[Show abstract][Hide abstract] ABSTRACT: Identification of third-generation, cephalosporin-resistant Enterobacteriaceae (3GC-RE) carriers by rectal screening at admission seems to be an important step in the prevention of transmission and outbreaks; however, little is known about its effectiveness. The aim of this study was to evaluate the impact of 'targeted screening' at patient admission to intensive care units (ICUs) on the incidence of 3GC-RE hospital-acquired infections (HAIs) and compare it to 'universal screening'.
We undertook a quasi-experimental study of two ICUs (unit A: intervention group; unit B: control group) at a university-affiliated hospital between 1 January 2008 and 31 December 2011. In unit A, patients were screened universally for 3GC-RE at admission during period 1 (1 January 2008 through 30 September 2010). During period 2 (2011 calendar year), the intervention was implemented in unit A; patients transferred from another unit or hospital were screened selectively. In unit B, all patients were screened throughout periods 1 and 2. 3GC-RE-related HAI incidence rates were expressed per 1,000 patient-days. Incidence rate ratios (IRRs) were examined by multivariate Poisson regression modelling.
In unit A, 3GC-RE-related HAI incidence rates decreased from 5.4 (95% confidence interval (CI), 4.1 to 7.0) during period 1 to 1.3 (95% CI, 0.5 to 2.9) during period 2 (P < 0.001). No changes were observed in unit B between periods 1 and 2 (P = 0.5). In unit A, the adjusted incidence of 3GC-RE-related HAIs decreased in period 2 compared with period 1 (adjusted IRR, 0.3; 95% CI, 0.1 to 0.9; P = 0.03) independently of temporal trend, trauma and age. No changes were seen in unit B (P = 0.4). The total number of rectal swabs taken showed an 85% decrease in unit A between period 1 and 2 (P < 0.001).
Targeted screening of 3GC-RE carriers at ICU admission was not associated with an increase in 3GC-RE-related HAI incidence compared with universal screening. Total number of rectal swabs decreased significantly. These findings suggest that targeted screening may be worth assessing as an alternative to universal screening.
[Show abstract][Hide abstract] ABSTRACT: To assess the prevalence of decisions to forgo life-sustaining treatment (DFLST), the patients characteristics, and to estimate the impact of DFLST stages on mortality.
Observational study of a prospective database between 2005 and 2012 from 13 ICUs. DFLST were defined as follows: no escalation of treatment (stage 1), not to start or escalate treatment even if such treatment is considered in the future; withholding (stage 2), not to start or escalate necessary treatment; withdrawal (stage 3), to stop necessary treatment. The impact of daily DFLST stage on day-30 hospital mortality was tested with a discrete-time Cox's model and adjusted for admission severity and daily SOFA score.
Of 10,080 patients, 1290 (13 %) made DFLST. The highest DFLST stage during the ICU stay was no escalation of treatment in 339 (26 %) patients, withholding in 502 (39 %) patients, and withdrawal in 449 (35 %) patients. Older patients, patients with at least one chronic disease, and patients with greater ICU severity were significantly more numerous in the DFLST group. Day-30 mortality was 13 % for non-DFLST patients, 35 % for no escalation of treatment, 75 % for withholding, 93 % for withdrawal. After adjustment, an increase in day-30 mortality was associated with withholding and withdrawal (hazard ratio 95 % CI 5.93 [4.95-7.12] and 20.05 [15.58-25.79], P < 0.0001), but not with no escalation of treatment (HR 1.14 [0.91-1.44], P = 0.25).
DFLST were made in 13 % of ICU patients. Withholding, withdrawal, older age, more comorbidities, and higher severity of illness were associated with higher mortality. No escalation of treatment was not associated with increased mortality.
Intensive Care Medicine 07/2015; 41(10). DOI:10.1007/s00134-015-3944-5 · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Physicians play an important role in strategies to control health care spending. Being aware of the cost of prescriptions is surely the first step to incorporating cost-consciousness into medical practice. The aim of this study was to evaluate current intensivists' knowledge of the costs of common prescriptions and to identify factors influencing the accuracy of cost estimations.
Junior and senior physicians in 99 French intensive care units were asked, by questionnaire, to estimate the true hospital costs of 46 selected prescriptions commonly used in critical care practice.
With an 83 % response rate, 1092 questionnaires were examined, completed by 575 (53 %) and 517 (47 %) junior and senior intensivists, respectively. Only 315 (29 %) of the overall estimates were within 50 % of the true cost. Response errors included a 14,756 ± 301 underestimation, i.e., -58 ± 1 % of the total sum (25,595 ). High-cost drugs (>1000 ) were significantly (p < 0.001) the most underestimated prescriptions (-67 ± 1 %). Junior grade physicians underestimated more costs than senior physicians (p < 0.001). Using multivariate analysis, junior physicians [odds ratio (OR), 2.1; 95 % confidence interval (95 % CI), 1.43-3.08; p = 0.0002] and female gender (OR, 1.4; 95 % CI, 1.04-1.89; p = 0.02) were both independently associated with incorrect cost estimations.
ICU physicians have a poor awareness of prescriptions costs, especially with regards to high-cost drugs. Considerable emphasis and effort are still required to integrate the cost-containment problem into the daily prescriptions in ICUs.
Intensive Care Medicine 05/2015; 41(8). DOI:10.1007/s00134-015-3859-1 · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia.
We performed a multicenter, open-label trial in which we randomly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy, standard oxygen therapy delivered through a face mask, or noninvasive positive-pressure ventilation. The primary outcome was the proportion of patients intubated at day 28; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28.
A total of 310 patients were included in the analyses. The intubation rate (primary outcome) was 38% (40 of 106 patients) in the high-flow-oxygen group, 47% (44 of 94) in the standard group, and 50% (55 of 110) in the noninvasive-ventilation group (P=0.18 for all comparisons). The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the noninvasive-ventilation group; P=0.02 for all comparisons). The hazard ratio for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with standard oxygen versus high-flow oxygen (P=0.046) and 2.50 (95% CI, 1.31 to 4.78) with noninvasive ventilation versus high-flow oxygen (P=0.006).
In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health; FLORALI ClinicalTrials.gov number, NCT01320384.).
New England Journal of Medicine 05/2015; 372(23). DOI:10.1056/NEJMoa1503326 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Centers for Disease Control and Prevention built up new surveillance paradigms for the patients on mechanical ventilation and the ventilator-associated events, comprising ventilator-associated conditions and infection-related ventilator-associated complications. We assess 1) the current epidemiology of ventilator-associated event, 2) the relationship between ventilator-associated event and ventilator-associated pneumonia, and 3) the impact of ventilator-associated event on antimicrobials consumption and mechanical ventilation duration.
Inception cohort study from the longitudinal prospective French multicenter OUTCOMEREA database (1996-2012).
Patients on mechanical ventilation for greater than or equal to 5 consecutive days were classified as to the presence of a ventilator-associated event episode, using slightly modified Centers for Disease Control and Prevention definitions.
Among the 3,028 patients, 2,331 patients (77%) had at least one ventilator-associated condition, and 869 patients (29%) had one infection-related ventilator-associated complication episode. Multiple causes, or the lack of identified cause, were frequent. The leading causes associated with ventilator-associated condition and infection-related ventilator-associated complication were nosocomial infections (27.3% and 43.8%), including ventilator-associated pneumonia (14.5% and 27.6%). Sensitivity and specificity of diagnosing ventilator-associated pneumonia were 0.92 and 0.28 for ventilator-associated condition and 0.67 and 0.75 for infection-related ventilator-associated complication, respectively. A good correlation was observed between ventilator-associated condition and infection-related ventilator-associated complication episodes, and ventilator-associated pneumonia occurrence: R = 0.69 and 0.82 (p < 0.0001). The median number of days alive without antibiotics and mechanical ventilation at day 28 was significantly higher in patients without any ventilator-associated event (p < 0.05). Ventilator-associated condition and infection-related ventilator-associated complication rates were closely correlated with antibiotic use within each ICU: R = 0.987 and 0.99, respectively (p < 0.0001).
Ventilator-associated event is very common in a population at risk and more importantly highly related to antimicrobial consumption and may serve as surrogate quality indicator for improvement programs.
Critical care medicine 05/2015; 43(9). DOI:10.1097/CCM.0000000000001091 · 6.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute epiglottitis is a potentially life threatening disease, with a growing incidence in the adult population. Its long-term outcome after Intensive Care Unit (ICU) hospitalization has rarely been studied.
Thirty-four adult patients admitted for acute epiglottitis were included in this retrospective multicentric study. The mean age was 44±12 years (sex ratio: 5.8). Sixteen patients (47%) had a history of smoking while 8 (24%) had no previous medical history. The average time of disease progression before ICU was 2.6±3.6 days. The main reasons for hospitalization were continuous monitoring (17 cases, 50%) and acute respiratory distress (10 cases, 29%). Microbiological documentation could be made in 9 cases (26%), with Streptococcus spp. present in 7 cases (21%). Organ failure at ICU admission occurred in 8 cases (24%). Thirteen patients (38%) required respiratory assistance during ICU stay; 9 (26%) required surgery. Two patients (6%) died following hypoxemic cardiac arrest. Five patients (15%) had sequelae at 1 year. Patients requiring respiratory assistance had a longer duration of symptoms and more frequent anti inflammatory use before ICU admission and sequelae at 1 year (p<0.05 versus non-ventilated patients). After logistic regression analysis, only exposure to anti-inflammatory drugs before admission was independently associated with airway intervention (OR, 4.96; 95% CI, 1.06-23.16).
The profile of the cases consisted of young smoking men with little comorbidity. Streptococcus spp. infection represented the main etiology. Outcome was favorable if early respiratory tract protection could be performed in good conditions. Morbidity and sequelae were greater in patients requiring airway intervention.
PLoS ONE 05/2015; 10(5):e0125736. DOI:10.1371/journal.pone.0125736 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To characterize etiology, clinical course and outcomes of patients in prolonged refractory status epilepticus (PRSE) and looking for prognostic factors.
Retrospective study conducted in patients hospitalized from January 1, 2001 to December 31, 2011 in 19 polyvalent intensive care units in French university and general hospitals. Patients were adults with a generalized convulsive refractory status epilepticus that lasted more than seven days, despite treatment including an anesthetic drug and mechanical ventilation. Patients with anoxic encephalopathy were excluded. Follow-up phone call was used to determine functional outcome using modified Rankin Scale (mRS) with mRS 0-3 defining good and mRS 4-6 poor outcome.
78 patients (35 female) were included. Median age was 57 years. Causes of status epilepticus were various, mainly including prior epilepsy (14.1%), CNS infection (12.8%), and stroke (12.8%). No etiology was found in 27 (34.6%) patients. PRSE was considered controlled in only 53 (67.9%) patients after a median duration of 17 (IQR 12-26) days. The median length of ICU stay was 28 (19-48) days. Forty-one (52.5%) patients died in the ICU, 26 from multiple organ failure, 8 from care withdrawal, 2 from sudden cardiac arrest, 1 from brain death and 4 from unknown causes. PRSE was previously resolved in 20 patients who died in the ICU. At one-year follow-up, there were 12 patients with good outcome and 58 with poor outcome and 8 lost of follow-up. On multivariate analysis, only vasopressor use was a predictor of poor outcome (OR 6.54; 95%CI 1.09-39.29; p = 0.04).
Poor outcome was observed in about 80% of this population of PRSE. Most patients died from systemic complications linked to their ICU stay. Some patients can recover satisfactorily over time though we did not identify any robust factor of good outcome.
[Show abstract][Hide abstract] ABSTRACT: Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock.
In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics.
We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81-0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66-0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89-1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00-1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27-8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78-0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00-1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day.
In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.
Intensive Care Medicine 03/2015; 41(5). DOI:10.1007/s00134-015-3730-4 · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rationale: Ethanol rapidly eradicated experimental biofilm. Clinical studies of ethanol lock to prevent catheter-related infections (CRIs) suggest preventive efficacy. No such studies have been done in intensive care units (ICU). Objectives: To determine whether ethanol lock decreases the risk of major CRI in patients with short-term dialysis catheters (DCs) Methods: A randomized, double-blind, placebo-controlled trial was performed in 16 ICUs in 7 university hospitals and 1 general hospital in France between June 2009 and December 2011. Adults with insertion of a nontunneled, nonantimicrobial-impregnated double-lumen DC for an expected duration greater than 48 hours, to perform renal replacement therapy (RRT) or plasma exchange (PE), were randomly allocated (1:1) to receive a 2-minute catheter lock with either 60% w/w ethanol solution (ethanol group) or 0.9% saline solution (control group), at the end of DC insertion and after each RRT or PE session. The main outcome was major CRI defined as either catheter-related clinical sepsis without bloodstream infection or catheter-related bloodstream infection (CRBSI), during the ICU stay. Measurements and Main Results: The intent-to-treat analysis included 1460 patients (2172 catheters, 12,944 catheter-days, and 8442 study locks). Median DC duration was 4 days (interquartile range [IQR], 2-8) and was similar in both groups. Major CRI incidence did not differ between the ethanol and control groups (3.83 vs 2.64/1000 catheter-days, respectively; HR, 1.55; 95% CI, 0.83-2.87; P=0.17). No significant differences occurred for catheter colonization (P=0.57) or CRBSI (P=0.99). Conclusions: A 2-minute ethanol lock does not decrease the frequency of infection of DCs in ICU patients.
American Journal of Respiratory and Critical Care Medicine 02/2015; 191(9). DOI:10.1164/rccm.201408-1431OC · 13.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Staff behaviours to optimise patient safety may be influenced by burnout, depression and strength of the safety culture. We evaluated whether burnout, symptoms of depression and safety culture affected the frequency of medical errors and adverse events (selected using Delphi techniques) in ICUs.
Prospective, observational, multicentre (31 ICUs) study from August 2009 to December 2011.
Burnout, depression symptoms and safety culture were evaluated using the Maslach Burnout Inventory (MBI), CES-Depression scale and Safety Attitudes Questionnaire, respectively. Of 1,988 staff members, 1,534 (77.2 %) participated. Frequencies of medical errors and adverse events were 804.5/1,000 and 167.4/1,000 patient-days, respectively. Burnout prevalence was 3 or 40 % depending on the definition (severe emotional exhaustion, depersonalisation and low personal accomplishment; or MBI score greater than -9). Depression symptoms were identified in 62/330 (18.8 %) physicians and 188/1,204 (15.6 %) nurses/nursing assistants. Median safety culture score was 60.7/100 [56.8-64.7] in physicians and 57.5/100 [52.4-61.9] in nurses/nursing assistants. Depression symptoms were an independent risk factor for medical errors. Burnout was not associated with medical errors. The safety culture score had a limited influence on medical errors. Other independent risk factors for medical errors or adverse events were related to ICU organisation (40 % of ICU staff off work on the previous day), staff (specific safety training) and patients (workload). One-on-one training of junior physicians during duties and existence of a hospital risk-management unit were associated with lower risks.
The frequency of selected medical errors in ICUs was high and was increased when staff members had symptoms of depression.
Intensive Care Medicine 01/2015; 41(2). DOI:10.1007/s00134-014-3601-4 · 7.21 Impact Factor