of such therapy in medical patients receiving mechanical ventilation is suggested, especially in patients at high risk of death.
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                Author and article information

                Journal
                Crit Care Res Pract
                Crit Care Res Pract
                CCRP
                Critical Care Research and Practice
                Hindawi Publishing Corporation
                2090-1305
                2090-1313
                2013
                29 December 2013
                : 2013
                : 279479
                Affiliations
                1Department of Critical Care Medicine, University Hospital of Larissa, University of Thessaly School of Medicine, Biopolis, GR41000 Larisa, Greece
                2Department of Critical Care Medicine, General Hospital of Serres, GR62100 Serres, Greece
                3Department of Hematology Laboratory, General Hospital of Serres, GR62100 Serres, Greece
                Author notes
                *Eirini Tsakiridou: etsakirid@ 123456yahoo.gr

                Academic Editor: Marc J. Shapiro

                Article
                10.1155/2013/279479
                3891611
                24459586
                c99bb57a-2381-4ece-9281-739803779b38
                Copyright © 2013 Eirini Tsakiridou et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 24 April 2013
                : 17 July 2013
                : 9 October 2013
                Categories
                Clinical Study

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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