Severe sepsis and septic shock in the elderly: An overview

Candida auris is an emerging multidrug-resistant fungal pathogen reported worldwide. Infections due to C. auris are usually nosocomial and associated with high rates of fluconazole resistance and mortality. Echinocandins are utilized as the first-line treatment. However, echinocandins are only available intravenously and are associated with increasingly higher rates of resistance by C. auris. Thus, a need exists for novel treatments that demonstrate potent activity against C. auris. Ibrexafungerp is a first-in-class triterpenoid antifungal agent. Similar to echinocandins, ibrexafungerp inhibits (1→3)-β-D-glucan synthase, a key component of the fungal cell wall, resulting in fungicidal activity against Candida spp. Ibrexafungerp demonstrates broad in vitro activity against various Candida spp. including C. auris and C. auris isolates with fks mutations. Minimum inhibitory concentration (MIC₅₀ and MIC₉₀) values in >400 C. auris isolates were 0.5 μg/mL and 1.0 μg/mL, respectively. Clinical results were reported for two patients with invasive candidiasis or candidemia due to C. auris treated during the CARES (Candidiasis Caused by Candida Auris) trial, an ongoing open-label study. These patients experienced a complete response after treatment with ibrexafungerp. Thus, ibrexafungerp represents a promising new antifungal agent for treating C. auris infections.

Background and Aims: The insertion of central venous catheters (CVCs) is an integral part of the management of critically ill patients. We aimed to study the impact of ultrasonography (USG) on CVC insertion in intensive care. Setting and Design: A prospective study of 450 patients requiring CVC in the intensive care unit (ICU) of a tertiary care hospital. Methods and Materials: The patients were randomized into two groups: to have CVC insertion with USG-guidance or with the anatomic landmark technique (ALT). Data were collected on patient demographics; operator experience; and method, site and side of insertion. Outcome measures included successful insertion of CVC, number of attempts needed and complications. Results: Internal jugular vein (IJV) cannulation was successful in 177/194 patients (91.2%) using ALT and in 200/205 patients (97.6%) using USG guidance, a significant difference of 6.4% (P = 0.006). Using ALT, 72.7% of cannulations could be accomplished in the first attempt as compared with 84.4% with USG guidance (P = 0.004). The overall complication rate was 28/399 (7%), with 19 (9.8%) complications in the ALT group and 9 (4.4%) in the USG group (age-, sex-, and operator-adjusted OR = 0.35, 95% CI: 0.13-0.96; P = 0.03). For subclavian vein catheterization, the success rate was 26/28 (92.9%) in the ALT group and 17/17 (100%) in the USG group (P = 0.52). Using ALT, 71.4% cannulation could be accomplished in the first attempt as compared with 82.4% under USG guidance (P = 0.49). The overall complication rate was 6/45 (13.3%), with 4 (14.3%) complications in the ALT group and 2 (11.8%) in the USG group (P > 0.99). Conclusions: Real-time USG guidance improves success rates, reduces the number of attempts and decreases the complications associated with CVC insertion, especially for the IJV, and should become the standard of care in intensive care.

Background and Aim: There is scarcity of data from the Indian subcontinent regarding the profile and outcome of patients presenting with acute poisoning admitted to intensive care units (ICU). We undertook this retrospective analysis to assess the course and outcome of such patients admitted in an ICU of a tertiary care private hospital. Methods: We analyzed data from 138 patients admitted to ICU with acute poisoning between July 2006 and March 2009. Data regarding type of poisoning, time of presentation, reason for ICU admission, ICU course and outcome were obtained. Results: Seventy (50.7%) patients were males and majority (47.8%) of admissions were from age group 21 to 30 years. The most common agents were benzodiazepines, 41/138 (29.7%), followed by alcohol, 34/138 (24.63%) and opioids, 10/138 (7.2%). Thirty-two (23%) consumed two or more agents. Commonest mode of toxicity was suicidal (78.3%) and the route of exposure was mainly oral (97.8%). The highest incidence of toxicity was due to drugs (46.3%) followed by household agents (13%). Organ failure was present in 67 patients (48.5%). During their ICU course, dialysis was required in four, inotropic support in 14 and ventilator support in 13 patients. ICU mortality was 3/138 (2.8%). All deaths were due to aluminium phosphide poisoning. Conclusions: The present data give an insight into epidemiology of poisoning and represents a trend in urban India. The spectrum differs as we cater to urban middle and upper class. There is an increasing variety and complexity of toxins, with substance abuse attributing to significant number of cases.