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C Bourigault,
V Nael,
E Garnier,
M Coste-Burel,
S Chevaliez, D Villers,
H Abbey,
A Haloun,
J-M Pawlotsky,
H Sénéchal,
J-M Thiolet,
D Lepelletier
The Journal of hospital infection 07/2011; 79(2):175-7. · 3.01 Impact Factor
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ABSTRACT: Survival rates vary significantly between intensive care units, most notably in patients requiring mechanical ventilation (MV). The present study sought to estimate the effect of hospital MV volume on hospital mortality. We included 179,197 consecutive patients who received mechanical ventilation in 294 hospitals. Multivariate logistic regression models with random intercepts were used to estimate the effect of annual MV volume in each hospital, adjusting for differences in severity of illness and case mix. Median annual MV volume was 162 patients (interquartile range 99-282). Hospital mortality in MV patients was 31.4% overall, 40.8% in the lowest annual volume quartile and 28.2% in the highest quartile. After adjustment for severity of illness, age, diagnosis and organ failure, higher MV volume was associated with significantly lower hospital mortality among MV patients (OR 0.9985 per 10 additional patients, 95% CI 0.9978-0.9992; p = 0.0001). A significant centre effect on hospital mortality persisted after adjustment for volume effect (p < 0.0001). Our study demonstrated higher hospital MV volume to be independently associated with increased survival among MV patients. Significant differences in outcomes persisted between centres after adjustment for hospital MV volume, supporting a role for other significant determinants of the centre effect.
European Respiratory Journal 02/2011; 37(2):364-70. · 5.89 Impact Factor
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ABSTRACT: Peripheral blood stem cell transplantation is a frequent option, especially for patients with hematological malignancies.
A first patient received this treatment for acute myeloblastic leukemia, the second for Richter's syndrome (follicular lymphoma). In both cases, allograft (unrelated donor, non myeloablative conditioning) was followed by graft versus host disease (GVH) requiring an immunosuppressive treatment. Respectively 15 and three months after graft, these two patients presented with multiple organ failure including very severe hepatic dysfunction. The diagnosis was made according to positive blood PCR, positive BAL, and hepatic histological findings.
Adenoviruses, frequent in pediatrics, can be responsible for extremely severe infections among immunocompromised adults. T lymphocyte depletion plays a key role.
Adenoviral infections can be fatal among immunocompromised patients. Diagnostic improvement should lead to early treatment, which however, remains to be clearly defined.
Médecine et Maladies Infectieuses 08/2009; 40(5):296-8. · 0.72 Impact Factor
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ABSTRACT: High dose steroids and intravenous immunoglobulins are the gold treatment of acute immune thrombocytopenic purpura, before splenectomy for severe and refractory forms of the disease. Authors report two cases of severe acute refractory immune thombocytopenia with a dramatic response to plasma exchanges.
The first case was an idiopathic form, complicated by hemorragic peritoneal effusion. After failure of steroids, intravenous immunoglobulins and splenectomy and 2 courses of rituximab, plasmapheresis normalized in 3 days platelet count. In the second observation, ITP was associated to systemic lupus with antiphospholipids antibodies and multivisceral failure, despite steroids and intravenous immunoglobulins. After 3 plasma exchanges, platelet count was normalized, and the patient is under remission after 24 months follow-up.
Plasmapheresis must be evaluated as an emergency treatment in refractory forms of acute immune thrombocytopenic purpura.
La Revue de Médecine Interne 11/2005; 26(10):824-6. · 0.61 Impact Factor
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ABSTRACT: Methicillin resistance and infections caused by methicillin-resistant Staphylococcus aureus represent a growing problem and a challenge for health-care institutions. We evaluated risk factors, morbidity and cost of infections caused by methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) Staphylococcus aureus.
We performed an un-matched case-control study in an 20-bed medical intensive care unit from 1994-2001 at Nantes teaching hospital, France. All patients with pneumonia, bacteraemia and urinary MRSA (cases) or MSSA (controls) nosocomial infections were included in the study.
Twenty four patients with MRSA infection were compared to 64 patients with MSSA infections. Patients with MRSA infection were older (56 vs. 45 years, P < 0.01), had longer length of stay (47 vs. 35 days, P < 0.05) and were infected later (22 vs. 10 days, P < 0.00001) than patients with MSSA infection. No difference was observed between the two groups according to the Omega index, acute simplify index and mortality. MRSA infections involved extra cost due to antimicrobial treatment (184 vs. 72 Euros, P < 0.005) and length of stay (37,278 vs. 27,755 Euros, P < 0.05).
Patient infected by MRSA seems to be different from patient infected by MSSA but without consequence on Omega index and mortality. But methicillin-resistance involves extra cost due to antimicrobial treatment and length of stay.
Pathologie Biologie 10/2004; 52(8):474-9. · 1.53 Impact Factor
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ABSTRACT: Hospital units report on their inpatient care activity by writing yearly activity reports, which are used by their Medical Information Department (MID) to develop standardized summaries for communication to healthcare authorities. The data are categorized by uniform patient groups and used to describe inpatient care activity and to guide resource allocation. The objective of this study was to evaluate the completeness of activity reports from intensive care units (ICUs) in France.
Activity reports sent in 1998 and 1999 by French ICUs participating in the study were collected using dedicated abstracting software supplied to the relevant MIDs. Completeness of data in the activity reports was evaluated, with special attention to the SAPSII score, Omega rating of ICU procedures according to the Classification of Medical Procedures, and primary and secondary diagnoses.
The 106 ICUs that volunteered for the study reported data on 107,652-hospital stays. Mean age and SAPSII were 55 +/- 21 years and 35 +/- 21 years, respectively. Mean ICU and hospital lengths of stay were 6.2 +/- 12.4 and 16.1 +/- 21.6 days, respectively. Mean ICU and hospital mortality rates were 15% and 19%. The SAPSII and Omega procedures were reported for 81% and 80% of stays, respectively. The SAPSII and Omega procedures were calculated or coded in 94% (100/106) and 96% (102/106) of ICUs, respectively. Mean number of Omega procedures was 4.3+/-3.9. However, only 5% (5/106) of ICUs entered the SAPSII for every stay, and 21% (22/106) of ICUs failed to enter the SAPSII for over 20% of stays. Similarly, 53% (56/106) of ICUs rated no more than five Omega procedures on average per stay. The primary diagnosis was reported for all stays, and the mean number of secondary diagnoses was 3.5 +/- 3.8. In 80% (86/106) of ICUs, no more than five secondary diagnoses were coded on average per stay.
The analysis of this national database shows that data communicated to the MIDs and therefore to the healthcare authorities, are incomplete regarding SAPSII, ICU procedures, treatment intensity, and diagnoses. This may lead to the underestimation of ICU activity and resource needs, particularly if the SAPSII and selected procedures identified as markers for high-intensity critical care are used in the future.
Annales Françaises d Anesthésie et de Réanimation 03/2004; 23(1):15-20. · 0.84 Impact Factor
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ABSTRACT: The aim of this study was to assess renal and respiratory tolerance of aerosolized tobramycin in intubated and mechanically ventilated patients with nosocomial pneumonia.
This was a multicenter, randomized, double-blind, placebo controlled study. Thirty-eight mechanically ventilated patients with documented nosocomial pneumonia were included. Patients treated with intravenous betalactam and tobramycin were randomly allocated to receive aerosolized tobramycin (6 mg/kg/day, n = 21) or placebo (n = 17). The aerosol was administered via a pneumatic nebulizer once a day for 5 days.
Respiratory tolerance was good in all but two patients. No acute renal failure occurred. By day 10, 7 patients in the tobramycin group (35%) had been extubated versus 3 in the placebo group (18.5%, p = 0.18). By day 28, 6 patients had died (2 in the tobramycin group and 4 in the placebo group, p = 0.23).
Aerosolized tobramycin was well tolerated in ventilated patients with documented nosocomial pneumonia.
La Presse Médicale 02/2000; 29(2):76-8. · 0.67 Impact Factor
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ABSTRACT: To assess the incidence and to evaluate the feasibility of inter-unit continuous surveillance of intensive care unit (ICU)-acquired infections.
Prospective multicentre, longitudinal, incidence survey.
Five ICUs in university hospitals in western France.
All patients admitted to the ICU during two 3-month periods (1994-1995).
The main clinical characteristics of the patients, ICU-acquired infections, length of exposure to invasive devices and the micro-organisms isolated were analysed. The study included 1589 patients (16970 patient-days) and the infection rate was 21.6 % (13.1 % of patients). The ventilator-associated pneumonia rate was 9.6 %, sinusitis 1.5 %, central venous catheter-associated infection 3.5 %, central venous catheter-associated bacteraemia 4.8 %, catheter-associated urinary tract infection 7.8 % and bacteraemia 4.5 %. The incidence density rate of ICU-acquired infections was 20.3% patient-days. Ventilator-associated pneumonia and sinusitis rates were 9.4 and 1.5% ventilation-days, respectively. Central venous catheter-associated infection and central venous catheter-associated bacteraemia rates were 2.8 and 3.8% catheter-days, respectively. The catheter-associated urinary tract infection rate was 8.5% urinary catheter-days and the bacteraemia rate 4.2% patient-days. Six independent risk factors for ICU-acquired infection were found by stepwise logistic regression analysis: absence of infection on admission, age > 60 years, length of stay, mechanical ventilation, central venous catheter and admission to one particular unit. A total of 410 strains of micro-organisms were isolated, 16.8 % of which were Staphylococcus aureus (58.0% methicillin-resistant).
This prospective study using standardised collection of data on the ICU-acquired infection rate in five ICUs identified six risk factors. It also emphasized the difficulty of achieving truly standardised definitions and methods of diagnosis of such infections.
Intensive Care Medicine 10/1998; 24(10):1040-6. · 5.40 Impact Factor
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ABSTRACT: Acinetobacter baumannii is an important opportunistic pathogen that is rapidly evolving toward multidrug resistance and is involved in various nosocomial infections that are often severe. It is difficult to prevent A. baumannii infection because A. baumannii is ubiquitous and the epidemiology of the infections it causes is complex.
To study the epidemiology of A. baumannii infections and assess the relation between fluoroquinolone use and the persistence of multidrug-resistant clones.
Three case-control studies and a retrospective cohort study.
A 20-bed medical and surgical intensive care unit.
Acinetobacter baumannii was isolated from 45 patients in urine (31%), the lower respiratory tract (26.7%), wounds (17.8%), blood (11.1%), skin (6.7%), cerebrospinal fluid (4.4%), and sinus specimens (2.2%). One death was due to A. baumannii infection.
Antimicrobial resistance pattern and molecular typing were used to characterize isolates. The incidence of A. baumannii infection and the use of fluoroquinolones were calculated annually.
Initially, 28 patients developed A. baumannii infection. Eleven isolates had the same antimicrobial susceptibility profile, genotypic profile, or both (epidemic cases), and 17 were heterogeneous (endemic cases). A surgical procedure done in an emergency operating room was the main risk factor for epidemic cases, whereas previous receipt of a fluoroquinolone was the only risk factor for endemic cases. The opening of a new operating room combined with the restriction of fluoroquinolone use contributed to a transitory reduction in the incidence of infection. When a third epidemiologic study was done, previous receipt of a fluoroquinolone was again an independent risk factor and a parallel was seen between the amount of intravenous fluoroquinolones prescribed and the incidence of endemic infection.
Epidemic infections coexisted with endemic infections favored by the selection pressure of intravenous fluoroquinolones.
Annals of internal medicine 09/1998; 129(3):182-9. · 16.73 Impact Factor
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ABSTRACT: The purpose of this study was to determine the utility of spiral CT in the diagnosis of brain death.
Spiral CT was evaluated prospectively in 14 brain-dead patients and in 11 healthy subjects. A two-phase protocol was used. Twenty seconds after intravenous injection of a nonionic iodinized contrast medium, the CT table was drawn through the gantry at a rate of 10 mm/s while scanning was in progress. The second scanning phase was started automatically a mean of 54 seconds later, using the same parameters. Opacification or absence of opacification of carotid, vertebral, and basilar arteries and intracerebral veins was ascertained for each image in both phases. The diagnosis of brain death was confirmed by elecroencephalography (n = 7), angiography (n = 5), or both (n = 2). Statistical analysis with the Fisher exact test enabled us to compare the brain-dead patients with the healthy control subjects.
In brain death, the pericallosal and terminal arteries of the cortex did not opacify during the two phases of spiral CT, whereas the superficial temporal arteries were always visible. The internal cerebral veins, the great cerebral vein, and the straight sinus did not opacify, whereas the superior ophthalmic veins were visible on both sides 13 times. For each vessel type, specificity was 100% for nonvascular opacification criteria on the right and left sides.
Two-phase spiral CT can demonstrate the absence of intracerebral blood flow in brain death.
American Journal of Neuroradiology 05/1998; 19(4):641-7. · 2.93 Impact Factor
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ABSTRACT: Animal study results have suggested a role in sepsis for human interleukin for DA1.a cells/leukemia inhibitory factor (HILDA/LIF). HILDA/LIF and interleukin-6 (IL-6) levels were prospectively studied by serial ELISAs in 34 septic patients. HILDA/LIF was detected in 11 of 34 patients at plasma levels of 100-37,000 pg/mL. Peak HILDA/LIF levels correlated with increased temperature and creatinine and IL-6 and with decreased arterial CO2 (P < .05). Multivariate analysis showed that shock and decreased arterial CO2 accounted for 75% of peak HILDA/LIF plasma variations (R2 = .753). Fatal outcome was most often associated with detectable HILDA/LIF (> 56 pg/mL) and peak IL-6 plasma levels > 850 pg/mL (sensitivity, 83%; specificity, 87%), but both (at respective levels of > 480 and > 850 pg/mL) were associated with fatal outcome. HILDA/LIF was detected in septic patients exhibiting shock, and its levels correlated with higher mortality and shorter survival.
The Journal of Infectious Diseases 02/1995; 171(1):232-6. · 6.41 Impact Factor
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ABSTRACT: The precise diagnosis of lower respiratory tract infection in the critically ill newborn remains a difficult challenge. The bronchoscopic protected specimen brush (PSB) is a reliable method in intubated adults. Because the bronchoscopic procedure is not generally available for young children, Zucker proposed a blind technique for introducing the PSB into the distal airways. His results were promising but were not compared with any bacteriologic reference method. Therefore, we wanted to evaluate this technique in comparison with the open lung biopsy (OLB) when it could be ethically accomplished. Eleven PSB were collected simultaneously with an OLB. The sensitivity of the PSB procedure was 100%, its specificity 88%, its positive predictive value 66%, and its negative predictive value 100%. There were no complications secondary to the PSB procedure. In this short study, the PSB procedure using a blind technique is safe and feasible to obtain uncontaminated specimens in intubated and ventilated newborns, and is largely accurate in identifying the bacterial etiologic agent of lower respiratory tract infection.
Pediatric Pulmonology 02/1990; 8(4):268-72. · 2.53 Impact Factor
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ABSTRACT: A prospective study was carried out in a medical and surgical ICU to determine the incidence of nosocomial urinary tract infection (NUTI) and to identify the most important risk factors. Over a 6 month period, 180 patients were included. All had an indwelling catheter. Six risk factors were studied: age, sex, illness (medical, surgical, trauma), hospital or extra-hospital origin, simplified acute physiology score and length of bladder catheterization. Forty three patients developed a NUTI. Length of bladder catheterization was the only significant different risk factor in infected and non-infected patients. Kaplan Meir analysis was used to determine time to development of NUTI. The risk rose from 19% for 5 day long catheterization to 50% for 14 day long catheterization.
Agressologie: revue internationale de physio-biologie et de pharmacologie appliquées aux effets de l'agression 02/1990; 31(8 Spec No):503-4.
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Critical Care Medicine 03/1987; 15(2):173-4. · 6.33 Impact Factor
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ABSTRACT: The influence of patients' age on survival, level of therapy and length of stay was analyzed from data collected in 792 consecutive admissions to eight intensive care units. Mortality rate increased progressively with age; over 65 years of age, it was more than double that of patients under 45 years (36.8% versus 14.8%). However, mortality rate in patients over 75 years was equal to that observed in the 55 to 59 years group. There was a significant relationship between age and acute physiology score (APS) and the influence of age upon outcome decreased when APS increased. The number of TISS (therapeutic intervention scoring system) points delivered to patients increased slightly but significantly with age (r = 0.14). Standard care was responsible for the main part of this increase. Both in survivors and in non-survivors the length of stay was not different comparing the stay of the oldest patient with that of the younger age groups. We conclude that, in ICU patients, age is an important factor of prognosis but not as important as the severity of illness, and that there is no major difference in outcome of patients over 65 years of age compared to the entire study group of ICU patients.
Intensive Care Medicine 02/1987; 13(1):9-13. · 5.40 Impact Factor
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ABSTRACT: The reliability of a bronchoscopic protected catheter brush (BPCB) in the diagnosis of lower respiratory tract infection was studied in 17 intubated and ventilated patients, including seven patients free from such infection (group 1) and ten patients with suspected infection (group 2). A first sample was obtained in the lower trachea by aspiration through the fiberoptic bronchoscope and a second in a distal bronchus by the BPCB procedure. In group 1, all BPCB cultures were sterile, although lower tracheal cultures yielded two or more bacterial species, showing that uncontaminated specimens can be obtained by the BPCB procedure. In three patients of group 2, BPCB cultures remained sterile as a nonbacterial pulmonary disease was certified by open lung biopsy. In seven patients from group 2, BPCB cultures yielded all of the organisms isolated simultaneously by reference methods (ie, cultures of blood or pleural fluid, serologic tests, and open lung biopsy). In two of these patients, contamination of the BPCB specimens was ascertained by the reference method bacterial results. In this study the BPCB procedure was able to obtain uncontaminated specimens in intubated and ventilated patients and was mainly accurate in identifying the bacterial etiologic agents of lower respiratory tract infections.
Chest 11/1985; 88(4):527-30. · 5.25 Impact Factor
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ABSTRACT: We used 14 easily measured biologic and clinical variables to develop a simple scoring system reflecting the risk of death in ICU patients. The simplified acute physiology score (SAPS) was evaluated in 679 consecutive patients admitted to eight multidisciplinary referral ICUs in France. Surgery accounted for 40% of admissions. Data were collected during the first 24 h after ICU admission. SAPS correctly classified patients in groups of increasing probability of death, irrespective of diagnosis, and compared favorably with the acute physiology score (APS), a more complex scoring system which has also been applied to ICU patients. SAPS was a simpler and less time-consuming method for comparative studies and management evaluation between different ICUs.
Critical Care Medicine 12/1984; 12(11):975-7. · 6.33 Impact Factor
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Annales de l'anesthésiologie française 02/1980; 21(3):237-9.
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ABSTRACT: 238 cases of chest trauma were studied according to the same protocol. With this protocol we can perform on the one hand a comprehensive study of the prognosis according to the thoracic lesions and associated lesions and on the other hand a prognostic study according to the delay of admission in a intensive care unit. All our data show that the most serious lesion is the pulmonary contusion and that mortality increases if an associated lesion is present, according to its nature. On the other hand a comparison was performed between the patients directly admitted in the intensive care unit (GI) and the patients hospitalized after a delay (GII) this comparison shows that in G II patients the rate of complications was higher, the mortality more important and respiratory sequelae more frequent than for patients of GI with thoracic lesions of the same importance or less important. These data show that an early admission of chest trauma patients in an intensive care unit is desirable and that the duration of this hospitalization must be at least 3 or 6 days.
La semaine des hôpitaux : organe fondé par l'Association d'enseignement médical des hôpitaux de Paris. 56(21-24):1060-6.
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ABSTRACT: The Standard Mortality Ratio (SMR), comparing the observed in-hospital mortality to the predicted, may measure the intensive care units (ICU) performance.
Multicentric retrospective national study.
A probability model using a severity score such SAPS II calculated the predicted mortality rate. A national French study has been undertaken to compare the SMR of ICUs and looked for explanation.
One hundred six units, 34 were medical (32%), 18 surgical (17%) and 57 medical/surgical (51%) participated to the study. Forty-six ICUs (43%) were located in teaching hospitals. The SMR of the 87,099 stays was 0.84 (0.82-0.85). The SMR of ICUs varied from 0.41 to 1.55. Ten units had a SMR>0.85, which suggested a low performance. They had more stays for cardiovascular failures, as compared with others. The best units (SMR<0.82) had more stays for drug overdose. The SMR increased with the number of organ failures, from 0.47 with zero failure to 1.11 with 4 or more organ failures. The stays with cardiovascular failure, either unique or associated, had a higher SMR. The 7935 stays with a drug overdose had a SMR of 0.12 (0.10-0.14), which suggested a bad calibration of the model in theses cases.
The case mix must be taken in account when comparing the ICUs performance by the mean of SMR, particularly when the units admitted a lot of drug overdoses.
Annales francaises d'anesthesie et de reanimation 25(11-12):1111-8. · 0.77 Impact Factor
