[Show abstract][Hide abstract] ABSTRACT: There is no consensus on optimal screening procedures for multidrug-resistant Enterobacteriaceae (MDRE) in intensive care units (ICUs). Therefore, we assessed five strategies for the detection of extended-spectrum beta-lactamase (ESBL) and high-level expressed AmpC cephalosporinase (HL-CASE) producers. During a 3-month period, a rectal screening swab sample was collected daily from every ICU patient, from the first 24 hours to the last day of ICU stay. Samples were plated on MDRE-selective media. Bacteria were identified using MALDI-TOF mass spectrometry and antibiograms were performed using disk diffusion. MDRE were isolated from 682/2348 (29.0%) screening samples collected from 93/269 (34.6%) patients. Incidences of patients with ESBL and HL-CASE-producers were 17.8 and 19.3 per 100 admissions, respectively. In 48/93 patients, MDRE carriage was intermittent. Compared to systematic screening at admission, systematic screening at discharge did not significantly increase the rate of MDRE detection among the 93 patients (62% versus 70%). In contrast, screening at admission and discharge, screening at admission and weekly thereafter, and screening at admission and weekly thereafter and at discharge significantly increased MDRE detection (77%, p=0.02; 76%, p=0.01; 86%, p<0.001, respectively). The difference in MDRE detection between these strategies relies essentially on the levels of detection of patients with HL-CASE-producers. The most reasonable strategy would be to collect two samples, one at admission and one at discharge, which would detect 87.5% of the ESBL-strains, 67.3% of the HL-CASE-strains and 77.4% of all MDRE-strains. This study should facilitate decision-making concerning the most suitable screening policy for MDRE detection in a given ICU setting.This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: Background: Patients aged >80 years represent a growing population admitted to intensive care units (ICUs). However, little is known about ICU-acquired infection (IAI) in this population, and the rate of invasive procedures is increasing. Aim: To evaluate the frequency and effects of IAI in elderly (>= 80 years) and younger patients. Methods: Retrospective evaluation of consecutive patients hospitalized for three days or more over a three-year period in an 18-bed ICU in an academic medical centre. Findings: Elderly patients represented 18.9% of the study population. At admission, the mean number of organ dysfunctions was similar in elderly and younger patients. The use of invasive procedures was also similar in elderly and younger patients, as follows: invasive mechanical ventilation for more than two days, 67.4% vs 55%; central venous catheterization, 56.9% vs 51.4%; and renal replacement therapy, 17.6% vs 17.8%, respectively. The frequency of IAI was 16.5% in elderly patients and 13.9% in younger patients (P = 0.28), with 20.5 vs 18.9 IAI episodes per 1000 ICU-days, respectively (P = 0.2). A Cox model identified central venous catheterization and invasive mechanical ventilation for more than two days as independent risk factors for IAI. The associations between IAI and prolonged ICU stay, increased nursing workload, and ICU and hospital mortality rates were similar in elderly and younger patients. Conclusions: The frequency of IAI was similar in elderly and younger patients, as were the associations between IAI and length of ICU stay, nursing workload and ICU mortality in an ICU with a high rate of invasive procedures.
[Show abstract][Hide abstract] ABSTRACT: Apoptosis is the most common pathway of neutrophil death under both physiological and inflammatory conditions. In this study, we describe an apoptotic pathway in human neutrophils that is triggered via the surface molecule CD24. In normal neutrophils, CD24 ligation induces death through depolarization of the mitochondrial membrane in a manner dependent on caspase-3 and caspase-9 and reactive oxygen species. Proinflammatory cytokines such as TNF-alpha, IFN-gamma, and GM-CSF upregulated the expression of CD24 in vitro, favoring the emergence of a new CD16high/CD24high subset of cultured neutrophils. We observed that CD24 expression (at both mRNA and protein levels) was significantly downregulated in neutrophils from sepsis patients but not from patients with systemic inflammatory response syndrome. This downregulation was reproduced by incubation of neutrophils from healthy controls with corticosteroids or with plasma collected from sepsis patients, but not with IL-10 or TGF-beta. Decreased CD24 expression observed on sepsis neutrophils was associated with lack of functionality of the molecule, because cross-ligation of CD24 failed to trigger apoptosis in neutrophils from sepsis patients. Our results suggest a novel aspect of CD24-mediated immunoregulation and represent, to our knowledge, the first report showing the role of CD24 in the delayed/defective cell death in sepsis.
The Journal of Immunology 03/2014; 5:5. DOI:10.4049/jimmunol.1301055 · 4.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to describe the features of a large cohort of patients with postoperative mediastinitis, with particular regard to Gram-negative bacteria (GNB), and assess their outcome. This bicentric retrospective cohort included all patients who were hospitalized in the Intensive Care Unit with mediastinitis after cardiac surgery during a 9-year period. Three hundred and nine patients developed a mediastinitis with a mean age of 65 years and a mean standard Euroscore of six points. Ninety-one patients (29.4%) developed a GNB mediastinitis (GNBm). Of the 364 pathogens involved, 103 GNB were identified. GNBm were more frequently polymicrobial (44% versus 3.2%; p <0.001). Being female was the sole independent risk factor of GNBm in multivariate analysis. Initial antimicrobial therapy was significantly more frequently inappropriate with GNBm compared with other microorganisms (24.6% versus 1.9%; p <0.001). Independent risk factors for inappropriateness of initial antimicrobial treatment were GNBm (OR = 8.58, 95%CI 2.53-29.02, p 0.0006), and polymicrobial mediastinitis (OR = 4.52, 95%CI 1.68-12.12, p 0.0028). GNBm were associated with more drainage failure, secondary infection, need for prolonged mechanical ventilation and/or use of vasopressors. Thirty-day hospital mortality was significantly higher with GNBm (31.9 % versus 17.0%; p 0.004). GNBm was identified as an independent risk factor of hospital mortality (OR = 2.31, 95%CI 1.16-4.61, p 0.0179).
[Show abstract][Hide abstract] ABSTRACT: Las mediastinitis consecutivas a cirugía cardíaca se definen por la presencia de pus o tejidos necróticos en el mediastino o el esternón o por la identificación de agentes patógenos en las muestras mediastínicas. La incidencia de esta afección posquirúrgica (1-1,5%) no se ha modificado desde hace unos 20 años. Los agentes patógenos causales más frecuentes son los estafilococos. Según las series, predominan Staphylococcus aureus (S. aureus) o los estafilococos coagulasa-negativos. La frecuencia de las cepas de S. aureus resistentes a la meticilina depende de la ecología de cada centro asistencial. Los principales factores de riesgo de mediastinitis son la diabetes, la obesidad, la enfermedad pulmonar obstructiva crónica (EPOC), la duración de la circulación extracorpórea, la cirugía de revascularización coronaria con arterias mamarias internas, la reintervención para hemostasia postoperatoria, la inestabilidad hemodinámica y la prolongación de la ventilación mecánica postoperatorias. El diagnóstico, que se sospecha por la presencia de signos locales (inflamación y dolor en la cicatriz) y sistémicos, debe confirmarse mediante el estudio bacteriológico de muestras mediastínicas obtenidas por punción retroesternal. El pronóstico de las mediastinitis es grave, con una mortalidad de alrededor del 20% y un aumento considerable del tiempo de hospitalización. El tratamiento consiste en la reintervención de urgencia, con un desbridamiento mediastínico y esternal minucioso. Pueden emplearse dos técnicas quirúrgicas. Las técnicas a tórax cerrado con drenaje aspirativo por drenes de redón deberían usarse en primer lugar. Las técnicas a tórax abierto, con cicatrización por presión negativa, se reservan para las formas muy graves desde el principio o tras el fracaso del tratamiento inicial. Antes de la cirugía se instaura un tratamiento antibiótico doble intravenoso. La duración total de la antibioticoterapia es de 6 semanas. Los programas de seguimiento así como los protocolos de prevención y tratamiento estandarizados de las mediastinitis permiten reducir la incidencia y mejorar el pronóstico.
[Show abstract][Hide abstract] ABSTRACT: Non invasive ventilation (NIV) has become a cornerstone therapy of acute respiratory failure and is thus increasingly used in Rationale: the intensive care unit (ICU). To date, few data are available on how caregivers, patients and their relative perceive NIV. We therefore designed a study with three distinct objectives: (1) to compare the perception of NIV use between physicians and nurses, (2) to compare the perception of NIV use among patients and their relatives, (3) to put in perspective these two sets of data. Prospective multicenter survey in 33 ICU in France and Belgium. Physicians and nurses answered to a 50 items Patients and methods: questionnaire describing their feeling and perception of NIV. During the same period, patients who received NIV during their ICU stay without being intubated (NIV success) and their relatives answered on discharge a 30-items questionnaire describing their feeling regarding NIV. Patients who did not understand French and who had delirium (CAM-ICU) were not included in the study. In questionnaires, each item was quantified from 1 (« not agree at all ») to 10 (« totally agree »). 751 nurses (29 [25-35] years old), 312 physicians (32 [28-40] years old), 396 patients (age 69 [60-80] years old, SAPS II 36 [28-42], Results : 57% male) et 145 relatives (age 59 [47-69] years old, 38 % male) were included. Compared with physicians, nurses perceived NIV as more binding and stressful (p<0.0001) and more time consuming (score 6 [4-7]). For a large majority of patients and their relatives, NIV was felt as an effective treatment (respectively 8 [6-10] and 9 [8-10], respectively), which they did not regret to have been treated with (score 1[1-3]). However, both patients and relatives described NIV as an aggressive (4[1-7]) and stressful treatment (4[1-7]), whose principles had been little explained (5[1-10]). Although both nurses, physicians perceived NIV as an efficient therapy, nurses who are closer to the patients than physicians Conclusions: during NIV sessions have a more negative perception of the tolerance and burden of care of NIV. In addition, patients who succeeded NIV and their relatives considered NIV as an effective treatment for the price of discomfort and significant trauma and complained of a lack of information on NIV. The impact of this negative perception and lack of information on care-giving and long-term psychological consequences remains to be determined. This abstract is funded by: None Am J Respir Crit Care Med 187;2013:A3092 Internet address: www.atsjournals.org Online Abstracts Issue
[Show abstract][Hide abstract] ABSTRACT: Background:
Growth-arrest-specific protein 6 (GAS6) is a vitamin K-dependent protein expressed by endothelial cells and leukocytes participating in cell survival, migration and proliferation and involved in many pathological situations. The aim of our study was to assess its implication in ARDS and its variation according to PEEP setting, considering that different cyclic stresses could alter GAS6 plasma levels.
Our subjects were enrolled in the ExPress study comparing a minimal alveolar distention (low-PEEP) ventilatory strategy to a maximal alveolar recruitment (high-PEEP) strategy in ARDS. Plasma GAS6, interleukin-8 (IL-8), and vascular endothelial growth factor (VEGF) levels were measured at day 0 and day 3 by enzyme-linked immunosorbent assay in blood samples prospectively collected during the study for a subset of 52 subjects included in 8 centers during year 2005.
We found that GAS6 plasma level was elevated in the whole population at day 0: median 106 ng/mL IQR 77-139 ng/mL, with significant correlations with IL-8, the Simplified Acute Physiology Score II and the Organ Dysfunction and Infection scores. Statistically significant decreases in GAS6 and IL-8 plasma levels were observed between day 0 and day 3 in the high-PEEP group (P = .02); while there were no differences between day 0 and day 3 in the low-PEEP group.
GAS6 plasma level is elevated in ARDS patients. The high-PEEP strategy is associated with a decrease in GAS6 and IL-8 plasma levels at day 3, without significant differences in day 28 mortality between the 2 groups. (Clinicaltrials.gov NCT00188058).
Respiratory care 04/2013; 58(11). DOI:10.4187/respcare.02129 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Noninvasive ventilation (NIV) is a very effective technique for severe acute exacerbations of COPD/COLD and acute pulmonary edema, but its interest is still a matter of debate for severe asthma attacks. However, despite a slow decrease in asthma mortality, which actually mainly concerns older people, the prevalence of asthma is still raising and is associated to a high level of emergency visits and ICU hospitalizations for severe asthma attacks. Unfortunately, the level of knowledge on this topic is based only on observational studies and on 4 small RCTs, likely to be underpowered to demonstrate any benefit on the rate of tracheal intubation or on mortality. Nevertheless, some benefits have been shown with regard to functional improvement and length of hospital stay. From a technical point of view, one can expect in the future some improvements by combining NIV and nebulization and/or helium-oxygen therapy. Finally, there is a need for positive large randomized clinical trials before routine clinical use can be firmly recommended.
[Show abstract][Hide abstract] ABSTRACT: Ventricular assist devices (VADs) have become an established therapeutic option for patients with end-stage heart failure. The appearance of heart failure in VAD patients seems unexpected. Nevertheless, this phenomenon is not rare. We report six cases of VAD patients with clinical presentation of heart failure at different times after implantation and describe the mechanisms involved. The aetiology of this heart failure, like its clinical presentation, varies and has yet to be identified. (C) 2012 Published by Elsevier Masson SAS.
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Noninvasive ventilation (NIV) is a treatment option in patients with acute respiratory failure who are good candidates for intensive care but have declined tracheal intubation. The aim of our study was to report outcomes after NIV in patients with a do-not-intubate (DNI) order.
Prospective observational cohort study in all patients who received NIV for acute respiratory failure in 54 ICUs in France and Belgium, in 2010/2011.
Goals of care, comfort, and vital status were assessed daily. On day 90, a telephone interview with patients and relatives recorded health-related quality of life (HRQOL), posttraumatic stress disorder-related symptoms, and symptoms of anxiety and depression. Post-ICU burden was compared between DNI patients and patients receiving NIV with no treatment-limitation decisions (TLD). Of 780 NIV patients, 574 received NIV with no TLD, and 134 had DNI orders. Hospital mortality was 44 % in DNI patients and 12 % in the no-TLD group. Mortality in the DNI group was lowest in COPD patients compared to other patients in the DNI group (34 vs. 51 %, P = 0.01). In the DNI group, HRQOL showed no significant decline on day 90 compared to baseline; day-90 data of patients and relatives did not differ from those in the no-TLD group.
Do-not-intubate status was present among one-fifth of ICU patients who received NIV. DNI patients who were alive on day 90 experienced no decrease in HRQOL compared to baseline. The prevalences of anxiety, depression, and PTSD-related symptoms in these patients and their relatives were similar to those seen after NIV was used as part of full-code management (clinicaltrial.govNCT01449331).
Intensive Care Medicine 11/2012; 39(2). DOI:10.1007/s00134-012-2746-2 · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Drowning following a fall from a bridge can lead to cardiac arrest caused by hypoxia, hypothermia, or severe traumatic injury. Every year patients are brought to our hospital who have nearly drowned in the local river after a jump from a bridge (approximate height 16-22 meters). We report traumatic injuries in patients admitted to our hospital for out-of-hospital cardiac arrest due to drowning.
We retrospectively reviewed the charts of all patients admitted to the intensive care units of our hospital for out-of-hospital cardiac arrest due to drowning after a jump from a bridge in the Seine River between 2002 and 2010. All clinical or radiologic evidence of trauma was recorded.
A total of 37 patients where admitted to our hospital for out-of-hospital cardiac arrest due to drowning. Fourteen patients had radiologic examinations. Five of these examinations showed evidence of severe trauma. In one case, clinical examination showed evidence of severe peripheral neurologic trauma. Seven of these patients (19%) were discharged from the hospital alive.
Patients found nearly drowned in a river spanned by a medium-height bridge should undergo spinal immobilization and complete radiologic examination as soon as possible.
Prehospital Emergency Care 04/2012; 16(3):356-60. DOI:10.3109/10903127.2012.670691 · 1.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate hemodynamic and functional changes of the failed left ventricle by Velocity Vector Imaging (VVI) and tissue Doppler, 22 patients with cardiogenic shock supported by extracorporeal life support (ECLS) were imaged during ECLS output variations inducing severe load manipulations.
The following data were acquired: (1) mean arterial pressure, aortic Doppler velocity-time integral, left ventricular end-diastolic volume, and mitral Doppler E wave; (2) tissue Doppler systolic (Sa) and early diastolic (Ea) velocities; and (3) systolic peak velocity (Sv), strain, and strain rate using VVI.
Load variations were documented by a significant decrease in afterload (mean arterial pressure, -21%), an increase in preload (left ventricular end-diastolic volume, +12%; E, +46%; E/Ea ratio, +22%), and an increase in the velocity-time integral (+45%). VVI parameters increased (Sv, +36%; strain, +81%; and strain rate, +67%; P < .05), unlike tissue Doppler systolic velocities (+2%; P = NS). Whatever the ECLS flow, Sa was higher in patients who survived.
VVI parameters are not useful in characterizing the failed left ventricle with rapidly varying load conditions. Tissue Doppler systolic velocities appear to be load independent and thus could help in the management of ECLS patients.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 03/2012; 25(6):632-40. DOI:10.1016/j.echo.2012.02.009 · 4.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pneumonia is the most common infectious complication of drowning. Pneumonia is potentially life threatening and should be treated by effective antibiotic therapy. However the risk factors, microbiological causes, diagnostic approach and appropriate therapy for pneumonia associated with drowning are not well described. The microbiological ecology of the body of water where immersion occurred could be of import. The aim of this study was to report on microorganisms involved in pneumonia associated with drowning and out of hospital cardiac arrest after successful cardiopulmonary resuscitation. Additionally, we retrieved and undertook microbiological analysis on samples of water from our local river.
This retrospective study included all patients having suffered an out of hospital cardiac arrest due to drowning and admitted to our tertiary care academic hospital between 2002 and 2010. Data concerning bacteriological lung samples (tracheal aspirate or bronchoalveolar lavage) at admission were reported and compared to bacteriological samples obtained from our local river (the river Seine).
A total of thirty-seven patients were included in the study. Lung samples were obtained for twenty-one of these patients. Lung samples were positive in nineteen cases, with a high frequency of multi-drug resistant bacteria. Samples from the Seine River found microorganisms similar to those found in drowning associated pneumonia.
Drowning associated pneumonia can be due to multi drug resistant bacteria. When treating drowning associated pneumonia, antibiotics should be effective against bacteria similar to those found in the body of water where immersion occurred.