Current Opinion in Critical Care最新文献

Purpose of review: This review addresses the growing concern over nosocomial infections in patients undergoing extracorporeal membrane oxygenation (ECMO) and/or continuous renal replacement therapy (CRRT). As the use of these modalities increases, particularly in critically ill patients, infection-related complications remain frequent, underdiagnosed, and inadequately addressed in existing guidelines. This review is timely given the urgent need to standardize diagnostic and preventive strategies in this high-risk population.

Recent findings: Recent studies highlight the multifactorial origin of infection risk in ECMO/CRRT patients, including device-related immunoparalysis. In patients on ECMO, nosocomial infections - particularly ventilator-associated pneumonia (VAP), bloodstream infections (BSIs), and cannula-related infections (CRIs) - are among the most frequent complications, with incidence rates ranging from 9% to 64%. VAP and BSIs occur at rates up to 61 and 38 per 1000 ECMO-days, respectively. Predominant pathogens include Enterobacterales, nonfermenting Gram-negative bacilli, Enterococcus spp., and fungi. Enterococcus-related BSIs are notably underrecognized and often inadequately treated. Duration of ECMO support is the most consistent infection risk factor, along with illness severity and CRRT co-initiation. Nosocomial infections are associated with a 32% relative increase in mortality.

Summary: Nosocomial infections in ECMO/CRRT patients are common, diagnostically challenging, and strongly linked to poor outcomes. Their prevention and management require an integrated, tailored strategy. Standardized definitions, improved surveillance, and targeted antimicrobial stewardship are urgently needed to mitigate risks in this vulnerable population.

Purpose of review: Emergency department (ED) outcomes of the critically ill and injured patient are intricately linked with timeliness of care, advances in resuscitation skills and technology, and the cohesive function of a dedicated team of multiprofessionals. This review highlights the most recent developments in ED resuscitation and their impact on outcomes for critically ill and injured patients, emphasizing the crucial interplay between technological advancements, organizational strategies, and team dynamics in optimizing emergency care.

Recent findings: The literature reveals notable enhancements in resuscitation techniques and protocols, integrating technologic advances, such as artificial intelligence and machine learning, which have shown promising improvement in efficiency, diagnostics, and timeliness to therapeutics. Optimization of the physical ED environment to expedite delivery of care, with an emphasis on effective communication, standardized protocols and guidelines, and teamwork are crucial elements in improving overall patient outcomes. Significant challenges persist, despite these advancements, particularly in ED overcrowding, clinician burnout, and delays in definitive treatment.

Summary: The findings highlight the importance of a collaborative multidisciplinary approach to resuscitation in the ED. Implementing a multifaceted approach involving technology, diagnostic accuracy, therapeutic interventions, and education offers an opportunity to improve outcomes in the ED. Future research should continue to focus strategies to address the systematic issues that impact overall patient care in the emergency setting.

Purpose of review: Corticosteroid therapy remains controversial in the management of septic shock. The putative benefits of glucocorticoids on immunomodulation and rescue of hypothalamic-pituitary-adrenal (HPA) axis dysregulation has made it an attractive target for clinical research. However, conflicting trial results have introduced uncertainty into clinical guidance, while risk of harm continues to be a concern. This review summarizes and interprets the current body of evidence for the role of corticosteroid therapy in septic shock and suggests future directions for continued investigation.

Recent findings: Updated guidelines continue to recommend corticosteroids in septic shock, but more robust data for corticosteroids have emerged in community acquired pneumonia (CAP) and acute respiratory distress syndrome (ARDS), which may account for some of the benefit seen in trials on septic shock. Systematic reviews have suggested potential benefits of combination therapy with fludrocortisone, but further research is needed. Significant variation exists in corticosteroid prescribing practices across providers and ICU settings.

Summary: Many uncertainties remain regarding utility of corticosteroids in septic shock. However, they remain a tool for refractory shock in appropriate patients where benefits outweigh harm. Future research should focus on individualized approaches to corticosteroid therapy.

Purpose of review: To discuss current and future role of artificial intelligence in predicting severe infections and supporting decisions on antibiotic treatment in critically ill patients in intensive care units (ICU), focusing in particular on some relevant conceptual changes compared to classical clinical reasoning.

Recent findings: Several studies have evaluated the ability of machine learning techniques for severe infection prediction, while other studies have explored the potential of large language models (LLM)-based tools to assist clinicians in deciding which antimicrobial agent(s) to prescribe to patients with severe infections.

Summary: The support of artificial intelligence for infection prediction and antimicrobial prescribing has shown the potential to improve the treatment of severe infections in ICU. However, the limited number of studies focused on ICU should be highlighted, along with the need to thoroughly address the issue of patients' privacy and to improve the ethical and legal frameworks for decision accountability, as well as the transparency and quality of training data. A standardized approach to the accuracy-interpretability trade-off would also be essential to outline a correct and shared approach both for the future conduct of studies and for the interpretation of their evidence for clinical practice.

Purpose of review: Acute respiratory distress syndrome (ARDS) remains a major cause of critical illness with high morbidity and mortality. Despite advances in supportive care, targeted therapies have failed, in part due to an incomplete understanding of alveolar immune dysregulation. This review provides a timely synthesis of emerging mechanisms in alveolar immune dysregulation that underlie the development and persistence of ARDS.

Recent findings: Recent studies highlight the role of neutrophil heterogeneity, alveolar macrophage-derived extracellular vesicle signaling, and epithelial barrier dysfunction in driving hyperinflammation and susceptibility to secondary infections. Mechanical ventilation strategies, particularly those influencing driving pressure, further shape the alveolar immune environment. Cross-talk between immune cells and mechanical forces appears central to the pathogenesis of sustained lung injury.

Summary: Understanding the dynamic interplay between alveolar immune responses and secondary insults is critical for the development of precision medicine approaches in ARDS. Future research should prioritize the identification of compartment-specific biomarkers and therapeutic targets aimed at restoring immune balance and preventing nonresolving lung injury.

Purpose of review: Symptoms of posttraumatic stress disorder (PTSD) affect up to a third of relatives of ICU patients. This review updates the epidemiology, risk factors, and emphasizes the importance of PTSD prevention to mitigate long-term impact on family members. It also sheds light on the latest artificial intelligence-based approaches attempting to predict PTSD and the numerous challenges they face before reaching clinical application.

Recent findings: Recent literature confirms that one third of relatives of ICU patients present significant PTSD-related symptoms at least 3  months after ICU discharge. A vast majority of risk factors associated with PTSD are non modifiable demographic characteristics, but some are modifiable and accessible to targeted interventions that aim to enhance the overall quality of families' experiences in the ICU. Recent research attempts to develop models to accurately predict family PTSD based on easily accessible data at the time of ICU discharge.

Summary: Relatives of ICU patients are at high risk of developing PTSD in the aftermath of an ICU stay. Accurate prediction of PTSD in relatives using artificial intelligence-based prediction systems could help stratify relatives at high risk, allowing timely management to mitigate its long-term impact. Beyond classification metrics benchmarks , further research is required to assess these algorithms in terms of clinical relevance, risk of bias and clinician adoption.

Purpose of review: This review aims to summarize the recent publications and future perspectives on the use of ICU scoring systems mainly for the assessment of ICU performance, resource use and benchmarking. Additionally, we provide current limitations and future directions on the use of scoring systems.

Recent findings: Generalizability and precision remain major challenges to the use of ICU-score systems. Recent innovations in this field have been driven by the expansion of national and international critical care registries, alongside advancements in data science.Models developed using data from specific regions lack broader applicability. Simplified scoring systems have been proposed to address the urgent need for a global ICU predictive model. Scoring systems can facilitate research, outcome prediction, and healthcare quality comparisons across different settings. A global ICU score system would need minimal data collection requirements, but its use would be inherently limited by the trade-off between generalizability and precision. In parallel, the search for more precise models has led to recent advances. Artificial intelligence-based models have improved predictive abilities compared to traditional scores. Omics data integration and diverse variables and dimensions may interact to predict outcomes. Dynamic models can update such predictions. However, implementation challenges persist, including the need for validation across diverse settings and addressing issues such as transparency, reproducibility, and potential biases.

Summary: Traditionally, ICU scoring systems enable the assessment of patients' severity of illness and consequently the risk-adjusted evaluation of ICU performance and resource use. The expansion of national ICU registries has advanced their use internationally for quality assessment, quality improvement and benchmarking. Novel approaches and methodologies, including the use of machine learning and data science, are making progress in improving the scores performance and expanding their use beyond risk-adjusted mortality.

Purpose of review: To provide an updated overview of optimal antibiotic duration in ventilator-associated pneumonia (VAP), integrating guideline recommendations, clinical evidence, and expert opinion.

Recent findings: A randomized controlled trial, retrospective studies and meta-analyses support shorter (≤7-8-day) regimens for immunocompetent patients with VAP, reducing toxicity and, potentially, resistance development without compromising outcomes. However, while short-course regimens are increasingly supported, recent trials of newer agents often report durations >7 days, reflecting real-world challenges in resistant pathogens and trial design.

Summary: VAP remains the leading healthcare-associated infection in intensive care units (ICUs), related to worse outcomes and contributing substantially to antimicrobial use. Historically, prolonged antibiotic courses (≥10-14) were standard, particularly for cases involving multidrug-resistant (MDR) or extensively drug-resistant (XDR) organisms. This review synthesizes current evidence supporting shorter course therapy for VAP (≤7-8 days), emphasizing the importance of clinical response and individualization. While guideline convergence on 7-8 days has grown, exceptions apply for specific pathogens (e.g., nonfermenters, MDR or XDR organisms), bacteremia, slow response, or structural lung disease. Biomarkers like procalcitonin may assist in select cases but lack VAP-specific validation. Regular reassessment is essential to balance efficacy with stewardship. Evidence gaps remain for immunocompromised patients and ultra-short regimens.

Purpose of review: In candidemia, the standard 14-day antifungal treatment after blood culture clearance has been long accepted, despite being based on limited and outdated evidence. This review discusses the rationale for re-evaluating treatment duration, in the context of growing interest in optimizing antifungal use.

Recent findings: A small number of retrospective studies have explored shorter treatment courses in uncomplicated candidemia, suggesting similar outcomes in terms of mortality and recurrence compared to the traditional 14-day regimen. However, these data are limited and potentially biased, with no randomized controlled trials available to provide definitive guidance. Moreover, no validated clinical, microbiological, or biomarker-based algorithms currently exist to inform individualized treatment duration in daily practice.

Summary: The historical 14-day rule for candidemia treatment is increasingly challenged by recent literature, yet the available evidence remains scarce and methodologically limited. A well designed randomized controlled trial is urgently needed to establish the efficacy and safety of shorter antifungal courses. These data would be essential to inform clinical decisions and support antifungal stewardship by minimizing unnecessary treatments, lowering costs, limiting resistance, and improving patient outcomes.

Purpose of review: This review aims to summarize current recommendations for the management of serious infections, such as bloodstream infections (BSIs) and ventilator-associated pneumonia, caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) pathogens, focusing on evidence from randomized controlled trials (RCTs) and emerging treatment options.

Recent findings: Vancomycin, linezolid, and daptomycin represent the main therapeutic options for the management of methicillin-resistant Staphylococcus aureus infections; among newer agents, ceftobiprole has recently gained approval for BSI treatment. For vancomycin-resistant Enterococcus faecium BSIs, linezolid and daptomycin remain commonly employed despite the lack of comparative RCTs guiding treatment decisions. The management of MDR/XDR Gram-negative infections is challenging, owing to sparse clinical trials for robust guidance and rapid emergence of diverse resistance mechanisms. New beta-lactam/beta-lactamase inhibitor combinations remain the cornerstone of treatment for carbapenem-resistant Enterobacterales and carbapenem-resistant Pseudomonas aeruginosa. Cefiderocol and the combination of ceftazidime-avibactam plus aztreonam represent the current last-resort options for metallo-β-lactamase producers. For carbapenem-resistant Acinetobacter baumannii, sulbactam-durlobactam has demonstrated at least comparable activity compared to colistin but is unavailable in most countries.

Summary: Optimal management of serious infections by MDR/XDR pathogens requires up-to-date knowledge of evolving treatment options and resistance mechanisms. Further high-quality clinical trials are needed to guide evidence-based therapy.