Current Opinion in Critical Care最新文献

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.

Purpose of review: To investigate the potential association between colonization of the rectal and oropharyngeal mucosa by multidrug-resistant (MDR) Gram-negative bacilli and the subsequent nosocomial sepsis due to the same pathogen in order to provide a rational basis for early de-escalation when standard clinical samples are negative.

Recent findings: Compelling metagenomic data shows that profound shifts in gut and respiratory microbiota occur over time in the context of antibiotic therapy, critical illness and intubation leading to predominance of P. aeruginosa and MDR-Enterobacterales. Detection of these microorganisms through culture or molecular methods in mucosal swab samples is associated with a clinically relevant risk of subsequent nosocomial sepsis caused by the same pathogens. Conversely, their absence confers a high negative predictive value (NPV, >95%) for infection due to these microorganisms.

Summary: In settings with a high prevalence of antimicrobial resistance, the empirical use of broad-spectrum antibiotics in sepsis is often necessary. However, in culture-negative sepsis, these agents are frequently continued to the full treatment duration, entailing potential collateral damage and a significant economic burden. In this context, clinical evidence suggests that failure to detect P. aeruginosa or MDR-Enterobacterales carries a high NPV for subsequent infection by these microorganisms. We propose an algorithm that ensures adequate empirical coverage while enabling antibiotic de-escalation in culture-negative cases based on colonization status.

Purpose of review: This review explores the rationale and evidence supporting the 'direct to operating room (DTOR)' treatment paradigm to improve critically injured patient outcomes. We examine elements that impact DTOR system development including prehospital care, patient selection, as well as infrastructure and logistic considerations.

Recent findings: DTOR systems require the ability to identify patients prior to emergency department arrival who would benefit from DTOR care, and immediately transport a patient upon emergency department arrival to an operative setting and bypass emergency department resuscitation. This typically involves positioning an operating room within or immediately adjacent to the emergency department. Effective DTOR systems decrease time to hemorrhage control and improve survival likelihood - particularly for patients hypotensive from a penetrating injury.

Summary: In a health system with the ability to reliably identify patients during prehospital transport or immediately upon emergency department arrival who are highly likely to require operative intervention, a DTOR approach improves operative outcomes and survival.

Purpose of review: This review addresses the novel concept of critical illness as a potential chronic disease. The high clinical and economic burdens of chronic critical illness and post-ICU syndromes are mainly due to refractoriness to therapy and consequently lead to significant complications. Interventions need to be preventive in nature and therefore a robust disease model is warranted.

Recent findings: There are three paradigms that are leveraged to create a new critical illness-based chronic disease (CIBCD) model: metabolic model of critical illness, intensive metabolic support (IMS; insulinization and nutrition support), and driver-based chronic disease modeling. The CIBCD model consists of four stages: risk, predisease, (chronic) disease, and complications. The principal goal of the CIBCD model is to expose early opportunities to prevent disease progression, particularly further morbidity, complications, and mortality. IMS is used to target seminal pathophysiological events such as immune-neuroendocrine axis (INA) activation and failure to downregulate INA activation because of preexisting chronic diseases and recurrent pathological insults.

Summary: The CIBCD model complements our understanding of critical illness and provides needed structure to preventive actions that can improve clinical outcomes. Many research, knowledge, and practice gaps exist, which will need to be addressed to optimize and validate this model.

Purpose of review: Despite improvements in reperfusion and adjunctive therapies cardiogenic shock associated with acute myocardial infarction is still associated with a mortality of 40-50%. Therefore, mechanical circulatory support devices are increasingly used. One option is veno-arterial extracorporal membrane oxygenation (VA-ECMO). VA-ECMO can be implanted percutaneously and blood is actively pumped into a tubing system outside the body which also incorporates an artificial lung for oxygenation and removal of carbon dioxide and then sent back retrograde in the aorta. This review summarizes the current evidence for the use of VA-ECMO in cardiogenic shock.

Recent findings: Four randomized clinical trials including the large ECLS-SHOCK trial with 417 patients and two individual patient data meta-analyses did not show any mortality benefit with the routine use of VA-ECMO, but a consistent increase in bleeding and peripheral vascular ischemic complications. So far, patients with STEMI and a low likelihood of brain injury might be an attractive group for the use of VA-ECMO. In addition patients in need for oxygenation might benefit from VA-ECMO.

Summary: The results of the ECLS-SHOCK trial and the meta-analyses call for a conservative approach regarding a routine unselected use of early VA-ECMO in patients with infarct-related cardiogenic shock.

Purpose of review: Provision of adequate protein in the nutritional regimen remains a concern for clinicians in the intensive care setting, to counteract the accelerated catabolism, breakdown of skeletal muscle, and functional impairment with acquired weakness that occurs.

Recent findings: The plasticity of skeletal muscle leads to complexity in determining optimal protein dosing, where steps to sustain protein synthesis are offset by anabolic resistance, disuse atrophy, intramuscular inflammation, and blunted mammalian target of rapamycin (mTOR) sensing with poor incorporation of exogenous amino acids into new muscle formation. High protein dosing in the early phases of critical illness is ineffective at improving clinical outcomes and may be toxic in an environment of mitochondrial dysfunction, where an elevated urea/creatinine ratio can be interpreted as a biomarker for poor tolerance, elevated ammonia production, and increasing muscle proteolysis.

Summary: The most effective strategy to mitigate the adverse consequences of reduced muscle mass and strength is to provide low dose protein during the acute phases of critical illness, combine nutrient delivery with exercise and early mobilization, consider fish oil or specialized pro-resolving mediators to enhance resolution of inflammation, and subsequently increase protein provision to standard doses or higher as the patient progresses to recovery and rehabilitation.