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25Th International Symposium on Infections in the Critically Ill Patient medical sciences Meeting Report 25thMeeting InternationalReport Symposium on Infections in the Critically25th International Ill Patient Symposium on Infections in the Critically Ill Patient Antonio Artigas 1,*, Jean Carlet 2,*, Ricard Ferrer 3,*, Michael Niederman 4,* and AntoniAntonio Torres Artigas5,* 1,*, Jean Carlet 2,*, Ricard Ferrer 3,*, Michael Niederman 4,* and Antoni Torres 5,* 1 1 CriticalCritical Care Care Center, Sabadell Hospital, University Institute Parc TaulTaulí,í, AutonomousAutonomous UniversityUniversity ofof Barcelona, Barcelona,08193 Ciberes, Ciberes, Spain Spain 2 2 PresidentPresident of of the the World World Alliance Alliance against against Anti Antibioticbiotic Resistance Resistance (WAAAR), (WAAAR), Paris, 75008 France Paris, France 3 3 IntestiveIntestive Care Care Medicine Medicine Department, Department, Vall Vall d’Hebron d’Hebron University University Hospital. Hospital, Barcelona, 08035 Barcelona, Spain Spain 4 4 DivisionDivision of of Pulmonary Pulmonary and and Critical Critical care Care Medicine, Medicine, New New York York Presbyterian Presbyterian Hospital, Hospital, Weill Weill Cornell Cornell Medical Medical College,College, USA New York, NY 10065, USA 5 5 PulmonologyPulmonology Department, Department, Clinic Clinic Hospital, Hospital, Universi Universityty of of Barcelona, Barcelona, Barcel CIBERona, Enfermedades CIBER Enfermedades Respiratorias, Respiratorias,08036 Barcelona, Spain Spain * * Correspondence:Correspondence: [email protected] [email protected] (A.A.); (A.A.); jeancarl [email protected]@gmail.com (J.C.); (J.C.); [email protected] [email protected] (R.F.); (R.F.); [email protected]@current-science.com (M.N.); (M.N.); [email protected] [email protected] (A.T.) (A.T.) Received: 10 February 2020; Accepted: 12 February 2020; Published: 13 February 2020 Received: 12 February 2020; Accepted: 12 February 2020; Published: 13 February 2020 1.1. IntroductionIntroduction ThisThis 25th 25th International International Symposium Symposium on on Infections Infections in thein Criticallythe Critically Ill Patient Ill Patient aims toaims review to review current concepts,current concepts, technology technology and present and advances present advances in infections in infections in critically in ill critically patient. ill Sepsis, patient. Pulmonary Sepsis, InfectionsPulmonary and Infections their therapeutic and their andtherapeutic preventive and strategies preventive will strategies be the topics will be presented the topics by presented international by expertsinternational who will experts review who and will update review sepsis and update as a global sepsis international as a global international problem. problem. NewNew guidelinesguidelines epidemiologicalepidemiological information on sepsis, fluid fluid therapy therapy and and vasopressors, vasopressors, a a personalizepersonalize sepsissepsis care and and new new therapies therapies and and futu futurere randomized randomized control control trials trials are provided. are provided. The Theimmune immune response response and and the the emerging emerging methods methods to tope personalizersonalize sepsis sepsis care care including including new new biomarkers, biomarkers, sepsissepsis phenotypesphenotypes andand endend typestypes andand immunomonitoringimmunomonitoring of of patients patients with with sepsis sepsis represent represent a anew new complementarycomplementary viewview toto treattreat patientspatients with severe infections and and organ organ failure failure in in addition addition to to early early antibioticantibiotic andand thethe controlcontrol ofof sourcesource ofof infection.infection. New insights of of cell cell therapies therapies and and extracorporeal extracorporeal treatmenttreatment will will be be provided. provided. TheThe preliminary preliminary informationinformation aboutabout the European severe community pneumonia pneumonia guidelines guidelines and and newnew diagnostic diagnostic approaches approaches for nosocomialfor nosocomial pulmonary pulmonary infections, infections, new antibiotics new antibiotics and the optimization and the ofoptimization their use represent of their keyuse factorsrepresent to improvekey factors outcome to improve and prevention outcome and of severe prevention infections of severe in the criticallyinfections ill in patients. the critically ill patients. Med.Med. Sci. Sci.2020 2020,,8 8,, 13; 13; doi: doi:10.3390/medsci801001310.3390/medsci8010013 www.mdpi.com/journal/medsciwww.mdpi.com/journal/medsci Med. Sci. 2020, 8, 13 2 of 54 Antonio Artigas, MD Ricard Ferrer, MD Corporación Sanitaria Universitaria Parc Tauli Intensive Care Department CIBER Enfermedades Respiratorias University Hospital Vall d'Hebron Autonomous University of Barcelona CIBER Enfermedades Respiratorias Barcelona, Spain Barcelona, Spain Antonio Torres, MD Pneumology Department Clinic Hospital University of Barcelona CIBER Enfermedades Respiratorias Barcelona, Spain 2. Abstracts Speakers 2.1. SESION I. SEPSIS 2.1.1. How 25 Years of Research Has Changed My Practice in Sepsis? Jean-Louis Vincent Dept of Intensive care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium Despite decades of sepsis research, no specific immunomodulatory sepsis therapies are currently available, except perhaps corticosteroids, so from that point of view, research has not changed my clinical practice very much. However, research and changes in other aspects of patient management and process of care have certainly influenced the way I treat my patients with sepsis. There are perhaps three key areas that have altered over the years: 1. One of the most important realizations has been the importance of the time factor when managing patients with sepsis time is tissue. Making a rapid diagnosis and starting appropriate − treatment promptly are keys to limiting organ dysfunction and maximizing patient outcomes. Increased awareness of sepsis in the ICU but also in other hospital departments and before hospital admission is helping identify patients earlier so that appropriate monitoring, investigations and treatment can be started. Rapid response teams that can attend patients with suspected sepsis on the general ward are now present in many hospitals. The need for adequate, rapid resuscitation has also been highlighted and increasingly fluids and vasopressors are started simultaneously rather than waiting to see what effect may fluid has before vasoactive agents are introduced. Any period of hypotension can be harmful, and it is better to start these two branches of resuscitation together to restore a minimum perfusion pressure as soon as possible. Vasopressor agents can then be weaned once the patient’s hemodynamic status is optimized. An important research result in the last 25 years was the finding that norepinephrine should be used in preference to dopamine as the first-line vasopressor. The importance of removal of excess fluid once the patient has stabilized has also come to the fore with persistent positive fluid balance associated with worse outcomes. My management of the patient with sepsis is thus guided by the SOSD paradigm: salvage, optimization, stabilization, de-escalation. I use changes in blood lactate levels over time to provide an indication of response to treatment, with increasing or stable levels suggesting diagnosis and/or treatment needs to be reviewed and possibly altered. 2. Another area where practice has changed is that we have become much less invasive. Echography is much more widely available and practiced routinely at the bedside in many units for initial hemodynamic assessment and diagnosis of associated cardiac conditions. The pulmonary artery catheter still has a place in severely ill, complex patients but non-invasive techniques have replaced it in some patients. The move towards less-invasive monitoring is set to continue as technology advances and devices become smaller, more effective and efficient, and more available. Med. Sci. 2020, 8, 13 3 of 54 3. A third area, the need to personalize therapies, has also been stressed in recent years and is reflected in using fewer one-size-fits-all targets and adapting treatments according to the characteristics and needs of individual patients. As just one example, a target mean arterial pressure of 65 mmHg may be appropriate for many patients, but a patient with chronic hypertension may benefit from a higher target, and in a younger patient with no evidence of arteriosclerosis, a lower pressure may be adequate. Similarly, blood transfusions should not be given based only on a hemoglobin concentration but the pros and cons weighed up in each patient, taken into consideration age, disease severity, and a history of cardiac ischemia among others. As we become more able to characterize the sepsis response in individual patients, we will be better able to select patients for inclusion in clinical trials according to their likelihood to respond to treatment rather than testing all agents in heterogeneous groups as was the rule until recently. This will result in more trial interventions demonstrating a beneficial effect on survival and I am confident that within the next 25 years, I will be including personalized immunomodulatory therapies in the management of my patients with sepsis. Suggested reading Vincent JL (2018) How I treat septic shock. Intensive Care Med 44:2242–2244. • Annane D, Renault A, Brun-Buisson C, et al. (2018) Hydrocortisone plus fludrocortisone for adults • with septic shock. N Engl J Med 378:809–818 Rhodes
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