Background: Optimal anti-bacterial activity of meropenem requires maintenance of its plasma concentration (Cp) above the minimum inhibitory concentration (MIC) of the pathogen for at least 40% of the dosing interval (fT > MIC > 40). We aimed to determine whether a 3-h extended infusion (EI) of meropenem achieves fT > MIC > 40 on the first and third days of therapy in patients with severe sepsis or septic shock. We also simulated the performance of the EI with respect to other pharmacokinetic (PK) targets such as fT > 4 × MIC > 40, fT > MIC = 100, and fT > 4 × MIC = 100.Methods: Arterial blood samples of 25 adults with severe sepsis or septic shock receiving meropenem 1000 mg as a 3-h EI eight hourly (Q8H) were obtained at various intervals during and after the first and seventh doses. Plasma meropenem concentrations were determined using a reverse-phase high-performance liquid chromatography assay, followed by modeling and simulation of PK data. European Committee on Antimicrobial Susceptibility Testing (EUCAST) definitions of MIC breakpoints for sensitive and resistant Gram-negative bacteria were used. Results:A 3-h EI of meropenem 1000 mg Q8H achieved fT > 2 µg/mL > 40 on the first and third days, providing activity against sensitive strains of Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter baumannii. However, it failed to achieve fT > 4 µg/mL > 40 to provide activity against strains susceptible to increased exposure in 33.3 and 39.1% patients on the first and the third days, respectively. Modeling and simulation showed that a bolus dose of 500 mg followed by 3-h EI of meropenem 1500 mg Q8H will achieve this target. A bolus of 500 mg followed by an infusion of 2000 mg would be required to achieve fT > 8 µg > 40. Targets of fT > 4 µg/mL = 100 and fT > 8 µg/mL = 100 may be achievable in two-thirds of patients by increasing the frequency of dosing to six hourly (Q6H). Conclusions:In patients with severe sepsis or septic shock, EI of 1000 mg of meropenem over 3 h administered Q8H is inadequate to provide activity (fT > 4 µg/mL > 40) against strains susceptible to increased exposure, which requires © The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article' s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article' a bolus of 500 mg followed by EI of 1500 mg Q8H. While fT > 8 µg/mL > 40 require escalation of EI dose, fT > 4 µg/ mL = 100 and fT > 8 µg/mL = 100 require escalation of both EI dose and frequency.

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Background and Aims:The transport of critically ill patients for procedures or imaging outside the Intensive Care Unit (ICU) is potentially hazardous; hence, the transport process must be organized and efficient. The literature about benefits of and untoward events (UEs) during intrahospital transport of pediatric critically ill patient is scarce. We, therefore, audited the UEs during and benefits of intrahospital transport of critically ill pediatric patients in our ICU.Subjects and Methods:Eighty critically ill pediatric (<18 years) cancer patients, transported from the ICU for either diagnostic or therapeutic procedure over a period of 6 months, were included in the study. The data collected included the destination (computed tomography scan, intervention radiology, magnetic resonance imaging scan, and operation theater), accompanying medical personnel, UEs, and benefits obtained during transport.Results:Among eighty pediatric patients, the median age was 8 years (range 2–17 years). During the transport, four (5%) patients required endotracheal intubation, three (3.75%) patients required intercostal drain placement, and six (7.5%) patients required cardiopulmonary resuscitation. Accidental removal of central venous catheter was reported in three (3.75%) patients, drain came out in four (5%) patients, and three (3.75%) patients had accidental extubation. Transport indirectly led to a change in antibiotic therapy in 24 (30%) patients and directly helped in change of therapy in the form of interventions in 20 (25%) patients.Conclusion:Critically ill children can be transported safely with adequate pretransport preparations, which may help in avoiding major UEs and benefit the patient by change in the therapy.

Introduction Ventilator-associated pneumonia (VAP) may be a life threatening nosocomial infection encountered in intensive care units. Currently the emergence of carbapenem-resistant Gram-negative pathogens has become worrisome threat worldwide. Material and methods Endotracheal aspirates samples were collected from patients who were under mechanical ventilation for > 48 h. The bacterial isolates were identified by MALDI-TOF-MS and antibiotic susceptibility testing performed. All carbapenem resistant isolates were tested by Modified Hodge test (MHT), modified carbapenem inactivation method (mCIM), and EDTA-CIM (eCIM) and PCR were performed to detect blaIMP, blaVIM and blaNDM producing MBL genes. Results VAP occurred in 172/353(48.7%), 23.3% had early-onset VAP and 76.7% had late-onset VAP. Males (69.2%) were found to suffer more from VAP. Prior antibiotic therapy, CPI>6, prior surgery and tracheostomy were associated with VAP. The mortality in VAP (58.1%) contrasted with non-VAP (40%). 99/169 (58.6%) Gram-negative isolates were resistant to carbapenems. Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae were common pathogens found in late onset VAP, whereas K. pneumoniae, A. baumannii and Staphylococcus aureus were common in early onset VAP. The PCR results detected blaNDM in 37/172(21.5%) and blaVIM in 30/172(17.4%); 15/172(8.7%) isolates carried both genes. Conclusion The blaNDM-1 and blaVIM genes are the main antibiotic-resistance genes that induce resistance patterns to carbapenems in VAP, highlighting CRE strains of potential public health concern and therapeutic challenge. Diagnostic laboratories in India must get on high caution for early MBL detection as it may limit the wide dispersal of MBL genes.

Background and Aims:With the expanding use of diagnostic and therapeutic radiological modalities in critically ill patients, doctors working in Intensive Care Units (ICUs) are increasingly exposed to ionizing radiation. This risk of radiation exposure occurs not only during bedside radiologic procedures, but also when ICU physicians accompany patients to radiology suites. The aim of this study was to quantify levels of radiation exposure among medical professionals working in the ICU.Materials and Methods:The study was carried out prospectively over 6 months in the ICU of a tertiary-referral cancer hospital. Two teams consisting of 4 ICU resident doctors each were instructed to wear thermoluminescent dosimeters (TLDs) during their duty shifts. Standard radiation protection precautions were used throughout the study period. TLDs were also placed in selected areas of the ICU to measure the amount of scattered radiation. TLDs were analyzed at the end of every 3 months.Results:The readings recorded on TLDs placed in the ICU were almost immeasurable. The mean value of residents' radiation exposure was 0.059 mSv, though the highest individual reading approached 0.1 mSv. The projected maximum yearly radiation exposure was 0.4 mSv.Conclusions:If standard radiation safety precautions are followed, the cumulative radiation exposure to ICU resident doctors is well within permissible limits and is not a cause of concern. However, with the increasing use of radiological procedures in the management of critically ill patients, there is a need to repeat such audits periodically to monitor radiation exposure.