Evaluation of current practices in surgical antimicrobial prophylaxis before and after implementation of local guidelines

The aim of antibiotic prophylaxis (ABP) is to prevent or at least decrease the incidence of postoperative surgical wound infections. In 1992 and 1995, ABP was the subject of two French consensus conferences. Following these conferences, the local Antibiotics Committee of Hopital Saint-Louis has undertaken a study to evaluate and eventually improve the current practices of ABP. This study was carried out in three steps: a first survey of ABP, the writing of local ABP guidelines and a second survey of ABP after the implementation of these recommendations. Concerning all surgical wards, the first survey found 69% (N = 100/145) of ABP practice is to be inappropriate vs. 18% (N = 25/139) in the second survey. Indications, choice of drugs, selection of dosage, administration timing and treatment duration were significantly improved in the second survey. Writing and implementing local recommendations promoted a more rational use of ABP. In addition, this study allowed Saint-Louis Hospital to set up recommendations for plastic surgery; such recommendations are poorly described in the literature.

Effectiveness of platelet transfusions after plasma exchange in adult thrombotic thrombocytopenic purpura: a report of two cases

Plasma infusion (PI) and plasma exchange (PE) are the most efficient treatment of thrombotic thrombocytopenic purpura (TTP), allowing achievement of complete remission in 60 to 90% of cases. Life-threatening bleeding, related to severe thrombocytopenia, is one of the main complications of the disease. Thrombocytopenia may also preclude invasive procedures such as splenectomy, which may be required during the management of TTP. Platelet concentrates transfusions are usually thought to worsen the disease, especially if not associated with the appropriate treatment of this latter, and thus should be avoided. We report hereon 2 patients with TTP who experienced a surgical procedure i.e., a cholecystectomy for a cholecystitis, and a splenectomy for a refractory TTP. In both patients, the surgical procedure was preceded by a 60 mL/kg plasma exchange with solvent/detergent treated plasma as replacement fluid, followed by platelet transfusion, with a corrected count increment of 57.1% (Patient 1) and 69.3% (Patient 2). Using this sequential treatment, the patients did not experience any deterioration of their status. Both patients had a favorable outcome after surgery. However, until such a procedure will be validated on a larger series of patients, it should be restricted to patients presenting with a refractory life-threatening thrombocytopenia and/or requiring surgery or any kind of invasive procedure. Am. J. Hematol. 68:198-201, 2001. Published 2001 Wiley-Liss, Inc.

Severity of illness scores: are they useful in febrile neutropenic adult patients in hematology wards? A prospective multicenter study

OBJECTIVE

To assess the prognostic value of two severity of illness scores, commonly used for critically ill patients, Simplified Acute Physiology Score (SAPS II) and Organ Dysfunctions and Infection (ODIN), in predicting mortality in febrile neutropenic patients in hematology wards.

DESIGN

A 2-month prospective multicenter study.

SETTING

Thirty-six hematologic and/or stem cell transplant units in France.

PATIENTS

All adult patients with a first febrile neutropenic episode (polymorphonuclear cells <500/mm(3)) were included.

INTERVENTIONS

SAPS II was calculated on day 1 of fever, and ODIN on days 1 and 8. The end point was the mortality rate on day 28.

MEASUREMENTS AND MAIN RESULTS

Twenty-eight (6.6%) of the 421 patients included died before day 28. The mortality rate predicted by SAPS II was 23.8%, indicating a poor calibration. The SAPS II score at day 1 was greater in nonsurvivors than in survivors (44 +/- 11 vs. 38 +/- 7, p <.0001), as was the number of patients with one or more organ failures at day 1 (14 vs. 2%, p <.0001), and day 8 (42 vs. 3%, p <.0001). The pattern of change in the scores over the first 8 days differed significantly between survivors and nonsurvivors. In multivariate analysis, only ODIN on day 1 and day 8, and spontaneous neutropenia were independent predictors for death.

CONCLUSIONS

SAPS II and ODIN scores are inaccurate for predicting individual outcome of febrile neutropenic patients in hematology wards. Serial measurements of these scores during the first week of hospitalization could be more accurate than a single measurement. Besides severity scores and organ failures, the type of neutropenia is at least as important in assessing the prognosis.

Compliance with triage to intensive care recommendations

DESIGN

Recommendations for triage to intensive care units (ICUs) have been issued but not evaluated.

SETTING

In this prospective, multicenter study, all patients granted or refused admission to 26 ICUs affiliated with the French Society for Critical Care were included during a 1-month period. Characteristics of participating ICUs and patients, circumstances of triage, and description of the triage decision with particular attention to compliance with published recommendations were recorded.

RESULTS

During the study period, 1,009 patients were and 283 were not admitted to the participating ICUs. Refused patients were more likely to be older than 65 yrs (odds ratio [OR], 3.53; confidence interval [CI], 1.98-5.32) and to have a poor chronic health status (OR, 3.09; CI, 2.05-4.67). An admission diagnosis of acute respiratory or renal failure, shock, or coma was associated with admission, whereas chronic severe respiratory and heart failure or metastatic disease without hope of remission were associated with refusal (OR, 2.24; CI, 1.38-3.64). Only four (range, 0-8) of the 20 recommendations for triage to ICU were observed; a full unit and triage over the phone were associated with significantly poorer compliance with recommendations (0 [0-2] vs. 6 [2-9], p =.0003; and 1 [0-6] vs. 6 [1-9], p <.0001; respectively).

CONCLUSION

Recommendations for triage to intensive care are rarely observed, particularly when the unit is full or triage is done over the phone. These recommendations may need to be redesigned to improve their practicability under real-life conditions, with special attention to phone triage and triaging to a full unit.

Delayed treatment contributes to mortality in ICU patients with severe active pulmonary tuberculosis and acute respiratory failure

OBJECTIVES

To clarify the patterns of pulmonary tuberculosis (TB) that should result in a high index of suspicion, to increase the chances of early therapy and to identify predictors of 30-day mortality.

PATIENTS AND METHODS

Retrospective, 7-year study in two medical intensive care units (ICUs). All patients admitted with pulmonary TB were enrolled. Clinical and laboratory data at admission and events within 48 h of admission were collected. Predictors of 30-day mortality were identified by univariate and multivariate analysis.

RESULTS

The study included 99 patients with a median age of 41 years. Immunodeficiency was present in 60 patients, including 38 with AIDS. Fifty-nine patients had pulmonary TB alone, 22 also had extrapulmonary TB and 18 had miliary. All 99 patients were admitted for acute respiratory failure, some also with shock (20), neurologic disorders (18) or acute renal failure (10). Mechanical ventilation was needed in 50 patients; 22 patients met criteria for acute respiratory distress syndrome (ARDS). The 30-day mortality rate was 26.2%. Four factors independently predicted mortality: a time from symptom onset to treatment of more than 1 month (OR, 3.49; CI, 1.20-10.20), the number of organ failures (OR, 3.15; CI, 1.76-5.76), a serum albumin level above 20 g/l (OR, 3.96; CI, 1.04-15.10), and a larger number of lobes involved on chest radiograph (OR, 1.83; CI, 1.12-2.98).

CONCLUSION

Delayed clinical suspicion and treatment of active pulmonary TB with respiratory failure may contribute to the persistently high mortality rates in ICU patients with these diseases.

Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity

OBJECTIVE

Anxiety and depression may have a major impact on a person's ability to make decisions. Characterization of symptoms that reflect anxiety and depression in family members visiting intensive care patients should be of major relevance to the ethics of involving family members in decision-making, particularly about end-of-life issues.

DESIGN

Prospective multicenter study.

SETTING

Forty-three French intensive care units (37 adult and six pediatric); each unit included 15 patients admitted for longer than 2 days.

PATIENTS

Six hundred thirty-seven patients and 920 family members.

INTERVENTIONS

Intensive care unit characteristics and data on the patient and family members were collected. Family members completed the Hospital Anxiety and Depression Scale to allow evaluation of the prevalence and potential factors associated with symptoms of anxiety and depression.

MEASUREMENTS AND MAIN RESULTS

Of 920 Hospital Anxiety and Depression Scale questionnaires that were completed by family members, all items were completed in 836 questionnaires, which formed the basis for this study. The prevalence of symptoms of anxiety and depression in family members was 69.1% and 35.4%, respectively. Symptoms of anxiety or depression were present in 72.7% of family members and 84% of spouses. Factors associated with symptoms of anxiety in a multivariate model included patient-related factors (absence of chronic disease), family-related factors (spouse, female gender, desire for professional psychological help, help being received by general practitioner), and caregiver-related factors (absence of regular physician and nurse meetings, absence of a room used only for meetings with family members). The multivariate model also identified three groups of factors associated with symptoms of depression: patient-related (age), family-related (spouse, female gender, not of French descent), and caregiver-related (no waiting room, perceived contradictions in the information provided by caregivers).

CONCLUSIONS

More than two-thirds of family members visiting patients in the intensive care unit suffer from symptoms of anxiety or depression. Involvement of anxious or depressed family members in end-of-life decisions should be carefully discussed.

French intensivists do not apply American recommendations regarding decisions to forgo life-sustaining therapy

OBJECTIVE

Recommendations for making and implementing decisions to forgo life-sustaining therapy in intensive care units have been developed in the United States, but the extent that they are realized in practice has yet to be measured.

DESIGN

Prospective, multicenter, 4-wk study. For each patient with an implemented decision to forgo life-sustaining therapy, the deliberation and decision implementation procedures were recorded.

SETTING

French intensive care units.

PATIENTS

All consecutive patients admitted to 26 French intensive care units.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,009 patients admitted, 208 died in the intensive care unit. A decision to forgo life-sustaining therapy was implemented in 105 patients. The number of supportive treatments forgone was 2.3 +/- 1.7 per patient. Decisions to forgo sustaining therapy were preceded by 3.5 +/- 2.5 deliberation sessions. Proxies were informed of the deliberations in 62 (59.1%) cases but participated in only 18 (17.1%) decisions. The patient's perception of his or her quality of life was rarely evaluated (11.5%), and only rarely did the decision involve evaluating the patient's wishes (7.6%), the patient's religious values (7.6%), or the cost of treatment (7.6%). Factors most frequently evaluated were medical team advice (95.3%), predicted reversibility of acute disease (90.5%), underlying disease severity (83.9%), and the patient's quality of life as evaluated by caregivers (80.1%).

CONCLUSIONS

A decision to withhold or withdraw life-sustaining therapy was implemented for half the patients who died in the French intensive care units studied. In many cases, the decision was taken without regard for one or more factors identified as relevant in U.S. guidelines.

Routine exploratory thoracentesis in ICU patients with pleural effusions: results of a French questionnaire study

PURPOSE

The purpose of this study was to report the opinions of intensivists regarding pleural effusions in patients in the intensive care unit (ICU).

MATERIALS AND METHODS

Questionnaires were sent to 1,032 intensivists, who were members of the French Society of Critical Care.

RESULTS

Four hundred thirty-one questionnaires (41.7%) were returned. Overall, the respondents' estimated the incidence of pleural effusion in ICU patients to be 22.19 +/- 17%, whereas 37 +/- 27% considered that exploratory thoracentesis was likely to determine the cause of the effusion, and 17.36 +/- 16% considered that its results were likely to result in a change in their therapeutic attitude. Sixty-five (15%) physicians, chiefly pulmonologists, performed exploratory thoracentesis routinely (Group 1). Compared with those who did not perform routine thoracentesis (Group 2), they ascribed a higher proportion of pleural effusions to infection (31.3% vs. 13.5%) and were more likely to consider that exploratory thoracentesis had a diagnostic and therapeutic contribution (51.2% vs. 34% and 23% vs. 16%, respectively). In addition to the respiratory medicine subspecialty, the practice of routine exploratory thoracentesis was significantly related to seniority, to the frequency of the suspicion of an infectious cause in the physician's practice, and to his or her appreciation of the risks associated with exploratory thoracentesis. Physicians from Group 1 were also more likely to describe exploratory thoracentesis as a noninvasive procedure.

CONCLUSIONS

The beliefs and attitudes of intensivists regarding pleural effusions and exploratory thoracentesis are divergent. This may be due to the lack of precise guidelines on the topic and prompt the design of further studies to establish precisely the epidemiology and causes of pleural effusions in ICU patients.

Efficacy and safety of gemifloxacin in the treatment of community-acquired pneumonia: a randomized, double-blind comparison with trovafloxacin

This multicentre, randomized, double blind, parallel group study compared the efficacy and safety of gemifloxacin (320 mg once daily) with trovafloxacin (200 mg once daily) in 571 patients with community-acquired pneumonia (CAP). Although treatment was given routinely for 7 days it could be extended to 14 days; two-thirds of patients were treated for 7 days. High clinical success rates were noted at follow-up in the per-protocol population in both the gemifloxacin group (95.8%) and the trovafloxacin group (93.6%), non-inferiority with 95% CI. In the intent-to-treat population, the clinical success rate at follow-up was significantly superior for gemifloxacin (87.6%) compared with trovafloxacin (81.1%; 95% CI 0.5, 12.4). The pathogens identified most commonly at presentation were Mycoplasma pneumoniae and Streptococcus pneumoniae. Gemifloxacin eradicated 100% of S. pneumoniae. One bacteraemic isolate of S. pneumoniae was associated with clinical failure in the trovafloxacin group (MIC of trovafloxacin 8 mg/L). Gemifloxacin was well tolerated and the incidence of transient liver function abnormalities was very low. Gemifloxacin is an effective and well-tolerated treatment for patients with CAP.

Meeting the needs of intensive care unit patient families: a multicenter study

Intensive care unit (ICU) caregivers should seek to develop collaborative relationships with their patients' family members, based on an open exchange of information and aimed at helping family members cope with their distress and allowing them to speak for the patient if necessary. We conducted a prospective multicenter study of family member satisfaction evaluated using the Critical Care Family Needs Inventory. Forty-three French ICUs participated in the study. ICU characteristics, patient and family member demographics, and data on satisfaction were collected. Factors associated with satisfaction were identified using a Poisson regression model. A total of 637 patients were included in the study, and 920 family members completed the questionnaire. Seven predictors of family satisfaction were found: one family-related factor, namely, family of French descent and six caregiver-related factors, namely, no perceived contradictions in information given by caregivers; information provided by a junior physician; patient to nurse ratio </= 3; knowledge of the specific role of each caregiver; help from the family's own doctor; and sufficient time spent giving information. Predictors of satisfaction are amenable to intervention and deserve to be investigated further with the goal of improving the satisfaction of ICU patients' family members.

Infection as a trigger of diabetic ketoacidosis in intensive care-unit patients

We determined the prevalence and indicators of infection in intensive care unit (ICU) patients with diabetic ketoacidosis (DKA) by performing a retrospective analysis of 123 episodes of DKA (in 113 patients) managed in a medical ICU between 1990 and 1997. In univariate analysis, features associated with infection were female sex, neurological symptoms at admission, fever during the week before admission, a need for colloids, a high blood lactate level at admission, and lack of complete clearance of ketonuria within 12 h. Multivariate analysis identified 3 independent predictors of infection: female sex (odds ratio [OR], 2.31; confidence interval [CI], 1.05-5.35), neurological symptoms at admission (OR, 2.83; CI, 1.18-6.8), and lack of complete clearance of ketonuria within 12 h (OR, 3.73; CI, 1.58-9.09). Infection is the leading trigger of DKA in ICU patients. Neurological symptoms at admission and lack of complete clearance of ketonuria within 12 h are useful warning signals of infection.

Bacterial resistance to antibiotics in France : a public health priority

For a few years, France has been faced to a rapid spread of anti-microbial resistance in hospitals and in general practice despite the many recommendations issued to solve this problem. In 1999, the Institut de Veille Sanitaire conducted a collective expe

Predictors of short-term mortality in critically ill patients with solid malignancies

Admission of cancer patients with serious medical complications to the ICU remains controversial primarily because of the high short-term mortality rates in these patients. However, the cancer patient population is heterogeneous regarding age, underlying conditions, and curability of their disease, suggesting that large variations may occur in the effectiveness of intensive care within this subgroup of critically ill patients.

OBJECTIVES

To identify factors predicting 30-day mortality in patients with solid tumors admitted to a medical ICU.

PATIENTS AND METHODS

We conducted a retrospective study in 120 consecutive cancer patients (excluding patients with hematological malignancies) admitted to the medical ICU of a 650-bed university hospital between January 1990 and July 1997. Medical history, physical and laboratory test findings at admission, and therapeutic interventions within the first 24 h in the ICU were recorded. The study endpoint was vital status 30 days after ICU admission. Stepwise logistic regression was used to identify independent prognostic factors.

RESULTS

The observed 30-day mortality rate was 58.7 % (n = 68), with most deaths (92 %) occurring in the ICU. Univariate predictors of 30-day mortality were either protective [prior surgery for the cancer (p = 0.01) and complete remission (p = 0.01)] or associated with higher mortality [Knaus scale C or D (p = 0.02), shock (p = 0.04), need for vasopressors (p = 0.0006) or for mechanical ventilation (p = 0.0001), SAPS II score greater than 36 (p = 0.0001), LOD score greater than 6 (p = 0.0001), and ODIN score > 2 (p = 0.0001)]. Three variables were independent predictors: previous surgery for the cancer (OR 0.20, 95 % CI 0.07-0.58), LOD score > 6 (OR 1.26, 95 % CI 1.09-1.44), and need for mechanical ventilation (OR 3.55, 95 % CI; 1.26-6.7). Variables previously thought to be indicative of a poor prognosis (i. e., advanced age, metastatic or progressive disease, neutropenia or bone marrow transplantation) were not predictive of outcome.

CONCLUSION

When transfer to an ICU is considered an option by patients and physicians, 30-day mortality is better estimated by an evaluation of acute organ dysfunction than by the characteristics of the underlying malignancy.

Rapid diagnosis of infectious pleural effusions by use of reagent strips

Reagent strips have not yet been tested for use in the diagnosis of infectious pleural effusions. A reagent strip was used to evaluate 82 patients with pleural effusions: 20 patients had transudative effusions, 35 had infectious exudative effusions (empyema in 14 and parapneumonic effusion in 21), and 27 had noninfectious exudative effusions. Pleural fluid protein, as evaluated by the reagent strip, proved accurate for the detection of exudative effusions (sensitivity, 93.1%; specificity, 50%; positive predictive value, 84.3%; negative predictive value, 71.5%; odds ratio [OR], 6.77; and 95% confidence interval [CI], 1.87-24). The reagent strip leukocyte esterase test effectively detected infectious exudative effusions (sensitivity, 42.8%; specificity, 91.3%; positive predictive value, 88.2%; negative predictive value, 51.2%; OR, 4.46; and 95% CI, 1.2-16.4). Pleural pH was significantly predicted by the reagent strip but was of no assistance in categorization of exudative effusions as infectious or noninfectious. Compared with physical, laboratory, and microbiological data, the reagent strip was as accurate for estimation of percentages of infectious and noninfectious exudative effusions. Thus, reagent strips may be a rapid, easy-to-use, and inexpensive technique for discriminating transudative from exudative pleural effusions and for categorizing exudative pleural effusions as infectious or noninfectious.

Half the families of intensive care unit patients experience inadequate communication with physicians

OBJECTIVE

Effective communication of simple, clear information to families of intensive care unit (ICU) patients is a vital component of quality care. The purpose of this study was to identify factors associated with poor comprehension by family members of the status of ICU patients.

DESIGN

Prospective study.

SETTING

University-affiliated medical intensive care unit.

PATIENTS AND METHODS

A total of 102 patients admitted to an ICU for >2 days.

INTERVENTION

The representatives of 76 patients who were visited by at least one person during their ICU stay were interviewed.

RESULTS

Mean patient age was 54+/-17 yrs and mean Simplified Acute Physiology Score II at admission was 40+/-20. The representative was the spouse in 47 cases (62%). Among representatives, 25 (33%) were of foreign descent and 12 (16%) did not speak French. Mean duration of the first meeting with a physician was 10+/-6 mins. In 34 cases (54%), the representative failed to comprehend the diagnosis, prognosis, or treatment of the patient. Factors associated with poor comprehension by representatives included patient-related, family-related, and physician-related factors. Patient-related factors included age <50 yrs (p = .03), unemployment (p = .01), referral from a hematology or oncology ward (p = .006), admission for acute respiratory failure (p = .005) or coma (p = .01), and a relatively favorable prognosis (p = .04). Family-related factors were foreign descent (p = .007), no knowledge of French (p = .03), representative not the spouse (p = .03), and no healthcare professional in the family (p = .01). Physician-related factors were first meeting with representative <10 mins (p = .03) and failure to give the representative an information brochure (p = .02). Moreover, after the first meeting, caregivers accurately predicted poor comprehension by representatives (p = .03).

CONCLUSIONS

Patient information is frequently not communicated effectively to family members by ICU physicians. Physicians should strive to identify patients and families who require special attention and to determine how their personal style of interrelating with family members may impair communication.

Gemifloxacin versus amoxicillin/clavulanate in the treatment of acute exacerbations of chronic bronchitis. The 070 Clinical Study group

Six hundred patients were evaluated in this randomized, double-blind, double-dummy, multicenter, parallel-group study comparing the efficacy and safety of gemifloxacin (320 mg once-daily for 5 days) and amoxicillin/clavulanate (500/125 mg three-times daily for 7 days) for the treatment of acute exacerbations of chronic bronchitis (AECB). Of note, more than 90% of study participants had stage 2 disease at study entry. The two drugs were found to be equally effective, with clinical success rates of 93.6% for gemifloxacin and 93.2% on amoxicillin/clavulanate (95% CI -3.9 to 4.6). Bacteriological success rates favored gemifloxacin (90.9% compared with 79.5% for amoxicillin/clavulanate; 95% CI -3.3 to 26.0); however, this difference was not statistically significant. Gemifloxacin and amoxicillin/clavulanate were both well tolerated. In summary, gemifloxacin was found to be well tolerated and effective for the treatment of AECB, suggesting it is well suited for empirical treatment of this common respiratory condition in the current clinical environment.

[Regulation of the use of antibiotics: objectives, means and perspectives]

Antibiotics account for an important fraction of hospital pharmaceutical expense, especially in intensive care units. Moreover, they represent a permanent threat for bacterial ecology. Induced resistance tends, in turn, to inflate the costs. In that way, economical point of view and concerns for quality and safety of care become convergent. Restrictive and(or) educational actions to regulate the prescriptions have therefore been settled in many centres. In the present review, based on published studies, we describe some examples of the results achieved from these actions. Computer-based networks and expert systems offer promising possibilities of improvement for the near future.

[Comparative study of fixation mode in total knee arthroplasty with preservation of the posterior cruciate ligament]

PURPOSE OF THE STUDY

We performed a prospective randomized study to compare two fixation modes, with and without cement, for total knee arthroplasty.

MATERIAL AND METHODS

The study series was composed of 96 cemented or noncemented total knee arthroplasties performed between May 1993 and October 1995. The only difference was the diamond interface used for cemented prostheses and the mesh interface used for uncemented prostheses. The operator was unaware of the type of fixation until the bone slices had been obtained. We assessed outcome in 73 cases with a mean follow-up of 27 months. The two populations were comparable for preoperative clinical status, bone tophicity and surgical procedure.

RESULTS

The mean duration of the operation was sgnificantly longer (> 10 min) for the cemented protheses. The complication rates were comparable but we did have two mobilizations of the tibial implant in the noncemented group. The total scores (127 +/- 29 in the cemented group versus 135 +/- 20 in the uncemented group) were significantly different. There were however more cases with degradation of the controlateral knee in the cemented group although the difference was not significant. When these cases were excluded from the analysis, the total scores for two groups were similar (143 and 140 respectively). Radiographic outcome was quite different with mobilization of the tibial implant in 2 cases and the rate of lucent borders was significantly higher in the noncemented group.

DISCUSSION AND CONCLUSION

While the clinical outcome was comparable, the quality of the fixation was significantly better with cemented arthroplasty, which remains the gold standard.