Background: Candidaemia is the most common form of invasive candidiasis. Resistant Candida blood stream infection (BSI) is rising, with limitations on the development of broader-spectrum antifungal agents worldwide. Our study aimed to identify the occurrence of antifungal-resistant candidaemia and the distribution of these species, determine the risk factors associated with antifungal resistance and evaluate the association of antifungal-resistant candidaemia with the length of intensive care unit (ICU) and hospital stay and with 30-day mortality. Methods: A retrospective cohort study was conducted at King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia. Adult patients diagnosed with candidaemia from January 2006 to December 2017 were included. Results: A total of 196 BSIs were identified in 94 males (49.74%) and 95 females (50.26%). C. glabrata was the most commonly isolated Candida species, with 59 (30%), followed by C. albicans with 46 (23%). Susceptibility data were available for 122/189 patients, of whom 26/122 (21%) were resistant to one or more antifungals. C. parapsilosis with available sensitivity data were found in 30/122 isolates, of which 10/30 (33%) were resistant to fluconazole. Risk factors significantly associated with antifungal-resistant candidaemia included previous echinocandin exposure (odds ratio (OR) =1.38; 95% confidence interval (CI) (1.02–1.85); P = 0.006) and invasive ventilation (OR = 1.3; 95% CI (1.08–1.57); P = 0.005). The median length of ICU stay was 29 days [range 12–49 days] in the antifungal-resistant group and 18 days [range 6.7–37.5 days] in the antifungal-sensitive group (P = 0.28). The median length of hospital stay was 51 days [range 21–138 days] in the antifungal-resistant group and 35 days [range 17–77 days] in the antifungal-sensitive group (P = 0.09). Thirty-day mortality was 15 (57.7%) and 54 (56.25%) among the antifungal-resistant and antifungal-sensitive groups, respectively (OR = 1.01; 95% CI (0.84–1.21); P = 0.89). Conclusions: Our results indicate a high frequancy of non- C. albicans candidaemia. The rise in C. parapsilosis resistance to fluconazole is alarming. Further studies are required to confirm this finding.

Purpose: Antibiotic de-escalation (ADE) in critically ill patients is controversial. Previous studies mainly focused on mortality; however, data are lacking about superinfection. Therefore, we aimed to identify the impact of ADE versus continuation of therapy on superinfections rate and other outcomes in critically ill patients. Methods: This was a two-center retrospective cohort study of adults initiated on broad-spectrum antibiotics in the intensive care unit (ICU) for ≥ 48 h. The primary outcome was the superinfection rate. Secondary outcomes included 30-day infection recurrence, ICU and hospital length of stay, and mortality. Results: 250 patients were included, 125 in each group (ADE group and continuation group). Broad spectrum antibiotic discontinuation occurred at a mean of 7.2 ± 5.2 days in the ADE arm vs. 10.3 ± 7.7 in the continuation arm (P value = 0.001). Superinfection was numerically lower in the ADE group (6.4% vs. 10.4%; P = 0.254), but the difference was not significant. Additionally, the ADE group had shorter days to infection recurrence (P = 0.045) but a longer hospital stay (26 (14–46) vs. 21 (10–36) days; P = 0.016) and a longer ICU stay (14 (6–23) vs. 8 (4–16) days; P = 0.002). Conclusion: No significant differences were found in superinfection rates among ICU patients whose broad-spectrum antibiotics were de-escalated versus patients whose antibiotics were continued. Future research into the association between rapid diagnostics with antibiotic de-escalation in the setting of high resistance is warranted.

Background: Acetazolamide is a carbonic anhydrase inhibitor that inhibits proximal sodium bicarbonate reabsorption, thus increasing urinary bicarbonate excretion. Despite its widespread distribution in the body and beneficial effects on alkaline diuresis, its efficacy and the optimal dosage and duration of acetazolamide in treating metabolic acidosis remain areas of uncertainty. This review aims to assess the effectiveness of acetazolamide in treating chloride depletion alkalosis, mainly induced by diuretics, through a systematic evaluation of clinical research data. Methods: A comprehensive search was conducted on PubMed and Embase. This review included randomized controlled trials, observational studies, and case reports. Data extraction included dose, route, frequency, indication, duration of therapy, patient demographics, and outcomes. Results: A comprehensive search strategy identified 107 studies, of which 7 met the inclusion criteria after full-text review. The reviewed studies encompassed two randomized clinical trials, one case–control study, and three case reports, collectively involving 111 patients with metabolic alkalosis. The studies revealed varied outcomes regarding the efficacy of acetazolamide in treating metabolic alkalosis induced by diuretics. While some trials demonstrated significant improvements in serum bicarbonate levels and acid–base balance, others found no statistically significant reduction in the duration of mechanical ventilation. Case reports highlighted the successful use of acetazolamide in diverse patient populations, including pediatric patients with heart disease and individuals with chronic obstructive pulmonary disease. Conclusions: Acetazolamide holds promise in addressing chloride depletion alkalosis. However, a targeted clinical trial investigating its effectiveness in diuretic-induced metabolic alkalosis must strengthen the existing knowledge base.

Background Candidemia is the most common form of invasive candidiasis. Resistant Candida blood stream infection (BSI) is rising with limitation in the development of broader spectrum antifungal agents worldwide. Our study aimed to identify rate of antifungal resistance candidemia and distribution for species, determine risk factors associated with antifungal resistance and evaluate the association of antifungal resistance candidemia with length of Intensive Care Unit (ICU) and hospital stay and with 30-day mortality. Methods A retrospective cohort study was conducted at King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia. Adult patients diagnosed with candidemia from January 2006 to December 2017 were included. Results A total of 196 BSI was identified in 94 males (49.74%) and 95 females (50.26%). C.glabrata was the most common isolated Candida 59 (30%) followed by C. albicans 46 (23%). Susceptibility data were available for 122/189 patients in which 26/122 (21%) found to have one or more antifungal resistance. C. parapsilosis isolates with available sensitivity data were 31/122 in which 10/31 (32%) were resistant to fluconazole. Risk factors significantly associated with antifungal resistance candidemia include previous echinocandin exposure (Odd Ratio (OR) =1.38; 95% Confidence Interval (CI) (1.02-1.85); P= 0.006) and invasive ventilation (OR=1.3; 95% CI (1.08-1.57); P= 0.005). Median length of ICU stay was 29 days [range12-49 days] in antifungal resistance group and 18 days [range 6.7-37.5 days] in antifungal sensitive group; Median length of hospital stay was 51days [range 21-138 days] in antifungal resistance group and 35 days [range 17-77 days] in antifungal sensitive group. Thirty- day mortality was 15 (57.7%) and 54 (56.25%) among antifungal resistance and antifungal sensitive group, respectively (OR=1.01; 95% CI (0.84-1.21); P= 0.89). Conclusions Our results indicate an increase in the rate of non-albicans candidemia. Candida parapsilosis resistance to fluconazole is alarming. Further studies are required to confirm this finding.

The World Health Organization (WHO) has identified carbapenem-resistant Pseudomonas aeruginosa (CRPA) as one of the three critical priority pathogens. There is scarce literature evaluating the treatment outcomes in patients with CRPA infections treated with traditional non-carbapenem β-lactam (NCBL) agents. Thus, this study aims to assess the effectiveness of traditional NCBL compared to novel β-lactam agents (NVL) for treating non-carbapenem β-lactam -susceptible CRPA. A single-center retrospective cohort study was conducted between January 2016 and December 2022. The study included adult patients 18 years and older with infection due to CRPA who were treated based on microbiology sensitivity with traditional NCBL or NVL for more than 48 h. The primary outcome was 30-day mortality. 124 patients were included: 98 (79%) in the NCBL group and 26 (20.9%) in the NVL group. 78 (62.9%) patients were male. The median (interquartile range (IQR)) age of included patients was 64 (45, 77) years. A total of 84 (67.7%) patients were critically ill, with an overall median (IQR) APACHE II score of 18 (13.5, 23). The rates of 30-day mortality in NCBL and NVL groups were 41 (41.8%) and 12 (46.2%), respectively; P = 0.692. In patients with CRPA infections susceptible to traditional NCBL, there was no statisticallly significant difference in 30-day mortality among patients who were treated with traditional NCBL compared with NVL. Further studies with larger sample sizes are needed to confirm these findings.

Background: Percent fluid overload greater than 5% is associated with increased mortality. The appropriate time for fluid deresuscitation depends on the patient's radiological and clinical findings. This study aimed to assess the applicability of percent fluid overload calculations for evaluating the need for fluid deresuscitation in critically ill patients. Methods: This was a single-center, prospective, observational study of critically ill adult patients requiring intravenous fluid administration. The study's primary outcome was median percent fluid accumulation on the day of fluid deresuscitation or intensive care unit (ICU) discharge, whichever came first. Results: A total of 388 patients was screened between August 1, 2021, and April 30, 2022. Of these, 100 with a mean age of 59.8±16.2 years were included for analysis. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15.4±8.0. Sixty-one patients (61.0%) required fluid deresuscitation during their ICU stay, while 39 (39.0%) did not. Median percent fluid accumulation on the day of deresuscitation or ICU discharge was 4.5% (interquartile range [IQR], 1.7%–9.1%) and 5.2% (IQR, 2.9%–7.7%) in patients requiring deresuscitation and those who did not, respectively. Hospital mortality occurred in 25 (40.9%) of patients with deresuscitation and six (15.3%) patients who did not require it (P=0.007). Conclusions: The percent fluid accumulation on the day of fluid deresuscitation or ICU discharge was not statistically different between patients who required fluid deresuscitation and those who did not. A larger sample size is needed to confirm these findings.