[Patients refused in admission to an intensive care unit. Prospective evaluation of the causes and outcome]

OBJECTIVES

To determine the reasons for refusing admission to an intensive care unit and the immediate outcome of the patients refused.

METHOD

All patients triaged for admission to a medical intensive care unit ICU during a three-month period were studied prospectively. The frequency and reason for refused admission were studied. The immediate outcome of the refused patients, together with the time lapse before their subsequent management were determined.

RESULTS

Out of 251 patients, 132 (53%) were refused admission. Primary reasons for refusal was lack of beds (92%). Nearly one patient out of 5 was not subsequently treated in an intensive care unit.

CONCLUSION

Some refusals could have been avoided if the downstream networks (short-hospitalisation, re-habilitation centres.) had been able to accommodate the patients proposed. Moreover, by abandoning the strategy of wide admission to intensive care to the benefit of a selective triage of the patients proposed, a certain number of refusals would probably have been avoided. Nevertheless, there are obvious difficulties in the application of the latter method.

[Risk factors for amoxicillin-clavulanate-resistant Escherichia coli in ICU patients]

OBJECTIVE

To determine risk factors of infections with amoxicillin-clavulanate-resistant Escherichia coli in ICU patients.

STUDY DESIGN

Prospective, consecutive sample survey study.

PATIENTS

A consecutive series of 133 patients from whom culture results were positive for E. coli during their ICU stay.

METHODS

Risk factors analysed included demographics, comorbid conditions, and antimicrobial drug exposure. Univariate and multivariate analysis were performed.

RESULTS

Multivariate logistic regression analysis identified only one significant independent factor associated with the emergence of amoxicillin-clavulanate-resistant E. coli: prior use of amoxicillin (odds ratio: 5.45).

CONCLUSION

Clinicians should avoid administering amoxicillin-clavulanate as empiric therapy for possible E. coli infection in patients that have recently been treated with amoxicillin.

Risk factors for piperacillin/tazobactam-resistant Escherichia coli in ICU patients: a clinical study

OBJECTIVE

To determine risk factors of infections with piperacillin/tazobactam-resistant Escherichia coli in critical care patients.

DESIGN

Prospective, consecutive sample survey study.

SETTING

Surgical intensive care unit (ICU) in a university hospital.

PATIENTS

A consecutive series of 133 patients from whom culture results were positive for E. coli during their ICU stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariate logistic regression analysis identified the following significant independent factors associated with the emergence of a piperacillin/tazobactam-resistant Escherichia coli: prior use of amoxicillin (odds ratio, 4.15) and amoxicillin/clavulanate (odds ratio, 3.25).

CONCLUSIONS

Treatment with amoxicillin or amoxicillin/clavulanate is a major risk factor for the detection of piperacillin/tazobactam-resistant E. coli in ICU patients.

[ARDS as an unusual presentation of bronchiolitis obliterans organizing pneumonia]

We report the case of a 46-year-old patient with liver transplantation who developed an acute respiratory distress syndrome (ARDS). The commonly associated clinical disorders, those associated with direct injury to the lung and those that cause indirect lung injury in the setting of a systemic process, were not responsible for the clinical picture. Finally, because of progressive clinical deterioration, an open-lung biopsy was performed and revealed a bronchiolitis obliterans with organizing pneumonia (BOOP). Physicians should be aware of this rare aetiology of ARDS.

[Thigh cellulitis: atypical presentation of intra-abdominal infection]

The initial clinical presentation of intraabdominal disease can be an extraabdominal location. We report three cases of patients admitted to our intensive care unit because of a severe soft tissue infection of the lower extremity. Systematic research of the primitive source by using computed tomography (CT) scan allows us to find perforation of the gastrointestinal tract. Despite an unusual presentation, a high index of suspicion for lower intestine perforation must always be considered in face of a patient presenting with a spontaneous thigh cellulitis. Immediate radical debridement, appropriate antibiotics, and intensive care support are critical to control these life-threatening infections.

Cervical necrotizing fasciitis: 10 years' experience at a single institution

OBJECTIVE

To evaluate clinical and microbiologic characteristics, modalities of treatment and outcome of patients with cervical necrotizing fasciitis admitted to our institution.

DESIGN

Retrospective clinical investigation.

PATIENTS AND METHODS

We reviewed the charts of 20 consecutive patients hospitalized in our Intensive Care Unit between January 1987 and June 1998 with the diagnosis of cervical necrotizing fasciitis.

RESULTS

All the patients required mechanical ventilation. Four of them had mediastinal involvement. The organisms most commonly implicated included Streptococcus, Prevotella, and Peptostreptococcus species. Patients with adequate surgery had a better outcome than those with inadequate surgical procedures. Because no evidence-based recommendations exist in the field of head and neck infections, hyperbaric oxygen was not used as adjunctive therapy. Of the 20 patients, 3 (15 %) died.

CONCLUSION

The main finding of this study is that prompt, rather than delayed, surgical débridement correlates with a decrease in morbidity and mortality. However, no definite conclusion is justified due to the relatively small number of patients. Immediate radical débridement, and early redébridement if needed, appropriate antibiotics and intensive care support are critical in controlling these life-threatening infections.

[The good use of antibiotics in intensive care: results of a program for rationalization of prescriptions]

OBJECTIVE

To assess the impact of an antibiotic prescribing programme in a intensive therapy unit.

TYPE OF STUDY

Prospective comparative study.

METHODS

We compared antibiotic prescriptions and bacterial susceptibility to antimicrobial agents before and after introduction of a programme focusing on injection control and therapeutic indications.

RESULTS

The introduction of the programme resulted in a major decrease in antibiotic administration. Moreover, the susceptibility of Pseudomonas aeruginosa to ticarcillin increased from 40 to 68%, and susceptibility of Staphylococcus aureus to methicillin increased from 55 to 73%.

CONCLUSIONS

Antibiotic control policies must be considered integral to any effort to decrease resistance and cost of therapy with antibiotics.

[Diagnostic criteria for progressive necrotizing external otitis. Are scintigraphic findings reliable?]

OBJECTIVES

Determine the role of 99m technetium scintigraphy for diagnosis in progressive necrotizing external otitis and assess the diagnostic criteria of this disease.

METHOD

A retrospective study was conducted in 16 patients hospitalized for suspected progressive necrotizing external otitis. Patient characteristics, clinical features, imaging findings and disease course were recorded in order to evaluate the classical criteria of diagnosis.

RESULTS

The clinical course and complementary test results showed that 99m technetium scintigraphy lacked specificity for progressive necrotizing external otitis. These findings are in disagreement with those reported in the literature.

CONCLUSION

Patient characteristics and clinical course are key elements for early diagnosis of this disease. Scintigraphy findings are contributive only when bone lysis (which occurs late) can be evidenced. A prospective study would be required to confirm the lack of specificity of scintigraphy in progressive necrotizing external otitis.

Major cellulitis following percutaneous tracheostomy

Percutaneous tracheostomy, a technique that can be performed at the bedside in the intensive care unit (ICU), is increasingly used for critically ill ventilator-dependent patients. Based on many clinical studies, this procedure appears to be simple, rapid and safer than conventional surgical tracheostomy. This technique produces a stoma tissue tract that fits snugly around the cannula, and this could explain the low incidence of infective complications. However, we report two cases of life-threatening cellulitis, a serious complication that has rarely been reported previously.

[Cervical necrotizing fasciitis disclosing HIV infection]

Necrotizing fasciitis is a rapidly progressing necrotizing process which affects subcutaneous tissue and fascia. The leading cause of these infections in neck is odontogenic infection. Its occurrence is reported to be rare, but often fatal. The therapeutic regimen includes three essential principles: appropriate antimicrobial therapy, prompt surgical treatment, and supportive measures. Two cases of cervical necrotizing fasciitis revealing human immunodeficiency virus (HIV) infection are reported. Clinicians should be aware of this underlying condition, and every patient with cervical necrotizing fasciitis should be tested for HIV.

[Selective embolization of ruptured mycotic aneurysm of the duodeno-pancreatic arcade disclosing infectious endocarditis]

The authors report a case of rupture of a mycotic aneurysm of the duodenal pancreatic arcade in a 68 year old man presenting with shock, abdominal pain and rigidity, complicating a case of infectious endocarditis. Emergency treatment consisted of selective embolisation with a coil. This treatment, proposed in view of the clinical condition of the patient and the anatomical particularity of the regional arterial vascularisation, may be a valuable alternative to classical surgery in this type of pathology.